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October 14, 2025 <br />PR0450001 <br />4522 <br />Observations and Corrective Actions: <br />Page 2 of 4A reinspection fee of $179 per hour may be chargedReinspecion on/about: <br />EH-2/2023 <br />Date: <br />Program <br />Record: <br />Program <br />Element: <br />CORRECTIVE ACTIONS: <br />A large medical waste generator required to register with the EHD shall maintain individual treatment operation records, and <br />shipping and tracking documents for all untreated medical waste shipped offsite for treatment for 2 years. Provide EHD with <br />tracking records for chemotherapy waste. <br />13. HSC 117975 - LOG shall maintain treatment and tracking documents for 2 years. <br />OBSERVATIONS: <br />Chemotherapy waste was observed in the Pharmacy across from 530 W Acacia St., but no manifests for chemotherapy waste <br />was reviewed. <br />19. HSC 118215 - All medical waste shall be treated pursuant to this section. <br />OBSERVATIONS: <br />1. Documentation of annual calibration for the autoclave was not available for review. <br />2. Spore test records did not indicate whether the test result was positive or negative from January 17, 2024 to August 14, 2024 <br />(see PHOTO 1). <br />CORRECTIVE ACTIONS: <br />1. Thermometers, thermocouples, or other monitoring devices shall be checked for calibration annually. Records of the <br />calibration checks shall be maintained as part of the facility’s files and records for 2 years. Provide the EHD with calibration <br />documentation. <br />2. The biological indicator Geobacillus stearothermophillus or approved indicator shall be placed at the center of a load <br />processed under standard operating conditions at least monthly to confirm the attainment of adequate sterilization conditions. <br />Ensure spore test results are documented accurately. <br />23. HSC 117630 - Biohazard bag shall meet the standards set forth in this section. <br />OBSERVATIONS: <br />The secondary containers in the designated accumulation room of 530 W Acacia St. were not lined (see PHOTO 17). <br />CORRECTIVE ACTIONS: <br />The biohazard bag that is used to collect medical waste within a facility shall be manufacturer certified to meet the ASTM D1709 <br />dart drop test, provided that when the bag is prepared fortransport offsite, it is placed into a USDOT-approved container lined <br />with a biohazard bag that is ASTM D1709 and ASTM D1922 certified. Line the secondary containers with liners and provide <br />photographic evidence to the EHD. <br />24. HSC 118275 - Medical, biohazardous, sharps, trace chemo, pathology, or pharmaceutical waste shall be segregated <br />and contained pursuant to this section. The container shall be properly labeled. <br />OBSERVATIONS: <br />1. The sharps waste containers located in room #4 of the Emergency Room (see PHOTO 7), Cath Lab (see PHOTO 8), Scope <br />Process Room of Endoscopy (see PHOTO 11), Soiled Utility Room of Pre-Op (see PHOTO 13), room #221 (see PHOTO 14), <br />and room #330 (see PHOTO 16) contained mixed waste. <br />2. A pharmaceutical waste container located in Pharmacy was not properly labeled (see PHOTO 10). <br />CORRECTIVE ACTIONS: <br />1. Medical waste shall be contained separately from other waste at the point of origin. Train staff on proper waste segregation <br />and provide evidence of training to the EHD. <br />2. Nonradioactive and non-RCRA pharmaceutical wastes, that are regulated as medical waste, shall be placed in a container or <br />secondary container labeled with the words “HIGH HEAT OR INCINERATION ONLY” on the lid and sides, so as to be visible <br />from any lateral direction. Properly label the pharmaceutical waste container and provide photographic evidence of correction to <br />the EHD. <br />MEDICAL WASTE INSPECTION REPORT <br />San Joaquin County Environmental Health Department <br />1868 E. Hazelton Ave., Stockton, CA 95205 <br />(209) 468-3420 <br />www.sioqv.org/ehd