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Date (MM/DD/YY)�) o �o Body Art Inspection Report County of San Joaquin County,Environmental Health Department < 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number SQA (209)468-3420 mvw.siaov.org/ehd LA 'O Permit Type _ Facility Name AddressZi Code CT (.r 1�-S - ta-L)A g�3� n aqml JN PeermitIRegistrationHolder Name Permit Exp.Dtte Total Time Inspection Type RISK FACTORS AND INTERVENTIONS Risk factors are improper practices or procedures identified as contributing factors of cross-contamination. Interventions are control measures to prevent cross-contamination and transfer of pathogens from one person to another. In=In Compliance Out=Not in Compliance N/0=Not Observed NIA=Not Applicable COS=Corrected On Site r,TATTUO' D PERMANENT COSMETICS MACHINE Xi-cit;i CLEANING AND STERILIZATION # - "our ' cos :SAFETI "AND SANI7ATION"$,vx" `f OUT cos s4 In N/O 1. Autoclave is approved and effective-passed ❑ 0 18. Safe machine design ❑ ❑ N/A integrator test N! In 2. Process of cleaning,labeling,packaging andElI 19. Machines cleaned and disinfected between N/A sterlizling items correctly N clients In N/0 3. Autoclave loaded correctly/packages allowed to I O 20. Parts replaced between clients-grommets, N/ dry IWAI elastic bands,etc. ❑ I 4. Integrators used/monthly spore test/log rc PREVENTING CROSS CONTAMINATION q a, N/A maintained El El 5. Decontamination/sanitation area separate and ❑ ❑ In N/0 21. Workstation/procedure area decontaminated El ❑ N/A supplied* /A 6. Invoices and log kept for disposable,pre- 11 ri 0 22. Chemical disinfectant used ❑ N/ sterilized equipment,backupsupplies available` Chemical used: In N/0 7. Sharps containers supplied,labeled,used and El 11 In /0 23. Disinfectant used sufficient contact time Wet ❑ El/ disposed of correct) * A contact time provided: In N/ 8. Jewelry,tattoo and piercing equipment-storage In /0 24. Barriers available and used as part of and use procedure* ❑ ❑ � � a� j i In NIO 25. Products applied to skin are single 11 ❑ PRACTITIONER HEALTH AND HYGIENE /A use/dispensed ensed ase ficall NI 0 9. No eating,drinking or smoking-clean clothes ❑ ❑ In NANO 26. Storage of inks,pigments,needles,tubes,etc,, 11 ❑ In 0 10, Hands washed effectively and timely 11 11 In /0 27. Jewelry,Inks,Needles etc approved and used ❑ ❑ IA zz In /0 11. Handwashing facilities properly supplied and ❑ In /0 28. Cross-contamination avoided during all phases 0 ❑ N/A accessible,warm potable water* IA I of procedure AT-NO 12. Personal protective equipment available and i ,BEST BUSINE�SS PRACTICES„ NIAI used,eyewash station available* 11 ❑ fir- ,�.�•a'�� it 5 �r -,�,r rx•. t dr CUS OMERSICLIEN I N/O 29. Areas separated/no living or sleeping El 0 /A guarters/no animals In 13. Branding is completed with no other customers in ❑ ❑ In 10 30. Floors and walls clean and in good repair, N/A procedure area /A adequate light 14. Customers eighteen(18)years of age or older1116 NIO 31. Workstation,surfaces,including chairs,,etc.in NIA NIA good repair;trash removed frequently* In /KM A 15. Skin prepared for procedure. NI 32. Permit/registration and required signs posted* ❑ ❑ In 16. Client records available-Consent form& ❑ ❑ In /0 33. IPCP and employee training records and ❑ /Aquestionnaire He atitiis B vaccination status present In 17. Aftercare instructions given to client ❑ 0 ('1n iYO 34 Restrooms available,stocked* ❑ ❑ /A Received by(Print): J�G b t1 �. Received by(Signature): Phone: Specialist(Print): Specialist(Signature): Phone: ❑ This report is an Official Notice of Violation.Corrections must be completed in the time specified. A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Page I of 3