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R A fool ' Nlr 113 �o+��l''`�•oo Body Art Inspection Report Date(MM/DD/YY) County of San Joaquin County,Environmental Health Department < 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number gl7b/pnrs�.�r� �r; (209)468-3420 mymsioov.oro/ehd �IU �o.. Permit Type (7 4�fFORa�.. Facility Name 1 ^7 Address City ZZ''p Code CT C S2CT JLy531-t AWL ILI�Ob � W, 1`4� � \1CkCA ` 5'1'717 0 5011�0Lr�y'1.tI•1 Permit/Registration Holder Name Permit Exp.Date 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 N/A=Not Applicable COS=Corrected On Site :� {TATTOOAND PERMANENT,COSMETICS MACHINE �-tCLEANINGAN STERIUZATIOW , , '`otic ° cos:A x.<<, , a'`S EIY�ANDSANITATION�u ' " OUT cos 0 1. Autoclave is approved and effective-passed10 18. Safe machine design N/A integrator test ❑ ❑ / ❑ !0 2. Process of cleaning,labeling,packaging and ❑ ❑ 19. Machines cleaned and disinfected between ❑ ❑ sterliziin items correct) N/ clients 'In-40 3. Autoclave loaded correctly/packages allowed to 1 0 20. Parts replaced between clients-grommets, d ❑ ❑ N/ elastic bands,etc. ❑ ❑ 4. Integrators used/monthly spore test/log .PREVENTING CROSS CONTAMINATIONS ' x maintained ❑ ❑ � � 5. Decontamination/sanitation area separate and N/0 21. Workstation/procedure area decontaminated A supplied* ❑ ❑ N/A ❑ ❑ I 6. Invoices and fog kept for disposable,pre- ❑ ❑ In NIO 22. Chemical disinfectant used ❑ ❑ NIA sterilized equipment,backupsupplies available* NIA Chemical used: I /0 7. Sharps containers supplied,labeled,used and .I N/O 23. Disinfectant used sufficient contact time Wet NIA disposed of correctly ❑ ❑ /A contact time provided: ❑ 8. Jewelry,tattoo and piercing equipment-storage .In N/0 24. Barriers available and used as part of N/ and use ❑ ❑ /A procedure* ❑ ❑ -� � a rpt >t=z. , . . In NIO 25. Products applied to skin are single ❑ ❑ f -wt PRACTITIONER HEALTH AND HYGIENE /A use/dispensed aseptically In N/0 9. No eating,drinking or smoking-clean clothes ❑ ❑ I N/0 26. Storage of inks,pigments,needles,tubes,etc., ❑ ❑ /A 1 10. Hands washed effectively and timely N/0 27, Jewelry,Inks,Needles etc approved and used In N/0 11. Handwashing facilities properly supplied and 11In N10 28. Cross-contamination avoided during all phases N/A accessible,warm table water` ❑ IA of procedure El ❑ 0 12. Personal protective equipment available and BEST BUSINESS PRACTICES f ' N/ used,eyewash station available* ❑ El CS ` ' NIO a 29.x Areas separated/no livingor sleeping Imi;P IA uarters/no animals 13. Branding is completed with no other customers in ❑ ❑ I N/O 30, Floors and walls clean and in good repair, El [IN procedure area N/A ade uate li ht* 0 14. Customers eighteen(18)years of age or older ❑ ❑ J I N/0 31. Workstation,surfaces,including chairs,,etc.in ❑ ❑ N/A N/A good repair;trash removed frequently 15. Skin prepared for procedure. 10-4/0 32. Permit/registration and required signs posted 7tN/A ❑ ❑ L / ❑ 1:1 /0 16. Client records available-Consent form& ❑ ❑ /0 33. IPCP and employee training records and ❑ ❑ /A uestionnaire /A He atitiis B vaccination status resent In N/0 17. Aftercare instructions given to client I N/O 34 Restrooms available,stocked* N/A ❑ ❑ N/A ❑ ❑ Received b (Print): 0 �� Received b (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) Pagel of 3