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Received by (Print): Received by (Signature): Phone:
<br />Specialist (Print): Specialist (Signature): Phone:
<br />F1This report is an Official Notice of Violation. Corrections must be completed in the time specified.
<br />A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date.
<br />12
<br />Page 1 of
<br />Reinspection Date (on or about)
<br />Date (MM/DD/YY)
<br />Body Art Inspection Report
<br />County of San Joaquin County, Environmental Health Department
<br />1868 E. Hazelton Ave., Stockton CA 95205 Permit Number -AP—
<br />(209) 488-3420 %vww.sIQov.oLq1ehd
<br />Permit Type 4 ft 2
<br />Facility Name Address city Zip Code CT
<br />110"4 (A 164 i -10-1 6 1. a Alpc Mm, er --I -ztn, 6;y� kj
<br />Perm It/RegistrAtion Holder Name Permit Exp. Date Total Time Inspection Type
<br />RISK FACTORS
<br />AND
<br />INTERVENTIONS
<br />Risk factors are improper practices or procedures
<br />identified
<br />as contributing factors of cross -contamination.
<br />Interventions are control measures to prevent cross
<br />-contamination
<br />and transfer of pathogens from one person to another.
<br />In = In Compliance Out = Not in Compliance
<br />N/O
<br />= Not
<br />Observed
<br />N/A = Not Applicable COS = Corrected On Site
<br />x A-, - w
<br />ag
<br />gg% qg a —w-, 2, N
<br />v "M �,s
<br />rt&
<br />,1, _4 .0
<br />TQ RiAA,.t�(S ICS CNIIR4E
<br />STERIL
<br />gkTI0,N-
<br />In
<br />In N/0 18. Safe machine design 11 11
<br />I
<br />I n4O
<br />I . Autoclave is approved and effective - passed
<br />13
<br />❑
<br />0
<br />A
<br />integrator test
<br />In
<br />2. Process of cleaning, labeling, packaging and
<br />13
<br />13
<br />n N10
<br />19. Machines cleaned and disinfected between
<br />0
<br />0
<br />/A
<br />stedizilng items corrects
<br />A
<br />clients
<br />A/AO
<br />3. Autoclave loaded correctly/packages allowed to
<br />0
<br />❑
<br />0
<br />( &n N/0
<br />20. Parts replaced between clients - grommets,
<br />0
<br />13
<br />dry
<br />NIA
<br />elastic bands, etc.
<br />In
<br />4. Integrators used/monthly spore tesMog
<br />13
<br />0
<br />maintained
<br />In 21. Workstation/procedure area decontaminated
<br />0
<br />0
<br />In 0
<br />5. Decontamination/sanitation area separate and
<br />13
<br />13
<br />supplied *
<br />— N/A
<br />In N/0
<br />6. Invoices and log kept for disposable, pre-
<br />❑
<br />'0 N10
<br />22. Chemical disinfectant used
<br />13
<br />13
<br />N/A
<br />sterilized equipment, backup supplies available*
<br />NhA,
<br />Chemical used: IIAC�r—e, 0a
<br />In N/0
<br />7. Sharps containers supplied, labeled, used and
<br />In23.
<br />NF
<br />Disinfectant used sufficient contact time Wet
<br />0
<br />EI
<br />N/A
<br />disposed of correctly *
<br />contact time provided:
<br />1 0
<br />In
<br />8. Jewelry, tattoo and piercing equipment — storage
<br />0
<br />11
<br />In N/O
<br />24. Barriers available and used as part of
<br />K
<br />and use
<br />NIA
<br />procedure
<br />tog
<br />SIR g5,tP,,jfi, R IK
<br />I N/0
<br />25. Products applied to skin are single
<br />13
<br />0
<br />F
<br />0111"m
<br />ego=
<br />K!
<br />N/A
<br />use/dispensed aseptically
<br />InNV9.
<br />No eating, drinking or smoking - clean clothes
<br />Qn) N/0*A
<br />.26. Storage of inks, pigments, needles, tubes, etc.,
<br />[3
<br />0
<br />I
<br />0
<br />0
<br />z
<br />I
<br />In' 0
<br />10, Hands washed effectively and timely
<br />0
<br />13
<br />UnN/0
<br />27. Jewelry, Inks, Needles etc approved and used
<br />0
<br />0
<br />—NV/
<br />N6
<br />n N/O
<br />11, Handwashing facilities properly supplied and
<br />0
<br />0
<br />—
<br />In Q!V
<br />28. Cross -contamination avoided during all phases
<br />13
<br />11
<br />— /A
<br />accessible, warm potable water *
<br />NIA
<br />of procedur
<br />In N10 N/0
<br />12. Personal protective equipment available and
<br />0
<br />0
<br />r, !�
<br />NIA
<br />I used, eyewash station available
<br />I
<br />N/0
<br />29. Areas separated/no living or sleeping
<br />0 E3
<br />0 ,US, 0 ER J,
<br />14 no,
<br />18
<br />quarters/no animals
<br />NIO
<br />30. Floors and walls dean and in good repair,
<br />0
<br />0
<br />In NIO 13. Branding is completed with no other customers in
<br />0
<br />0
<br />— procedure area
<br />_N/A
<br />adeguate light *
<br />10 -11/0
<br />14. Customers eighteen (18) years of age or older13
<br />N In N/0
<br />31. Workstation, surfaces, including chairs, , etc. in
<br />0
<br />0
<br />N/A
<br />13
<br />N/A
<br />good repair; trash removed frequently *
<br />N/0
<br />(in)
<br />15. Skin prepared for procedure.
<br />11
<br />13
<br />I NIO
<br />( Y
<br />32, Permit/registration and required signs posted
<br />NIA
<br />/A
<br />�-WA
<br />'
<br />In N/O
<br />16. Client records available - Consent form &Un
<br />9-1
<br />11
<br />N/O
<br />33. IPCP and employee training records and
<br />0
<br />0
<br />NIA
<br />questionnaire
<br />1
<br />NIA
<br />Hepatitiis B vaccination status present
<br />In N/O
<br />17. Aftercare instructions given to client
<br />13
<br />N10
<br />34 Restrooms available, stocked
<br />0
<br />0
<br />NIA
<br />NIA
<br />Received by (Print): Received by (Signature): Phone:
<br />Specialist (Print): Specialist (Signature): Phone:
<br />F1This report is an Official Notice of Violation. Corrections must be completed in the time specified.
<br />A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date.
<br />12
<br />Page 1 of
<br />Reinspection Date (on or about)
<br />
|