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Date(MM/DD/YY) 4� Body Ari Inspection Report Permit Number San Joaquin County,Environmental Health Department Ny K 1868 East Hazelton Avenue,Stockton,CA 95205 (209)468-3420 fax(209)464-0138 www.sdcdeh.oro Permit Type -acility Name Address City Zip Code C �44 i S� vC �n��. &k-v u i n n rmit/Registration Holder Name Permit Exp.Date Total Time Inspection Type i 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/O=Not Observed N/A=Not Applicable COS=Corrected On Site CLEANING AND STERILIZATION COS MACHINE SAFETY AND SANITATION cont COS In 0 t 1. Autoclave effective-passed integrator test In O t 22 Parts replaced between clients-grommets,elastic bands, N/O / gN/O N/ etc. Out 2 Items cleaned,packaged and labeled N/0 NIA P EVENTING CROSS-CONTAMINATION In Out 3. Autoclave loaded correctly/packages allowed to dry n J O t 23. Workstation/procedure area decontaminated NIO In Out 4 Integrators used/monthly spore test/log maintained I!O ON A 24. Appropriate chemical disinfectant used I Out Decontamination/sanitation area separate and v N/O N/A 5' supplied appropriately Chemical used: (CJ 7a—out 6 Invoices and log kept for disposable,pre-sterilized Out 25. Disinfectant used appropriately/sufficient contact time N/0 N/A equipment N/0 NIA (lam Out 7 Sharps containers labeled,used and disposed of Wet contact time provided: �� N/O N/A appropriately In Out 8 Jewelry,tattoo and piercing equipment-clean and In Out 26. Barriers used N/O N/ sterilized O N/A (14 Out Products applied to skin are single use/dispensed PRACTITIONER HEALTH AND HYGIENE N/O NIA 27. aseptically On Out 9.9. No eating,drinking or smoking-clean clothes lit Out 28 Storage of inks,pigments,needles,tubes,etc. M6 N/A Ino Out 10. Hands washed effectively and timely N/O ON/A 29 . Jewelry,Inks,Needles etc approved and used correctly In Out 11 Handwashing facilities properly supplied and (iOut 30 Cross-contamination avoided during all phases of /O NIA accessible,warm water N/O NIA procedure N/0 ONIA 12. Hepatitis B vaccination IN+V�,L poucxqA BEST BUSINESS PRACTICES N/O out 13.13. Bloodborne Pathogen training N/O ON t 31. Areas separated/no living or sleeping quarters Source: In Out 32. Floors and walls clean and in good repair,adequate light PO N/A In Out 14 Appropriate personal protective equipment available In Out 33 Workstation,surfaces,including chairs,armrests,etc.in /O N/A and used /O NIA good repair In) ut 34. PermiUregistration posted CUSTOMERS/CLIENTS 0 N/A In gut, 15. Branding is completed with no other customers in I ut 35. Operation and employee training records present N/0 /Arocedure area /0 N/A Inut 16. Customers eighteen(18)years of age or older N/O N/ COMPLIANCE AND ENFORCEMENT In Out 17. Skin adequately prepared for procedure 36. Plan Review N/O N/ In Client records approved and available-Consent NIO /A, 18' form and questionnaire 37. Permits Obtained and Available In u 19. Appropriate aftercare instructions given to client 38. Impoundment N/O N/ MACHINE SAFETY AND SANITATION 39. Hearing Scheduled QjN Out 20. Safe machine design 40. Closure N/O N/A —G—Out 21. Machines cleaned and disinfected between clients N/0 N/A REG# PRACTITIONERIARTIST NAME REG# PRACTITIONERIARTIST NAME OBSERVATIONS AND CORRECTIVE ACTIONS Received by(Print): 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—of