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; o Body Art Inspect Report Date: l I �o1G �Iq <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 <br /> Record: h 1ZQ$JT 7 Y°r <br /> (209)468-3420 <br /> Program <br /> ,�,SrFORar www.siogv.org/ehd Element: / zn <br /> PR Number PRACTITIONERAARTIST NAME PR Number PRACTITIONERlARTIST NAME <br /> PR0537421 Leiu Thi Nguyen <br /> Observations and Corrective Actions: <br /> 6. A facility that uses single use instruments shall maintain record of purchase, log of procedures, names of practitioner and <br /> client, date of procedure, instruments used, and written evidence from the manufacture that the instruments have undergone <br /> sterilization. The record of purchase, evidence of sterilization, type and number of instruments used shall be maintained for a <br /> minimum of 90 days after use. HSC 119315(f)—The sterilization certificate and invoice was not available. Provide <br /> sterilization certificate and invoice for blades and instruments used. Provide sterilization certificate for Tina Davies <br /> blade-lot#09-202. <br /> 7. The sharps waste container shall be within arm's reach and labeled with the word "sharps waste"or with the biohazard symbol <br /> and the word "Biohazard". Sharp waste containers shall be disposed by a licensed waste hauler or approved mail back system. <br /> Documentation of proper disposal shall be maintained for 3 years. HSC 119314(e)—Documentation of sharp waste disposal <br /> or a written agreement was not present at the site. Provide EHD with a receipt and a written agreement from a licensed <br /> waste hauler or a mail-back system.—Corrected on site. <br /> 7. The sharps waste container shall be within arm's reach and labeled with the word "sharps waste"or with the biohazard symbol <br /> and the word"Biohazard". Sharp waste containers shall be disposed by a licensed waste hauler or approved mail back system. <br /> Documentation of proper disposal shall be maintained for 3 years. HSC 119314(e)—The sharps waste container is not <br /> properly labeled. Label the sharps container with the word "sharps waste" or with the biohazard symbol and the word <br /> "Biohazard." <br /> 13. Practitioner shall provide evidence of a completed, EHD approved, OSHA Bloodborne Pathogen Training consistent with <br /> section 119307. —The Bloodborne Pathogen Training Certificate that is posted in the procedure room is not from an EHD <br /> approved course. Complete an EHD approved BBP course,submit a copy of the certificate to the EHD. <br /> 18. The facilities client consent form and medical questionnaire must include all of the information listed in Form B, and are <br /> available for inspection. HSC 1193032—The client consent form and medical questionnaire did not include all the <br /> information from Form B. <br /> Include the following on the consent form: <br /> 1. Description of procedure <br /> 2. Description of what the client should expect following the procedure <br /> 3.A notice stating "inks are not FDA approved and health consequences are unknown." <br /> Include the following on the medical questionnaire: <br /> 1. History of herpes infection at the procedure site <br /> 2. History of diabetes <br /> 3. History of allergic reactions to latex <br /> 4. Histroy of allergic reactions to antibiotics <br /> 5. History of hemophilia or other bleeding disorders <br /> 6. History of cardiac valve disease <br /> 7.A list of current medications <br /> Reinspecion on/about: A reinspection fee of$152 per hour may be charged. Page 2 of 3 <br /> EH-11/17 <br />