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Body A�Inspection Report <br /> County <br /> S' -7 <br /> m���a�nc��.s�m���m��o�m�e <br /> Permit <br /> mows.*�e�n�=,smomv CA 95205 <br /> ' ^�=��=�-�� <br /> (209)468-3420www.simov.omq1ehd <br /> Permit Type &a I___. <br /> Facility Name Address City Zip Code or <br /> PermitlRegistration Holder Name Permit Exp.Date Total Time Inspection Type <br /> Risk factors are improper practices or procedures identified as contributing factors of cross-contamination. <br /> Interventions are control measures to prevent cross-contamination and transfer of pathogens from one person to another. <br /> In In Compliance Out Not in Compliance N/O Not Observed N/A Not Applicable COS Corrected On Site <br /> DSTERILIZATK <br /> I ISO <br /> Me, <br /> In N/O 1. Autoclave is approved and effective-passed DL ix_ 0 <br /> NIA integrator test <br /> In N/0 2. Process of cleaning,labeling,packaging and 0 <br /> NIA _ stedizjing items correctly rcenrts !=7 I <br /> In N/0 3. Autoclave loaded correctly/packages allowed to 13 n N/0 20. Parts replaced between clients-grommets, 0 0 <br /> In NIO 4. Integrators used/monthly spore test/log 2 <br /> NIA maintained <br /> In N/0 5. Decontamination/sanitation area separate and 13 In N/0 21. Workstation/procedure area decontaminated <br /> N/A supplied* _NIA <br /> N/O 6. Invoices and log kept for disposable,pre- 13 13 (&0 N/0 22. Chemical disinfectant used 0 13 <br /> /A sterilized equipment,backup supplies available _OLA Chemical used: <br /> In N/0 7. Sharps containers supplied,labeled,used and N10 23. Disinfectant used sufficient contact time Wet <br /> I!L 13 11 13 <br /> N/A disposed of correctly* — N/A contact time provided: <br /> In N/0 8. Jewelry,tattoo and piercing equipment-storage 0 0 In N/0 24. Barriers available and used as part of <br /> and use N/A procedure I <br /> 6114111' (9n N/0 25, Products applied to skin are single <br /> El 13 <br /> use/dispensed aseptically <br /> Mc N/A <br /> 0 N/0 9. No eating,drinking or smoking-clean clothes 0 1%hN/O 26, Storage of Inks,pigments,needles,tubes,etc., [1 13 <br /> 4N10 10. Hands washed effectively and timely In N/0 27. Jewelry,Inks,Needles etc approved and used <br /> /A NIA <br /> In N/0 11. Handwashing facilities properly supplied and In N/O 28. Cross-contamination avoided during all phases <br /> N/A accessible,warm potable water N/A I of procedure <br /> 1qN/0 12. Personal protective equipment available and <br /> 1A used,eyewash station available <br /> wi�g4TOM WE,1 10 29. Areas separated/no living or sleeping <br /> 0 El <br /> 01 04, 7 quarters/no animals <br /> VIn 0 13. Branding is completed with no other customers in 0 1 13 Wn N/0 30. Floors and walls dean and in good repair, 0 0 <br /> ih), procedure area — N/A adequate light* - I <br /> In N10 14. Customers eighteen(18)years of age or older 13 0 In N/O 31. Workstation,surfaces,including chairs,,etc.in 'Z E] <br /> /A _N/A good repair;trash removed frequently* <br /> N/0 15. Skin prepared for procedure. D [3 ' N/0 32, Permit/registration and required signs posted 13 0 <br /> Qn NIO 16. Client records available-Consent form& In N/0 33. 1 PCP and employee training records and <br /> A questionnaire NIA Hepatitis B vaccination status present <br /> NIA Pk N/A I :J0 <br /> In N/0 17. Aftercare instructions given to client 4.4 13 Restrooms available,stocked <br /> Received by(Print): Received by(Signature): Phone: <br /> [—� <br /> This report Official <br /> | | Areinspection fee may becharged if violations noted onthis report are not corrected bythe reinspection date. Reinspection Date(on orabout) <br /> Page, I %�- ' <br />