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/4k Body Art Inspection Report Date(MM/DD/YY) y�• / 3 / County of San Joaquin County,Environmental Health Department ��pfJ�$�,SL� c < 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number (209)468-3420 www.sigov.org/ehd Permit Type G/ Facility Name Address City Zip Code CT CXCA�1+r7 Tr9 ir� ��-�-r�-� X1-4,�� ►'D 4 9 if A 6-r an l- sS --. o in c_ kf mn fit' Permit/Registration Holder Name Permit Exp.Date Total Time Inspection Type A, 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 T 0 ....._ C S CS MACHINE' MI- CLEANING AND STERILIZATION. .° s.' SAF our COS In P40 1. Autoclave is approved and effective-passed 0 0 1 N/0 18. Safe machine design 0 0 / integrator test NIA In 0 2. Process of cleaning,labeling,packaging and 0 0 n N/0 19. Machines cleaned and disinfected between 0 0 NI sterliziing items correct) WA clients In PO 3. Autoclave loaded correctly/packages allowed to 0 0 N10 20. Parts replaced between clients-grommets, 0 0 NIA dry NIA elastic bands,etc. In 4. Integrators used/monthly spore testAog PREVEORTIC-11OS`S GdNI�AMINATION /A maintained 1 0 5. Decontamination/sanitation area separate and n N/O 21. Workstation/procedure area decontaminated 0 0 A supplied* N/A In 10 6. Invoices and log kept for disposable,pre- N/0 22. Chemical disinfectant used 0 0 N/A sterilized equipment,backu supplies available* N/A Chemical used: � In N/0 7. Sharps containers supplied,labeled,used and In N/0 23. Disinfectant used sufficient contact time Wet 0 0 NIA disposed of correctly N/A contact timeprovided: n N/O 8. Jewelry,tattoo and piercing equipment-storage 0 0 N/0 24. Barriers available and used as part of El 0 NIA and use N/A procedure n N/O 25. Products applied to skin are single El 0 PRACTITIONER HEALTH AND HYGIENE ' t :gF /A use/dispensed aseptically In 9. No eating,drinking or smoking-clean clothes 0 0 N/0 26. Storage of inks,pigments,needles,tubes,etc., 0 0 !A /A In 0 10. Hands washed effectively and timely 0 0 n N/0 27. Jewelry,Inks,Needles etc approved and used 0 0 NIA n N10 11. Handwashing facilities properly supplied and 0 n N/O 28. Cross-contamination avoided during all phases ❑ ❑ N/A accessible,warm potable water* NIA of procedure In N/0 12. Personal protective equipment available and 0 BEST BUSINESS P SCE � NIA used,eyewash station available CUSTOMERSICLIENTS in N/0 29. Areas separated/no living or sleeping 0 0 N/Aquarters/no animals* In N/0 13. Branding is completed with no other customers in 0 0 In NIO 30. Floors and walls clean and in good repair, � 0 procedure area A adequate light* n N10 14. Customers eighteen(18)years of age or older 0 0 n /0 31. Workstation,surfaces,including chairs,,etc.in 0 0 /A /A good repair;trash removed frequently* In N10 15. Skin prepared for procedure. 0 0 In N/0 32. Permit/registration and required signs posted* 0 0 N/A N/A In NIO 16. Client records available-Consent form& Wf 13 In NIO 33. IPCP and employee training records and 0 NIA questionnaire AIA He atitiis B vaccination status present In N/0 17. Aftercare instructions given to client n N/0 34 Restrooms available,stocked ❑ ❑ N/A 0 NIA Received by(Print): Received by(Signature): Phone: Specialist(Print); ✓ Specialist(Signature): Phone: This report is an Official Notice f Violation.Corrections must be completed in the time specified. F1 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,2 of 3