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ora o Body Art Inspection Report Date(MM/DD/YY) y County of San Joaquin County,Environmental Health Department n % 1868 E.Hazelton Ave.,Stockton CA 95205 Permit Number (209)468-3420 www.sioov.org/ehd Permit Type Facility Name Address City Zip Code CT Permit/Registration Holder Name Permit Exp.Date Total Time Inspec n Type 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 pO�4n Site a K:..{ ,.,r �x:. �r w i t Vice w =l , ,..Fj46dSM�i1s INT( rV.a.,, d '..T(., K , . s�SAF ... .,NC S. In N/0 1. Autoclave is approved and effective passed ❑ n O 18. Safe machine design ❑ ❑ N/A integrator test A In N/0 2. Process of cleaning,labeling,packaging and ® N/0 19. Machines cleaned and disinfected between ❑ NIA sterliziing items corrects N/A clients In WO 3. Autoclave loaded correctly/packages allowed toPILn /0 20. Parts replaced between clients-grommets, 11 13NIA d x elastic bands,etc. In N/0 4. Integrators used/monthly spore tesMog M- RE CW(leF 08MONTAIIIItTION ❑ � { N/A maintained r�,. . ��. ON In N10 5. Decontamination/sanitation area separate and ❑ In N/0 21. Workstation/procedure area decontaminated ❑ N/A supplied* N/A In NIO 6. Invoices and log kept for disposable,pre- ❑ 10 N/0 22. Chemical disinfectant used ❑ ❑ N/A sterilized equipment,backup supplies available* /A Chemical used: V NIO 7. Sharps containers supplied,labeled,used and13 ❑ n N/0 23. Disinfectant used sufficient contact time Wet 0 13 NIA disposed of correctly* N/A contact timeprovided: -A10 8. Jewelry,tattoo and piercing equipment-storage ❑ ❑ N10 24. Barriers available and used as part of ❑ IA and use /A rocedure n N/0 25. Products applied to skin are single z 400M ❑ ❑ P ti ITI. PII= EA(f l31 Ir.. g IMF N/A useldis ensedase ticali In N/0 9. No eating,drinking or smoking-dean clothes ❑ in N/0 26. Storage of inks,pigments,needles,tubes,etc., N/A N/A In 10. Hands washed effectively and timely n NIO 27. Jewelry,Inks,Needles etc approved and used 0" ❑ N!A ❑ ❑ In NIO 11. Handwashing facilities properly supplied and ❑ In N/0 28. Cross-contamination avoided during all phases ❑ N/A accessible,warm potable water* NIA of procedure 1 12. Personal protective equipment available and N 13used,eyewash station available* ,,. _ � � , t ' S ` :" '. ,°, M/A 29. Areas separated/no living or sleeping ❑ ❑quarters/no animals In NIO 13. Branding is completedwith ith no other customers in ❑ ❑ In 0 30. Floors and walls dean and in good repair, ❑ procedure area N/A adequate light* in N/0 14. Customers eighteen(18)years of age or older ❑ ❑ In NIG 31. Workstation,surfaces,including chairs,,etc.in jK ❑ NIA good repair;trash removed frequently* 10 15. Skin prepared for procedure. ❑ ❑ N/0 32. Permit/registration and required signs posted* ❑ N/A N/A In N/0 16. Client records available-Consent form& ❑ in N/0 33. IPCP and employee training records and NIAquestionnaire A He atitiis B vaccination status present In WO 17. Aftercare instructions given to client n /0 34 Restrooms available,stocked N/A 11 NIA ❑ ❑ Received by(Print): a,c 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_ f_