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o wlk` �o Body Art Inspection Report Date (MM/DD/YY)1Z- <br />z County of San Joaquin County, Environmental Health Department ® A <br />k 1868 E. Hazelton Ave., Stockton CA 95205 Permit Number �1 a <br />(209) 468-3420 www.siaov.oro/ehd 1 q <br />Permit Type <br />Fa "'ty me Address city ZtCode CT ) <br />PermitlRegistration r Name Permit Exp. Date Total Time Inspection Type <br />RISK FACTORS AND INTERVENTIONS <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 Com liance Out = Not in Com liance N/0 = <br />11 Ina N/0 1 <br />1. Autoclave is approved and effective - passed <br />OPW <br />/A <br />integrator test <br />procedure area <br />In N/0 <br />2. Process of cleaning, labeling, packaging and <br />❑ <br />10. Hands washed effectively and timely <br />stedWilng items correct) <br />0 <br />In /0 <br />3. Autoclave loaded correctly/packages allowed to <br />® ❑ <br />N/A <br />dry <br />11. Handwashing facilities properly supplied and10 <br />In N/0 <br />4. Integrators used/monthly spore testnog <br />PL 0 <br />/A <br />maintained <br />NIO <br />5. Decontamination/sanitation area separate and <br />0 <br />N/A <br />supplied <br />questionnaire <br />In N10 <br />6. Invoices and log kept for disposable, pre - <br />In N/0 <br />NIA <br />sterilized equipment, backu supplies available <br />In N/0 <br />7. Sharps containers supplied, labeled, used and <br />0 <br />N/A <br />disposed of correct) <br />27. Jewelry, Inks, Needles etc approved and used <br />I <br />8. Jewelry, tattoo and piercing equipment - storage <br />0 0 <br />�N/A <br />and use <br />QnJ40 <br />9. No eating, drinking or smoking - clean clothes <br />❑ <br />13 <br />N/A <br />procedure area <br />n /0 <br />10. Hands washed effectively and timely <br />® <br />0 <br />/A <br />contact timeprovided: <br />kz:;�N/A <br />11. Handwashing facilities properly supplied and10 <br />0 <br />0 <br />N/A <br />accessible, warm table water <br />In N/0 <br />12. Personal protective equipment available and <br />0 <br />11 <br />/0 <br />13. Branding is completed with no other customers in <br />❑ <br />0 <br />N/ <br />procedure area <br />n /0 <br />14. Customers eighteen (18) years of age or older <br />® <br />0 <br />/A <br />contact timeprovided: <br />I N/O <br />15. Skin prepared for procedure. <br />0 <br />13 <br />N/A <br />procedure <br />In N/0 <br />16. Client records available - Consent form & <br />® <br />13 <br />N/A <br />questionnaire <br />In N/0 <br />17. Aftercare instructions given to client <br />11 <br />N/A <br />Hepatitis B vaccination status present <br />N/A = Not Applicable CO -5= <br />In N/0 18. Safe machine design ❑ <br />/A <br />I N/O 19. Machines cleaned and disinfected between ❑ <br />N/A clients <br />I N/0 20. Parts replaced between clients - grommets, ❑ 11 <br />/A elastic bands, etc. <br />I ' N/O( 21. Workstation/procedure area decontaminated <br />N/A <br />In N/O <br />22. Chemical disinfet use <br />❑ <br />0 <br />IA <br />Chemical used: <br />In NIO <br />23. Disinfectant used suffi ' t co tact time Wet <br />0 <br />El <br />/A <br />contact timeprovided: <br />I-NIO <br />24. Barriers available and used as part of <br />13 <br />A <br />procedure <br />NIO <br />25. Products applied to skin are single <br />® <br />0 <br />/A <br />useldis ensed aseptically <br />I /0 <br />26. Storage of inks, pigments, needles, tubes, etc., <br />11 <br />NI <br />Hepatitis B vaccination status present <br />In <br />90 <br />27. Jewelry, Inks, Needles etc approved and used <br />0 <br />11 <br />/A <br />'In N/0 <br />28. Cross -contamination avoided during all phases <br />NIA <br />of Drocedure <br />N/0 <br />29. Areas separated/no living or sleeping <br />0 <br />11 <br />Aquarters/no <br />animals <br />In 0 <br />30. Floors and walls clean and in good repair, <br />0 <br />El <br />/A <br />adequate light * <br />I NIO <br />31. Workstation, surfaces, including chairs, , etc. in <br />N/A <br />good repair; trash removed frequently <br />In NIO <br />32. Pe rmit/registration and required signs posted * <br />p <br />El <br />N/A <br />In N/0 <br />33. IPCP and employee training records and <br />Hepatitis B vaccination status present <br />In <br />90 <br />34 Restrooms available, stocked <br />A <br />Specialist (Print): Specialist (Signature): Phone: <br />❑This report is an Official Notice of Violation. Corrections must be completed in the time specified. <br />A reinspection fee may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date (on or about) <br />Page lof <br />