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q �o MEDICAL WASTASPECTION REPORT Date: 114647-oiS <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E. Hazelton Ave.,Stockton,CA 95205 Record: <br /> c (209)468-3420 Program <br /> www.s*ogy.org/ehd Element: <br /> Observations and Corrective Actions: <br /> 9. This registered small quantity generator does not file a medical waste management plan(MWMP)with San Joaquin <br /> County Environmental Health Department(EHD). <br /> - A small quantity generator required to register with the EHD shall file with the EHD a MWMP on forms prescribed <br /> by the EHD.HSC117935—Review and revise MWMP as needed and submit by 1/4/2016. <br /> 10. This registered medical waste generator does not maintain individual treatment operating records and shipping and <br /> tracking documents for 3 years. <br /> - A medical waste generator required to register with the EHD shall maintain individual treatment operation records, <br /> and shipping and tracking documents for all untreated medical waste shipped offsite for treatment for 3 years. <br /> HSC117943(a) <br /> - Documentation shall be made available to the EHD onsite. HSC 117943(b)—Submit tracking documentation by <br /> 1/4/2016. <br /> 24. Pharmaceutical waste container located in the procedure room was not labeled properly. <br /> -Nonradioactive and non-RCRA pharmaceutical wastes,that are regulated as medical waste, shall be placed in a <br /> container or secondary container labeled with the words "HIGH HEAT" OR"INCINERATION ONLY"on the lid and <br /> sides, so as to be visible from any lateral direction. HSC 118275(a)(6)(B)—Facility disposes of biohazardous <br /> sharps that may or may not contain anaesthetics in a single sharps container. This container is then mailed <br /> back in a return box on which facility will attach a yellow sticker to indicate that the waste needs to be <br /> incinerated. The sharps container onsite did not have "incineration only" labels on the lid and sides. Add <br /> labels and submit evidence of compliance by 1/4/2016. <br /> 19. For steam sterilization, the temperature does not reach 250 F for 30 minutes. Thermometer is not calibrated <br /> annually. <br /> - Recording or indicating thermometers shall be checked during each complete cycle to ensure the attainment of 250 F <br /> for at least 30 minutes. HSC118215(2)(B) <br /> - Thermometers, thermocouples, or other monitoring devices shall be checked for calibration annually. Records of the <br /> calibration checks shall be maintained as part of the facility's files and records for 2 years. HSC 118215(a)(2)(B)— <br /> Calibrate autoclave thermometer and submit evidence of compliance by 1/4/2016. Autoclave must not be used <br /> until it has been calibrated. <br /> 19. For steam sterilization, the biological indicator Geobacillus stearothermophilus is used at least monthly. <br /> - The biological indicator Geobacillus stearothermophillus or approved indicator shall be placed at the center of a load <br /> processed under standard operating conditions at least monthly to confirm the attaimnent of adequate sterilization <br /> conditions. HSC 118215(a)(2)(D)—Results for spore tests conducted between 3/11/14 and 12/2/14 were <br /> unavailable. Obtain spore test results and submit by 1/4/2016. <br /> Reinspecion on/about: A reinspection fee of$130 per hour may be charged. Page 2 of 3 <br /> EH-08/2015 <br />