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oaa o Body Art Inspection Report Date(MM/DDtYY) -) y County of San Joaquin County,Environmental Health Department Permit Number 3,g41 " < 1868 E.Hazelton Ave.,Stockton CA 95285 (209)468-3420 www.sigov.or /q ehd Permit Type Facility Name Address City Ad Zip Code CT � , J "' Permit/Registration Holder Name Permit Exp.Date Total Time Inspection 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 Com liance Out=Not in Compliance N/O=Not Observed N/A=Not Applicable COS=Corrected On Site # F. 14 C NI y r+. .1 c� � tNG' F In 1. Autoclave is approved and effective-passed ❑ In NIO 18. Safe machine design ❑ ❑ NIA int rator test /A In 2. Process of cleaning,labeling,packaging and ❑ ® &N/0 19. Machines cleaned and disinfected between ❑ ❑ stediziing items corrects A clients In0 3. Autoclave loaded correctly/packages allowed to 13 13In N/O 20. Parts replaced between clients-grommets, 130 / d NIA elastic bands,etc. In0 4. Integrators used/monthly spore test/log ® ❑ 1. 101 t g N! maintained . �� E .,. _ IW 5. Decontamination/sanitation area separate and ❑ ❑ In N/O 21. Workstation/procedure area decontaminated ❑ 13IA supplied* IA n 10 6. Invoices and log kept for disposable,pre- ❑ ❑ in NIO 22. Chemical disinfectant used ❑ 13NIA sterilized equipent,backup supplies available* NIA Chemical used: t cJ', NIO 7. Sharps containers supplied,labeled,used and 0 E3 N/0 23, Disinfectant used sufficient contact time et ❑ E3nq/A disposed of correct) * /A contact timeprovided: I n,/X 8. Jewelry,tattoo and piercing equipment-storage ® ® n /0 24. Barriers available and used as part of 1 and use procedure M1 ` �� i N/O 25. Products applied to skin are single ❑ S PR. 1.. 1 h.. ,,, *, A 13 use/dispensed aseptically UV , UIn N/O 9. No eating,drinking or smoking-dean clothes ® ❑ In N/O 26. Storage of inks,pigments,needles,tubes,etc., IA /A _WNIO 10. Hands washed effectively and timely13 ® In N/O 27. Jewelry,Inks,Needles etc approved and used 0 13 N/A /A In N/O 11. Handwashing facilities properly supplied and ❑ ❑ (In N/O 28. Cross-contamination avoided during all phases E3 13A accessible,warm potable water* I NIA of procedure In N/O 12. Personal protective equipment available and T t"SS PR�C�GT[GS� � �0 0 � i NIAused a ewash station available ., Or,.... .. „j. . N/O 29. Areas separated/no living orsleeping ❑ ❑ � _ ,,v / uarters/no animals* In 13. Branding is completed with no other customers in ❑ NIO 30. Floors and walls dean and in good repair, ❑ ❑ / procedure area JA ade uate li ht N/0 14. Customers eighteen(18)years of age or older ❑ ❑ n N/0 31. Workstation,surfaces,including chairs,,etc.in 11 NIA N/A good repair,trash removed frequently* In N/0 15. Skin prepared for procedure. ❑ ❑ In N/0 32. Permit/registration and required signs posted* ❑ ❑ NIA A In N/0 16. Client records available-Consent form& ❑ ❑ n N/0 33. IPCP and employee training records and ❑ ❑ lA questionnaire NIA He atitiis B vaccination status present NIO 17. Aftercare instructions given to client ❑ ® In N/O 34 Restrooms available,stocked* ❑ ❑ N/A NIA �S r 0 Received by(Print): 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 maybe charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Pagel of