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T_ Body Art Ins een Report Date: 3%F%l9 zt z y San Joaquin County Environmental Health Department Program ❑ 1 1868 E. Hazelton Ave., Stockton, CA 95205 Record: P"S y?_ (og c4if'Foa�`?_ (209) 468-3420 Program W/20 Items washed, disinfected, packaged, labeled, and sterilized www.siogv.orq/ehd Element: CROSS -CONTAMINATION Facility Name Address City Zip Code Lodi Micro Clinic 755 s. fairmont avenue a-2 Lodi 95240 Name of Perm it/Registration Holder Permit Exp. Date Time In Time Out Inspection Type Romaldo Rodriguez 24. Appropriate chemical disinfectant used Final/Routine The above facility is inspected for compliance with Division 104, Part 15, Chapter 7 of California Health and Safety Code (HSC). El V = Violation C = Corrected On Site F1 Chemical used: Sani-Cloth, Barbicide V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION cont ❑ 1 Autoclave: approved and effective - passed integratorE] test Sharps containers labeled, used, and disposed of aro riatel ❑ 22 Parts replaced between clients - grommets, elastic bands, etc. El 2' Items washed, disinfected, packaged, labeled, and sterilized El Barriers used CROSS -CONTAMINATION ❑ 3. Autoclave loaded correctly/packages allowed to dry ❑ ❑ 23. Workstation/procedure area decontaminated ❑ 4. Integrators used/monthly spore test/log maintained ❑ Storage of inks, pigments, needles, tubes, etc. 24. Appropriate chemical disinfectant used El 5. Decontamination/sanitation area separated and supplied appro riatel El I F1 Chemical used: Sani-Cloth, Barbicide ® 6. Invoices and log kept for disposable, pre -sterilized ❑ ❑ 25. Disinfectant used appropriately/sufficient contact time Received by (Print): Romaldo Rodriguez Received by (Signature): Is v �' Phone: (209) 327-4435 Specialist (Print): Navjot Sahota Specialist (Signature): a_496 y 15�r� Phone: (209) 468-3178 C E C C E Reinspecion on/about: A reinspection fee of $152 per hour may be charged. Page 1 of,' EH -11/17 e ui mem HEI26. contact time provided: 2 min, 10 mins ❑ 7. Sharps containers labeled, used, and disposed of aro riatel E]Wet ❑ 8. Jewelry, tattoo and piercing equipment - clean and sterilized ❑ Barriers used PRACTITIONER HEALTH AND HYGIENE ❑ 27 Products applied to skin are single use/dispensed aseptically ❑ 9. No eating, drinking or smoking - clean clothes ❑ ❑ 28. Storage of inks, pigments, needles, tubes, etc. ❑ 10. Hands washed effectively and timely ❑ ❑ 29. Jewelry, Inks, Needles etc approved and used correctly F1 11. Handwashing facilities properly supplied and accessible, warm water El El 30. Cross -contamination avoided during all phases of procedure ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ❑ 13. Bloodbome Pathogen trainingElEl31. Areas separated/no living or sleeping quarters Source: Body Art Training Group ❑ 32. Floors and walls clean and in good repair, adequate light ❑ 14. Appropriate personal protective equipment available and used ❑ ❑ 33 Workstation, surfaces, including chairs, armrests, etc. in good repair CUSTOMERS/CLIENTS ❑ 34. Permit/registration posted El 15. Branding is completed with no other customers in procedure area El El35. Operation and employee training records present ❑ 16. Customers eighteen (18) years of age or older ❑ COMPLIANCE AND ENFORCEMENT ❑ 17. Skin adequately prepared for procedure ❑ ❑ 36. Plan(s) submitted for review ® 18. Client records approved and available - Consent form and questionnaire El El37. Permits obtained and available ❑ 19. Appropriate aftercare instructions given to client ❑ ❑ 38. Impoundment MACHINE SAFETY AND SANITATION ❑ 39. 1 Hearing scheduled ❑ 20. Safe machine design ❑ ❑ 40. Closure ❑ 21. Machines cleaned and disinfected between clients ❑ ❑ 41. �1 Received by (Print): Romaldo Rodriguez Received by (Signature): Is v �' Phone: (209) 327-4435 Specialist (Print): Navjot Sahota Specialist (Signature): a_496 y 15�r� Phone: (209) 468-3178 C E C C E Reinspecion on/about: A reinspection fee of $152 per hour may be charged. Page 1 of,' EH -11/17