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Body Art Inspection Report Date (MM/DD/YY) / County of San Joaquin County, Environmental Health Department ,p 53� 53Z a Permit Number j( < 1868 E. Hazelton Ave., Stockton CA 95205 (209) 468-3420 vAvw.siaov.oro/ehd Permit Type < r Fi Facility Name Address City Zip Code CT Wroni U Tft, S SIL N_ Uni'c A 2G(. ('nanye co" 85331 �+�So �n Permit egistration Holder Name Permit Exp. Date Total Time Inspection Type A A ('J n & OJI�M(A n Q,�ui'i alt. 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 On Site TATTOOAND PERMANENT COSMETICS MACHINE CLEANING `A AND, STERUZATION'-i,' AFYASITAION°'��r � our, cos In w 10 1. Autoclave is approved and effective - passed In N/O 18. Safe machine design 0 0 N/ integrator test /A d 2. Process of cleaning, labeling, packaging and 0 I N/O 19. Machines cleaned and disinfected between 0 0 sterlizling items correct) /A clients I N/0 3. Autoclave loaded correctly/packages allowed to N10 20. Parts replaced between clients - grommets, dry N/A elastic bands, etc. 11 In N10 4. Integrators used/monthly spore test/log + . 7PREVENTING CROSS CONTAMINATION 6 � ` a 3 a p.ha n N yg dti *z Skrf NIA maintained- skv.� . rs�� w� r,. _... N....� ? In N/0 5. Decontamination/sanitation area separate and ❑ In N/0 21. Workstation/procedure area decontaminated 0 N/A supplied * /A In N/0 6. Invoices and log kept for disposable, pre 1 NIO 22. Chemical disinfectant used N/A sterilized equipment, backupsupplies available * /A Chemical used: InA y 0 El In N10 7. Sharps containers supplied, labeled, used and I N/0 23. Disinfectant used sufficign contact ti a Wet N/A disposed of correctly * N/A contact time provided: i 1 • S "^"ti In N/0 8. Jewelry, tattoo and piercing equipment - storage 0 0 I N/0 24. Barriers available and used as part of 0 0 N/A and use /A procedure I NIO 25. Products applied to skin are single 11 0 PRACTITIONER HEALTH AND HYGIENE, /A use/dis ensed ase tical) In N/0 9. No eating, drinking or smoking - clean clothes D 0 NIO 26. Storage of inks, pigments, needles, tubes, etc., 0 0 /A N/A N/0 10. Hands washed effectively and timely 0 0 I A/0 27. Jewelry, Inks, Needles etc approved and used El A In N/0 11. Handwashing facilities properly supplied and (DIV N10 28. Cross -contamination avoided during all phases 11 0 N/A accessible, warm potable water * N/A of procedure In N/0 12. Personal protective equipment available and i BESTiBUSINEBS PRACTICES t 11 0 ¢ x N/A I used, eyewash station available +CUSTOMERSICLIEN�TS t > "' ` tw + n !0 29. Areas separated/no living or sleeping PC O 0 uarterstno animals In W 13. Branding is completed with no other customers in 0 In N10 30. Floors and walls clean and in good repair, 0 N/procedure area N/A adequate light * 10 14. Customers eighteen (18) years of age or older 0 In N/0 31, Workstation, surfaces, including chairs, , etc. in 0 N/A N/A good repair, trash removed frequentl * NIO 15. Skin prepared for procedure. 0 0 In N/0 32. Permit/registration and required signs posted * 0 0 N/A N/A In N/0 16. Client records available - Consent form &0 In N10 33. IPCP and employee training records and 0 N/A questionnaire N/A He atitiis B vaccination status present In N/0 17. Aftercare instructions given to client In N10 34 Restrooms available, stocked * 0 N/A N/A Received by (Print): S�2 P. fJ Received b (Signature): Phone: Specialist (Print): Specialist (Signature): Phone: F1This 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. Page I of 3 Reinspection Date (on or about)