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,o�qUl Body Art Inspection Report Date(MM/DD/YY) _ y County of San Joaquin County,Environmental Health Department at Permit Number 1868 E.Hazelton Ave.,Stockton CA 95205 +•) (209)468-3420 www.sigov.org/ehd � f Permit Type `j/-1 Facility Name Address city Zip Code CT ci7m '�t> Viftir_� 'S) q _,c%Yl ,_)f)L*,t ]If).— PermittRegistration Holder Name Pe it Exp.Date Total Time Inspection Type�r 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 TATTOO AND PERMANENT COSMETICR MACHINE CLEANING AND STERILIZATION our' cos SAFETY ANDSANRATI(3N our cos In 10 1. Autoclave is approved and effective-passed -0 In N/0 18. Safe machine design /A int rator test NIA 1 N/0 2. Process of cleaning,labeling,packaging and ❑ 13 In N/0 19. Machines cleaned and disinfected between 11 0 /A sterlizilng items correctly NIA clients In WO 3. Autoclave loaded correctly/packages allowed to ❑ CI In N/0 20. Parts replaced between clients-grommets, 0 0 /A dry N/A I elastic bands,etc. In N/0 4. Integrators used/monthly spore tesMog PREVEN I G G OSS-CONTAMINATION, /A maintained In N/0 5. Decontamination/sanitation area separate and 11 11 In N/0 21. Workstation/procedure area decontaminated ❑ ❑ NIA su lied* N/A In N/0 6, Invoices and log kept for disposable,pre- 0 11 In N/0 22. Chemical disinfectant used 0 U sterilized equipment,backu supplies available* N/A Chemical used: In /0 7. Sharps containers supplied,labeled,used and In N/0 23. Disinfectant used sufficient contact time Wet 13 11 NIA disposed of correct) * N/A contact timeprovided: In NIO 8. Jewelry,tattoo and piercing equipment—storage 0 0 In N10 24. Barriers available and used as part of EI 13 NIA and use N/A procedure In N/0 25. Products applied to skin are single PRACTITIONER HEALTH ANQ HYGOE N/A useldis ensed ase tical) InNNIO 9, No eating,drinking or smoking-clean clothes In N/O 26. Storage of inks,pigments,needles,tubes,etc., lA NIA In N/0 10. Hands washed effectively and timely 17 O In N/0 27. Jewelry,Inks,Needles etc approved and used 0 11 N/A NIA In N/0 11, Handwashing facilities properly supplied and In N/0 28. Cross-contamination avoided during all phases NIA accessible,warm potable water* NIA of procedure In N/O 12. Personal protective equipment available and 4 "fR 91=ST US!SS PRACTICES ;s NIA used,eyewash station available CUSTOMERSIGLIENTS In N/0 29. Areas separated/no living or sleeping �. IAquarters/no animals In N/0 13. Branding is completed with no other customers in 0 0 I NIO 30. Floors and walls clean and in good repair, 0 ❑ NIA procedure area /A adequate light* In N/O 14. Customers eighteen(18)years of age or older ❑ NIO 31. Workstation,surfaces,including chairs,,etc.in 0 N/A NIA good repair;trash removed frequently* In N/0 15. Skin prepared for procedure, 11 0 In N/0 32. Permit/registration and required signs posted 11 0 NIA IA I N/O 16. Client records available-Consent form& 0 13 I N/0 33. IPCP and employee training records and 0 0 /A questionnaire N/A He atitiis B vaccination status present ly N/0 17. Aftercare instructions given to client In N/0 34 Restrooms available,stocked* 11 0 NIA N/A Received by(Print): J` Receivedby(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) Page 11 of ILt