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Body Art Inspection Report Date(MWDD/YY) County of San Joaquin County,Environmental Health Department Permit Number 1868 E.Hazelton Ave.,Stockton CA 95205 (209)468-3420 www.sicjov.QLqLqhd Permit Type Facility Name Address city Zip Code CT 6LnGtr _ 1jq_%1QL1 Sarl L,44 Permit/Registration Holder Name Permit Exp.Date Total Time Inspection'Type /s -LnL�=c It link V 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 NIO=Not Observed N/A=Not Applicable COS=Corrected On Site 15 ER1 110"'o'sm Cha 0 In N/O 1. Autoclave is approved and effective-passed E3 N/0 18. Safe machine design 0 0 NIA integrator test NA In N/O 2. Process of cleaning,labeling,packaging and 1:3 (jD/N/0 19. Machines cleaned and disinfected between 13 0 NIA stediziing items correctly P47, -,,VA clients In N/O 3. Autoclave loaded corredy/packages allowed to 1:3 (6YN10 20. Parts replaced between clients-grommets, 0 0 NIA dry N/A elastic bands,etc. In N/0 4. Integrators used/monthly spore testilog ELI NIA maintained [3 In NIO 5. Decontamination/sanitation area separate and 13 Inr 21. Workstation/procedure area decontaminated 0 0 rA" supplied 9 1 N/O 6. Invoices and log kept for disposable,pre- 13 13 In WO 22. Chemical disinfectant used 0)0h2�i� 0 0 N/A sterilized tguipment,backup supplies available N/A Chemical used: 1n N/0 7. Sharps containers supplied,labeled,used and 0 In WO 23. Disinfectant used sufficient contact time Wet 13 13 NIA disposed of correctly* F'*t - N/A contact time provided: 140./ 8. Jewelry,tattoo and piercing equipment-storage 0 0 _7FX1,0 24. Barriers available and used as pad of 13 13 and use -N/A procedure i N10 25. Products applied to skin are singe 13 13 "NOT ANNE INE' W r H N/A useldispensed aseptically In N/O 9. No eating,drinking or smoking-dean clothes 0 &N/O 26, Storage of inks,pigments,needles,tubes,etc., 0 13 N/&-, 4m4 NIA In A)' 10. Hands washed effectively and timely 11 ® 27. Jewelry,Inks,Needles etc approved and used N 0 13 In N10 11. Handwashing facilities properly supplied and In28. Cross-contamination avoided during all phases AIA accessible,warm potable water 0 NO'I of procedure 13 0 n 0 12. Personal protective equipment available and 0 0 used,eyewash station available 60800R.811AIE,11 29. Areas separated/no living or sleeping quartersino animals In XO 13. Branding is completed with no other customers in 0 0 Iii-NIO 30. Floors and walls dean and in good repair, 0 PA) procedure area N/A adequate light* 0 14. Customers eighteen(18)years of age or older EI 13 In N/0 31. Workstation,surfaces,including chairs,,etc.in -0 /A_ N/A I good repair;trash removed frequently* In 15. Skin prepared for procedure, 0- In N/0 32. Permit/registration and required signs posted NP 0 0 In N/O 16. Client records available-Consent form& 13I IO 33. IPCP and employee training records and A21 0 NIA questionnaire NIA Hepatitis B vaccination status present In WO 17. Aftercare instructions given to clientIn N/0 34 Restrooms available,stocked 0 0 N/A 01 NIA <;ee- 142w( U 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 may be charged if violations noted on this report are not corrected by the reinspection date. Reinspection Date(on or about) Paged-of-6