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Body Art Inspean Report Date: San Joaquin County Environmental Health Department Program 1868 E. Hazelton Ave., Stockton, CA 95205 Record: ?U<> (209) 468-3420 Program �t,Fo"aa� www.siogy.orq/ehd L1>j Z� Element: Facility Name Address City Zip Code Forsaken Tattoo 13500 hwy. 88 Lockeford 95237 Name of Permit/Registration Holder Permit Exp. Date Time In Time Out Inspection Type Tony Henson 6/30/17 Routine The above facility is inspected for compliance with Division V = Violation 104, Part 15, C = Chapter 7 of California Health and Safety Code (HSC). Corrected On Site V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION (cont.) C ❑ 1 Autoclave: approved and effective - passed integrator test El ❑ 22. Parts replaced between clients - grommets, elastic bands, etc. El El 2. Items washed, disinfected, packaged, labeled, and sterilized ❑ PREVENTING CROSS -CONTAMINATION ❑ 3. Autoclave loaded correctly/packages allowed to dry ❑ [1 23. Workstation/procedure area decontaminated ❑ ❑ 4. Integrators used/monthly spore test/log maintained ❑ [1 24. Appropriate chemical disinfectant used ❑ ❑ 5 Decontamination/sanitation area separated and supplied appropriately ❑ Chemical used: ❑ 6 Invoices and log kept for disposable, pre -sterilized equipment F1 El 25. Disinfectant used appropriately/sufficient contact time ❑ F-17 Sharps containers labeled, used, and disposed of appropriately ❑ Wet contact time provided: ❑ 8' Jewelry, tattoo and piercing equipment - clean and ❑ ❑ 26. Barriers used E]sterilized HEALTH AND HYGIENE ❑ 27 Products applied to skin are single use/dispensed aseptically ElPRACTITIONER ❑ 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 ❑ ❑ 11 Handwashing facilities properly supplied and accessible, warm water El30 ❑ ' Cross -contamination avoided during all phases of procedure E] ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ❑ 13. Bloodbome Pathogen training ❑ ❑ 31. Areas separated/no living or sleeping quarters ❑ Source: ® 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. Permittregistration posted ❑ ❑ 15 Branding is completed with no other customers in rocedure area ❑ ❑ 35. Operation and employee training records present El ❑ 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 uestionnaire ElE]and ❑ 37. Permits obtained and available ❑ 19. Appropriate aftercare instructions given to client ❑ ❑ 38. Impoundment ❑ MACHINE SAFETY AND SANITATION ❑ 39. Hearing scheduled ❑ ❑ 20. Safe machine design ❑ ❑ 40. Closure ❑ ❑ 21. Machines cleaned and disinfected between clients ❑ ❑ 41. ❑ Received b (Print): Tony Henson Received b (Si natu Phone: 209 727-7061 Specialist (Print): Benjamin Escotto, Sr REHS Specialist (Signature): ti., &11,& Phone: (209) 468-3178 Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 1 of 2 EH -03/2015