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J QUih f�P' roG Body Art Inspece Report 40 Date: S h,'7 116 I 1 6 San Joaquin County Environmental Health Department Program i' ))'V^ 1868 E. Hazelton Ave., Stockton, CA 95205 Record: P AA S U 1 (209) 468-3420 �CFoa?�P www.siogv.org/ehd Program + . i� Element: L-( 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 6/30/16 Routine The above facility is inspected for compliance with Division 104, Part 15, Chapter 7 of California Health and Safety Code (HSC). V = Violation C = Corrected On Site V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION (cont.) C ❑ 1 Autoclave: approved and effective - passed integrator1:1 ❑ 22 Parts replaced between clients - grommets, elastic bands, El etc. ❑ 2 Items washed, disinfected, packaged, labeled, and E]sterilized PREVENTING CROSS -CONTAMINATION ❑ 3. Autoclave loaded correctly/packages allowed to dry ❑ ❑ 23. 1 Workstation/procedure area decontaminated ❑ ❑ 4. Integrators used/monthly spore testilog maintained ❑ ❑ 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 El El25. Disinfectant used appropriately/sufficient contact time ❑ 7 Sharps containers labeled, used, and disposed of Ela ro riatel E]Wet contact time provided: I F ❑ 8 Jewelry, tattoo and piercing equipment - clean and sterilized 11El26. Barriers used ❑ El 27. Products applied to skin are single use/dispensed ❑ PRACTITIONER HEALTH AND HYGIENE 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 ❑ ❑ 11 Handwashing facilities properly supplied and accessible, ❑ ❑30 Cross -contamination avoided during all phases of ❑ warm water procedure ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ❑ 13. Bloodborne Pathogen training❑ ❑ 31. Areas separated/no living or sleeping quarters ❑ Source: ❑ 32. Floors and walls clean and in good repair, adequate light ❑ Appropriate personal protective equipment available and Workstation, surfaces, includingchairs, armrests, etc. in ❑ 14. used ❑ ❑ 33. good repair ❑ CUSTOMERS/CLIENTS ❑ 34. Permit/registration posted ❑ ❑ 15. Branding is completed with no other customers in procedure area ❑ ❑ 35. 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 Eland uestionnaire ❑ El 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 ❑ rEl 21. Machines cleaned and disinfected between clients ❑ ❑ 41. ❑ Received b (Print): Tony Henson Received b Si nature . / Phone: 209 727-7061 Specialist (Print): Benjamin Escotto Sr REHS Specialist (Signature): Phone' (209) 468-3178 Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 1 of 2 EH -03/2015