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Environmental Health - Public
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EHD Program Facility Records by Street Name
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4100 – Safe Body Art
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PR0546977
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COMPLIANCE INFO
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Entry Properties
Last modified
10/10/2024 1:59:28 PM
Creation date
6/7/2023 2:20:57 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4100 – Safe Body Art
File Section
COMPLIANCE INFO
RECORD_ID
PR0546977
PE
4120 - BODY ART FACILITY-SINGLE USE
FACILITY_ID
FA0022860
FACILITY_NAME
PURE FORM GALLERY & TATTOO (EDGINGTON,WILLIAM)
STREET_NUMBER
213
Direction
W
STREET_NAME
YOSEMITE
STREET_TYPE
AVE
City
MANTECA
Zip
95336
CURRENT_STATUS
Active, billable
QC Status
Approved
Scanner
SJGOV\cfield
Supplemental fields
Site Address
213 W YOSEMITE AVE MANTECA 95336
Tags
EHD - Public
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Body Art Inspection Report Date: April 13,2022 <br /> �N San Joaquin County Environmental Health Department Program <br /> :• 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: PR0546977 <br /> (209)468-3420� Program www.siogv.org/ehd <br /> qt r QRel- Element: 4120 <br /> PR Number PRACTITIONER/ARTIST NAME PR Number PRACTITIONER/ARTIST NAME <br /> PR0540005 Wi liam Edgington(BBP exp. <br /> Observations and Corrective Actions: <br /> 6. A faci it -hat uses single use instruments shall maintain record of purchase, to of procedures, names of practitioner and <br /> Y 9 p , 9 p <br /> client, date of procedure, instruments used, and written evidence from the manufacture that the instruments have undergone <br /> sterilization. The record of purchase, evidence of sterilization, type and number of instruments used shall be maintained for a <br /> minimum of 90 da/s after use. HSC 119315(f)—The invoice and sterilization certificate for instrument KWADRON <br /> CARTRIDGE SYSTEM LOT# 1225 were not available. Provide EHD with the invoice and sterilization certificates for the <br /> instruments. <br /> 13. Practiticner shall provide evidence of a completed, EHD approved, OSHA Bloodborne Pathogen Training consistent with <br /> section 119:07. Bloodborne Pathogen Training certificate was not available at the time of inspection. Provide EHD with <br /> valid Bloodborne Pathogen Training certificate. <br /> 18. The fac lities client consent form and medical questionnaire must include all of the information listed in Form B, and are <br /> available for inspe:tion. HSC 119303—A few consent form was available to review. Consent forms should be kept at the <br /> facility and readily available to review at all times. <br /> 34. CertificEte of registration and health permit shall be posted in a conspicuous place. HSC 119306 and 119312— Health <br /> Permit was not available at the time of inspection. Post the Health Permit and provide EHD with photographic proof. <br /> 35. Operation anc employee training records shall be maintained for 3 years and made available for inspection. A written <br /> Infection Prevention and Control Plan (IPCP) shall be maintained, followed and updated. HSC 119313— Infection Prevention <br /> and Control Plan was not available at the time of inspection. IPCP is to be kept at the facility at all times. Provide EHD <br /> with IPCP. <br /> Unless otherwise noted, correct all violations and provide evidence of correction to <br /> the EHD bV May 3, 2022. <br /> Notes: <br /> 1. Ins�ectior report was emailed to William Edgington, at billythekidd5(a.gmail.com <br /> 2. Sharps waste container was last picked up in 2021 by Stericycle, Inc. <br /> 3. The holes on the wall in the restroom and the gap between the door frame and wall of the back door have to be repaired. <br /> Pro,iide EHD with photographic proof of repair. <br /> Reinspection on!about: A reinspection fee of$152 per hour may be charged. Page 2 of 2 <br /> EH-11/17 <br />
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