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PR Number PRACTITIONER/ARTIST NAME Jennifer Bou BBP expiration date April 12, 2024 Observations and Corrective Actions: PR Number PRACTITIONER/ARTIST NAME 7/26/2023 SR0087001 4103 6. Invoices and log kept for disposable, pre -sterilized equipment A facility that uses single use instruments shall maintain record of purchase, log of procedures, names of practitioner and client, date of procedure, instruments used, and written evidence from the manufacture that the instruments have undergone sterilization. The record of purchase, evidence of sterilization, type and number of instruments used shall be maintained for a minimum of 90 days after use. HSC 119315(f) OBSERVATIONS : Kwadron needle with lot number 0224 and Kwadron needle with lot nuber 0513 lack sterilization certificates. CORRECTIVE ACTION: Provide evidence of sterilization. 18 The facility's client consent form and medical questionnaire must include all of the information listed in Form B, and are available for inspection. HSC 119303 OBSERVATIONS: The facilities client consent forms and medical questionnaires do not include all information required. The Consent Form Requirements —Tattoo procedure lack the following: Description of procedure Notice that inks are not FDA approved and health consequences are unknown The Consent Form Requirements Medical Questionnaire requirements for BOTH Tattoo procedure and Permanent Tattoo procedur lack the following: History of allergic reactions to antibiotics History of hemophilia or other bleeding disorders History of cardiac valve disease CORRECTIVE ACTION: Provide all required information on consent forms. 31. A body art facility shall be separated from any residential areas used for sleeping, bathing, or meal preparation and shall not share a common entrance or toilet facility with residence. The toilet facility must have a sink with hot and cold water, containerized liquid soap, and single -use paper towels that are dispensed from a wall -mounted, touchless dispenser. HSC 119314 OBSERVATIONS: Soap and paper towels are lacking in restroom dispensers. Reinspection on/about: A reinspection fee of $162 per hour may be charged. Page 2 of 3 EH -11/17 OraUtry Body Art Inspection Report zl =� San Joaquin County Environmental Health Department Date: Program 1868 E. Hazelton Ave., Stockton, CA 95205 (209) 468-3420 <.r F www.sioay.org/ehd Program Element: PR Number PRACTITIONER/ARTIST NAME Jennifer Bou BBP expiration date April 12, 2024 Observations and Corrective Actions: PR Number PRACTITIONER/ARTIST NAME 7/26/2023 SR0087001 4103 6. Invoices and log kept for disposable, pre -sterilized equipment A facility that uses single use instruments shall maintain record of purchase, log of procedures, names of practitioner and client, date of procedure, instruments used, and written evidence from the manufacture that the instruments have undergone sterilization. The record of purchase, evidence of sterilization, type and number of instruments used shall be maintained for a minimum of 90 days after use. HSC 119315(f) OBSERVATIONS : Kwadron needle with lot number 0224 and Kwadron needle with lot nuber 0513 lack sterilization certificates. CORRECTIVE ACTION: Provide evidence of sterilization. 18 The facility's client consent form and medical questionnaire must include all of the information listed in Form B, and are available for inspection. HSC 119303 OBSERVATIONS: The facilities client consent forms and medical questionnaires do not include all information required. The Consent Form Requirements —Tattoo procedure lack the following: Description of procedure Notice that inks are not FDA approved and health consequences are unknown The Consent Form Requirements Medical Questionnaire requirements for BOTH Tattoo procedure and Permanent Tattoo procedur lack the following: History of allergic reactions to antibiotics History of hemophilia or other bleeding disorders History of cardiac valve disease CORRECTIVE ACTION: Provide all required information on consent forms. 31. A body art facility shall be separated from any residential areas used for sleeping, bathing, or meal preparation and shall not share a common entrance or toilet facility with residence. The toilet facility must have a sink with hot and cold water, containerized liquid soap, and single -use paper towels that are dispensed from a wall -mounted, touchless dispenser. HSC 119314 OBSERVATIONS: Soap and paper towels are lacking in restroom dispensers. Reinspection on/about: A reinspection fee of $162 per hour may be charged. Page 2 of 3 EH -11/17