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DIP-.6SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95202-6232 Telephone: (209)468-3420 Fax: (209) 464-0138 Web:www.sigov.org/ehd R HOTEL/MOTEL OFFICIAL INSPECTION REPORT Name of Facility: — Inspection Date: .ZO Address: PEZ�10 g PR# S� Owner/Operator. Phone: Annual Inspection ❑ Complaint Inspection ❑ Consultation Inspection ❑ Re-Inspection #Units in Facility: &Z #Units Inspected: Reinspection On or About: The items checked below are violations to be corrected. See Reverse Side of this Form for Detailed Summary of Violations and Code References. Room(s): ❑ Room Cleanliness: Lack of cleanliness&sanitation;Accumulation of debris,trash, garbage,combustible items or similar materials. Room Maintenance: General lack of repair or improper maintenance; Broken or non- ❑ 2 functioning sink/toileUbath; Lack of hot water. Floors: Not clean, properly covered or in good repair. Walls&Ceilings: Walls/ceilings in need of cleaning or repair: Holes,water damage, peeling or deteriorating paint; Dampness or excessive moisture in room. ❑ 3' Heating: Lack of approved heating in each unit;Approved heater not maintained in a safe, working condition; Lack of adequate heat(Standard: 70°F at 3 feet from floor). Drinking Utensils& Ice Buckets: Not protected from contamination; Lack of or improper ❑ 4. washing&sanitizing after each use(multi-use); Lack of or improper protective bagging (multi-use)or individual protective wrapping(single-use). F-1Beddin : Mattress/linens infested with lice, bedbugs,or other insects; Not free from filth or 5. foul matter; Unsafe; Linens not changed weekly or before new guest. ❑ 6 Garbage Receptacles: Inadequate number of garbage receptacles; Lack of or inadequate close fitting covers; Garbage receptacles unclean or in disrepair. ❑ 7 Public Areas: Unsafe or unsanitary conditions in kitchen, hallways,stairways,exits,or other publicly shared spaces, ❑ 8. Pest Control: Infestation of insects, vermin or rodents. ❑ 9. Other Nuisance:Any other condition which is hazardous to health. Other Substandard or Unsafe Conditions: Electrical, structural,or plumbing hazards; Lack YZ*V-2 I ^A-e to cy. 10. of or inadequate smoke detectors or fire extinguishers; Inadequate lighting; Inadequate protection from weather Inadequate sewage or water facilities. Pest control Used? t4 Yes ❑ No Company Name: Frequency: Hotel/Motel Business License? ❑ Yes ❑ No Multi-Jurisdictional Violations to be Referred to: ❑ City Building/Code Enforcement/Fire❑ County Code Enforcement/Fire❑ Other Rooms inspected: 10 5 1 p 3 z Z a o 5Z Z O Comments: All violations in rooms not inspected must also be corrected. All re-inspections-Uy-The Environmen-Fall Healthe e current hourly rate. Received �fuo'A[�I �` Title: Environmental Health Specialist1^'V Phone: L 3 — Page 1 of EHD 24-01 4-30-12 HOTELMOTEL OR