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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton , CA 95202-6232 � ,�y� Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www. sigov. org/ehd HOTEL/MOTEL OFFICIAL INSPECTION REPORT Nam f Facility: Inspection Date: Address: PE: PR#: N% Ownpr/O for S Phone: Y � 5- 712 Annual Inspection ❑ Complaint Inspection ❑ Consultation Inspection e-Inspection # Units in Facility: 2,0 # 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): ❑ 1 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/toilet/bath; 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 IF] 4. washing & sanitizing after each use (multi-use); Lack of or improper protective bagging (multi-use) or individual protective wrapping (single-use). s Beddin : Mattress/linens infested with lice, bedbugs, or other insects; Not free from filth or 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. ❑ 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. TOther Substandard or Unsafe Conditions: Electrical, structural, or plumbing hazards; Lack 11 of or inadequate smoke detectors or fire extinguishers; Inadequate lighting ; Inadequate protection from weather; Inadequate sewage or water facilities. Pest control Used? Yes ❑ No Company Name: L 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 : :t'& 15 Comments: IVO All violations in rooms not inspected must also be corrected. All re-inspections by the Environmental Health Department will be billed at the current hourly rate. RegL6 Title: Enealth Specialist: TPhone:itle: d� �t� /� Page 1 of EHD 24-01 4-30-12 d" b HOTEL/MOTEL OIR