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�oPq�1y SAN 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 HOTEL/MOTEL OFFICIAL INSPECTION REPORT Name of Facility: / / {, (' _ Inspection Date: Address: -t-c.� PE: Z PR�Z 4{O Z Owner/Operator: / f Q d� I Phone: �w G� l nnual Inspection ❑ Complaint Inspection ❑ Consultation Inspection ❑ Re-Inspection _ #Units in Facility: 17,Z # Units Inspected: T 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. Heating: Lack of approved heating in each unit;Approved heater not maintained in a safe, F-1 3. 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). ❑ 5 Bedding: 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. ❑ 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 I ICI ❑ 10. of or inadequate smoke detectors or fire extinguishers; Inadequate lighting; Inadequate protection from weather; Inadequate sewage or water facilities. Pest control Used? es ❑ No Company Name: Frequency: Hotel/Motel Business License? XYes ❑ No Multi-Jurisdictional Violations to be Referred to: ❑ City Building/Code Enforcement/Fire❑ County Code Enforcement/Fire❑ Other Rooms inspected: V I v 7 11 If 1 21 1 -2-3 7 13 , Zf y' I S' 3 11 3 1Z 31 Comments: 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. Received By: Title 111,16"1 IHS{.�" s _ Environmental Health Specialist: Phone: _3 y z Page 1 of EHD 24-01 4-30-12 HOTEL/MOTEL OIR