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Facility Name Address City Zip Code Lodi Micro Clinic 755 s. fairmont avenue a-2 Lodi 95240 Name of Perm it/Registration Holder Permit Exp. Date Time In Time Out Inspection Type Romaldo Rodriguez Initial consult. The above facility is inspected for compliance with Division 104, Part 15, Chapter 7 of California Health and Safety Code (HSC). V = Violation C = Corrected On Site V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION (cont.) C ❑ 1 Autoclave: approved and effective - passed integrator ❑ ❑ 22 Parts replaced between clients - grommets, elastic bands, test etc. ❑ 2. Items washed, disinfected, packaged, labeled, and sterilized E]I Body Art Inspe co Report • ✓ ��` �o l g ❑ 3. Date: Q San Joaquin County Environmental Health Department Program E]❑ 1868 E. Hazelton Ave., Stockton, CA 95205 Record: SR60 7 $ gam% c a `•4�/" �;, (209) 468-3420 www.sioqv.org/ehd Program IO3Element: Facility Name Address City Zip Code Lodi Micro Clinic 755 s. fairmont avenue a-2 Lodi 95240 Name of Perm it/Registration Holder Permit Exp. Date Time In Time Out Inspection Type Romaldo Rodriguez Initial consult. The above facility is inspected for compliance with Division 104, Part 15, Chapter 7 of California Health and Safety Code (HSC). V = Violation C = Corrected On Site V CLEANING AND STERILIZATION C V MACHINE SAFETY AND SANITATION (cont.) C ❑ 1 Autoclave: approved and effective - passed integrator ❑ ❑ 22 Parts replaced between clients - grommets, elastic bands, test etc. ❑ 2. Items washed, disinfected, packaged, labeled, and sterilized E]I PREVENTING CROSS -CONTAMINATION ❑ 3. Autoclave loaded correctly/packages allowed to dry❑ ❑ 23. Workstation/procedure area decontaminated E]❑ 4. Integrators used/monthly spore test/log maintained El [:1 24. Appropriate chemical disinfectant used El 5. Decontamination/sanitation area separated and supplied appropriately 11 Chemical used: Sani-Cloth, Babricide ® 6. Invoices and log kept for disposable, pre -sterilized equipment El 25. Disinfectant used appropriately/sufficient contact time ❑ ® 7• Sharps containers labeled, used, and disposed of appropriately El ❑ Wet contact time provided: 2 mins, 10 mins ❑ 8' Jewelry, tattoo and piercing equipment - clean and sterilized El El 26. Barriers used ❑ PRACTITIONER HEALTH AND HYGIENE ❑ 27' Products applied to skin are single use/dispensed aseptically El 9. No eating, drinking or smoking - clean clothes El [1 28. Storage of inks, pigments, needles, tubes, etc. El El Hands washed effectively and timely ❑ ❑ 29. Jewelry, Inks, Needles etc approved and used correctly ❑ ❑ 11. Handwashing facilities properly supplied and accessible, warm water ❑ ❑ 30. Cross -contamination avoided during all phases of procedure ❑ ❑ 12. Hepatitis B vaccination ❑ BEST BUSINESS PRACTICES ❑ 13. Bloodborne Pathogen training ❑ ❑ 31. Areas separated/no living or sleeping quarters ❑ Source: BOdy Art Training Group ❑ 32. Floors and walls clean and in good repair, adequate light ❑ 14. Appropriate personal protective equipment available and used ❑ El 33. Workstation, surfaces, including chairs, armrests, etc. in good repair El❑ CUSTOMERS/CLIENTS ❑ 34. Permit/registration posted ❑ ❑ 15. Branding is completed with no other customers in procedure area [E31 ❑ 35. Operation and employee training records present ❑ El 16. Customers eighteen (18) years of age or older COMPLIANCE AND ENFORCEMENT ❑ 17. Skin adequately prepared for procedure ❑ ❑ 36. Plan(s) submitted for review ❑ ® 18. Client records approved and available - Consent form and questionnaire [-I El37. Permits obtained and available ❑ ® 19. Appropriate aftercare instructions given to client ❑ ❑ 38. Impoundment ❑ MACHINE SAFETY AND SANITATION ❑ 39. Hearing scheduled ❑ ❑ 20. Safe machine design ❑ ❑ 40. Closure ❑ ❑ 21. Machines cleaned and disinfected between clients ❑ ❑ 41. ❑ Received b (Print): Romaldo Rodriguez Received b (Signature): Phone: (209) 327 - 4435 Specialist (Print): Harprit Mattu Sr REHS Specialist (Signature): Phone: 209 468-3284 Reinspecion on/about: A reinspection fee of $152 per hour may be charged. Page 1 of 2 EH -11/17