Loading...
HomeMy WebLinkAboutMINUTES - 08171999 - C44 CLAM BUARD AM August17, 1999 Claim Against the CoEmty, or District Governed by 3 the Board of Supervisors, Rming Endorsements, NOTICE TO CLAIMANT and Buard Action. All Section Werences are to ) The copy of this docu ant mailed to you is your California Governamnt Codes. notice of the action taken an your claim by the Board of Supervisors. {Paragraph 1V belowl, given .. r pursuant to Goverment Cade Section 913 and . u s 915.4. Please mote all "Warnings". AMOUNT: $100,000.00 CLAIMAI-r: A°T.den Abusafa en d :w 4a� O? F, ATTOPLNEY: c/o Melissa Abusafieh DATE RECEr'1sFb►: July 12, 1999 420 Grangnelli Avenue, #11 ADDRESS: Antioch CA 94509 BY DELIVERY TO CLERK ON: - July 1Z. 1999 BY MAIL POSTMARKED: Per Transr ittal I. FROAL Clerk of the Board of Supervisors Tt}: County Counsel Attached is a copy of the above-noted claim. PIRL BATCx°=H<� Ef.LOR.' Cle`rX Dated: July 13 1999 By: Deputy IL FROMCounty Counsel 10Clerk of the Board of Supervism (` } This claim complies substantially with Sections 910 and 910.2. J ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant.. The Board cannot act for 15 days (Section +910.8). ( ) Claire is not timely filed. The Clerk should return claim on ground that it was filed late and send warnirg A claimant's right to apply for leave to present a late claire (Section 911.3). ( ) Other: Dated: $y�% � n�: . � per' County Counsel £ r f v rf IL FROH Clerk of the Board "unty Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARDS ORDFI'ts By unanimous vete of the Supervisors present: This Claire is rejected in full. Other: I certify that this is a true and correct copy of the Board's Carder entered in its minutes for this date. Dated: Z L BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 13) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mil to file a court action on this claim. See Government Cade Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF 14fAIMG I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18, and that today I deposited in the United States Postal Service in Martinez„ California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Datek / By: PHIL BATCFMLOR By `� Deputy Clerk CC. Cotrtty Counsel County Administmtnr NOTICE OF CLAIM AGAINST THE A^ �; , HI , CALI ORNIA (G ernment Cade ss 91.0, 930. 2) Return to: MEWED City Clerk's Office City of Pittsburg JUL1999 2020 Railroad Avenue � Post Office Box 1538 —FE P ,tS�RIZ Pittsburg, California 9421)�RA Q STA pf Phone Number: CLAIMANT NAME: CLAIMANT'S ADDRESS: 16-1-a Number Street - C City State . Zip Code NAME AND ADDRESS OF PERSON TO WHOM NOTICES REGARDING THIS CL4IX SHOULD BE SENT (if different than above) : DATE OF THE ACCIDENT OR OCCURENCE: - - ' PLACE OF THE ACCIDENT OR OCCURENCE. { ' GENERAL DESCRIPTION OF THE ACCIDENT OR OCCURENCE (attach additional pages if more space is needed) : w r V.r,-? �, 61 4—A .. ✓ / a/ n a , NAMES, W3 O P C �P�YE� CADSIN TH �NIURY A OR SS: y` .y...�... � `4 .fit .. : ,�� ..� _ - �.y ¢ - .w � r lrl 6A+A` .�'";-e tb`Nf.-#.n F''..' L. "1. .+r'*> +°s ,p &-­4e,. . r e;,-., w, 1RWITNESSES: NAMES AN`D A } ESS OF WITNESSES: 7`"' xT•f/E L" �s d€ t`.' � y. gy "" � ��� ����'Q.rnrro �.i d''�''s�`�$ NAME ADDRESS , ` .; TELEPHONE 2 . _4_ �� NAME AND ADDRESS OF DOCTORS, HOSPITALS WHERE TREATED: NAME ADDRESS TELEPHONE i a b — Stead Y»✓ 9 [ � 5✓K..5 3' � 4.Adf";i% !2i4.8 F .v' Y.J' � A' 'L ...r 2. GENERAL DESCRIPTION OF 'THE LOSS, INJURY OR DAMGAGE SUFFERED: r. _t U,6 ',-� te a ° TOTAL AMOUNT CLAIMED: t THE BASIS OF COMPUTING THE TOTAL AMOUNT CLAIMED IS AS FOLLOWS: Damages incurred to date* Medical Expenses: $ ,.- Loss of Earnings: Special damages for: (Attach copies Ifavailable) I/We, the undersigned, declare under penalty of perjury that I/we have read the foregoing claim for damages and know the contents thereof, that the same is true of my/our own knowledge and belief, save and except as to those matters wherein stated on information and belief, and as to them, I/we believe it to be true. h DATED: Signature Airf CIa want( ) Received in the City Clerk's Office this day of Signature FOR CLAIMS RELATED TO INJURY TO PERSON OR PERSONAL PROPERTY, THIS FORM MUST BE FILED WITH THE CITY OF PITTSBURG WITHIN SIX MONTHS FROM THE ACCRUAL OF THE CAUSE OF ACTION. A CLAIM RELATED TO ANY OTHER CAUSE OF ACTION SHALL BE PRESENTED NO LATER THAN ONE ,YEAR AFTER ACCRUAL OF THE , CAUSE OF ACTION. ......................................................................_... ....................... ......... ......... ......... ......... ............. _. .......... ....... .. ....... ......... ......... ......... ......... ... ......_. ......... ......... ......... ......... ......... ......... ........._ ...... ............... ... ......... _....... CLAIM II 10ARQ-ACTIGII AI 115T17, 1999 Claim Against the County, or District Governed by } ft Board of Supervisors, Routing Endorserrents, } NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of tNs dDcunent riled to you is your California Government Cees. 1 notice of the action taken on your claim by the Board of Supervisors. {Paragraph IV belov4, given pursuant to Goverweni Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $^E 000 000 fiery rY CLAIMANT: Zachary Baca z ATMC3RNEY: Daniel A. Grout DATE RECEIVED: July 22, 1999 Attorney at Law ADDRESS: Taylor & Grout BY DELIVERY TO CLERK. ON: July 22, 1999 -- 458 Seventh Street Oakland CA 94607 BY MAILPOSTMARKED. land-delivered L FRC3AL Clerk of the Board of Supervisors T(> County Counsel Attached is a copy of the above-noted claim. PHIL BA Clerk 117 Dated: July 23, 1999 By: Deputy nit, � IL FROX County Counsel TO: Clerk of the Board of Supervisors This claire complies substantially with Sections 910 and 910.2. ' his claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). { ) Other: �k Dated. i x ! plie By: � ' pCou ' my Counsel . ., a 13L FR03&- Clerk of tie Board TO,. County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). TV, ;BOARD ORDDL By unanimous vote of the Supervisors present. 'This Claim is rejected in full. ( } Other: - --------- I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:_ 9L&&f � PHIL BATCHELOR, Clerk, By �� � Deputy Clerk WARNING (Gov. cede sectio 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF 1KAUX9G I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 19; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. �, Bated: �� � � � ` By: PHIL BATCHELOR Bya�;.� "�,��` 'Deputy Clerk CC_ Canty Cim=tl County Admsnistrmtor john L. Taylor (S .B. No. 39432) Daniel A. Grout (S .B. No. 168282) TAYLOR & GROUT � 456 Seventh Street k Jul- 1,999 Oakland, California 94607 Telephone: (510) 893-9800 Facsimile: (510) 893-9820 STATE OF CALIFORNIA CLAIM FOR DAMAGES (Gcv. Cade 5 905 et seq.) In the Matter of the VIOLATION OF CIVIL RIGHTS Claim of Zachary Baca AND OTHER TORTS, INCLUDING BUT NOT LIMITER TO: VIOLATION OF CIVIL RIGHTS UNDER. VS . CALIFORNIA AND U.S . CONSTITUTIONS; BATTERY; County of Contra Costa, ASSAULT; NEGLIGENCE; NEGLIGENT HIRING, TRAINING AND RETEN'T'ION; NEGLIGENT INFLICTION OF EMOTIONAL DISTRESS; INTENTIONAL Respondents INFLICTION OF EMOTIONAL ;I STRESS i . NAME OF CLAIMANT: Zachary Baca. CLAIMANT'S ADDRESS AND PHONE NUMBER: 4510 Melody Drive, Suite 20, Concord, CA 94520; 925 363-7884 . } l t t 1 ! 1 ADDRESS AND PHONE NUMBER FOR OFFICIAL COMMUNICATION: Daniel A. Grout TAYLOR & GROUT 458 Seventh Street Oakland, California 94607 Telephone: (510) 893-9800 Facsimile : (510) 893-9820 CLAIMANT'S DATE OF BIRTH: March 26, 1981 . CLAIMANT'S SOCIAL SECURITY NUMBER: 565-65-0147 2 . DAMAGES CLAIMED: a. General damages : $1, 000, 000 . 00 or as proven; b. Special damages : 1 . Medical care : Hospitalization and other medical treatment . Dollar amount unmown to claimant at this time. 2 . Future cost of vocational training: As proven. 3 . Future cost of in-home services : As proven. 4 . Lass of earning capacity: As proven. 5 . Future cost of Education Services : As proven. C . Costa of suit; d. Attorney' s fees; e. Additional relief as is fair and equitable. 3 . DATE, TIME, AND PLACE OF INJURY: February 5, 1999, Juvenile Hall, Martinez, Contra Costa County, California. 2 4 . THE CIRCUMSTANCES OF THE DAMAGE OR INJURY: Claimant was at all relevant times a juvenile in- custody resident of Juvenile Hall, Martinez, Contra Costa County, California and thereby in a special relationship with Respondents . Claimant was injured on February 5, 1.999 when he was negligently, maliciously, and unjustifiably assaulted, beaten, and restrained by employees of Resnonden't . As a direct and proximate result of the wrongful acts and omissions of Respondent, Claimant suffered severe physical injuries, severe emotional injuries, injuries to his well-being, and interference with his education, employment and financial well-being. Respondents further unreasonably failed to provide prompt and/or adequate medical care for Claimant, instead unreasonably and maliciously conspiring to cover-up and to prevent from disclosure Respondents' unreasonable, wrongful-, and tortious conduct against Claimant, by acts and omissions including, without limitation, making knowingly false statements and Reports concerning the incident . Each of the wrongful acts and omissions of Respondents caused physical injury, financial injury,injury, and general damage to Claimant . 3 Claimant reserves the right to allege additional responsible parties and additional facts relating to said occurrences when such additional facts and parties become known to Claimant . 5 . WHY DO YOU CLAIM CONTRA COSTA COUNTY IS RESPONSIBLE? Contra Costa County is vicariously liable for any and all of the wrongful acts and omissions of those individuals who directly caused Claimant' s injuries. Said individuals knowingly and intentionally, alternatively negligently, violated Claimant' s civil rights, subjected Claimant to cruel and unusual punishment, assaulted and battered Claimant, and intentionally and/or unreasonably deprived Claimant of medical care. Respondent County was negligent toward Claimant . The negligent and intentional acts and omissions of Respondents and their agents and employees were the cause of plaint-;'_ff' s injuries as -follows, without limitation: a. Respondents at all relevant times owed a duty to Claimant, based upon a special relationship, to take all reasonable steps to protect Claimant against known or foreseeable risks of harm. b. Respondents unreasonably failed to provide adequate medical assistance for Claimant . 4 C. Respondents intentionally caused Claimant to suffer extreme emotional distress. d. Respondents negligently caused Claimant to suffer extreme emotional distress . e. Respondents unreasonably failed to supervise adequately plaintiff to protect him from injury of the type incurred. f . Respondents unreasonably failed to supervise adequately in-custody residents other than Claimant to protect Claimant from injury of the type incurred. 9- Respondents unreasonably hired, trained and supervised Respondents' agents and employees . h. Respondents unreasonably failed to implement and/or maintain adequate administrative policies and procedures . 4 . Respondents unreasonably failed to '-Follow and/or adhere to Respondents, own administrative policies and procedures. j . Respondents unreasonably and maliciously made false representations concerning Claimant; and such actions were taken in order to prevent Claimant and others from learning of Respondents' own wrongful and tortious acts and omissions, in callous disregard of Claimant' s rights and all 5 to Claimant' s detriment . k. Respondents unreasonably and maliciously took retaliatory disciplinary action against Claimant, with actual and/or constructive knowledge that said disciplinary actions were unwarranted, inappropriate, and harmful to Claimant . M. Each of the foregoing acts and omissions of Respondents caused Claimant to suffer injuries as set forth herein. The foregoing allegations are asserted without limitation, as additional facts, responsible parties and/or theories of liability may be unknown to Claimant at this time . Claimant reserves the right to allege additional facts, responsible parties, and/or theories of liability relating to the occurrences alleged herein at a later time, according to proof . 5 . NAMES OF ANY CONTRA COSTA COUNTY JUVENILE HALL EMPLOYEES (AND THEIR DEPARTMENT) INVOLVED INJURY OR DAMAGES (IF APPLICABLE) . The names of the publi reserves the but unknown to Claimant at this time. Claimant �r right to amend this claim to insert the names of other Respondents named as DOE Respondents herein, once the true names and capacities of same become known to Claimant . 7 . WITNESSES TO DAMAGE OR INJURY: Unknown to Claimant at this time. 8 . LIST DAMAGES INCURRED TO DATE-. Claimant Zachary Baca has suffered and continues to suffer severe physical, mental, and emotional injuries, as well as financial damages . The exact nature and amount of Claimant' s damages are generally known to Respondent but unknown to Claimant at this time. In addition, Claimant will suffer damages in the future of a nature and in amounts as yet unknown. Pursuant to Goy-Qr=nt Code §910 . 6, Claimant reserves the right to amend this claim... WHEREFORE, Claimant requests relief of monetary damages of not less than $1, 000, 000 . 00, or according to proof . Respectfully submitted, Date : TAYLOR & GROUT DANIEL A. GROUT Attorney for Claimant 7 CLAIM BQAID OF SIS Its' QM C)F C''C2MA -C'O TA -M=- C I,TF'[1► hrtA BOARD ACTIASST 17, '1999 Claim Against the County, or District Governed by l the Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of teas document railed to you is your California Governrnent Codes. m a w Notice of the action taken on your claim by the Board of Supervisors. {Paragraph 1V beloW, given x; pursuant to Government Code Section 913 and 915.4. Kase note all *Warnings". AMOUNT: In Excess of $10,000.00 CLAIMANT: East Contra Costa Irrigation District ATTORNEY: Robert H. Greenfield DATE RECEIVED: July 20, 1999 c/o Robert H, . Greenfield 402! Jul 20 1999 ADDRESS: 4120 Cam Park Drive, Ste. BY DELri�ERY To CLERK ON: Y ' Cameron Park, CA 95682 July 19, 1999 BY MAIL POSTMARKED: L FRO;NL° Clerk of the Board of Supervisors T(> County Counsel Attached is a copy of the above-noted claim. Jul 20 1999 �LOR, Clerk r PHIL BAT Dated: s Y , $y. Deputy II. PRAM: County Counsel Tt3: Clerk of the Board of Supervisors r" ( 3 This claim complies substantially with Sections 910 and 910.2. ( ) This claire PAILS to comply substantially with Section4 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). } Claire is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) tither: Dated: 13y. aunty Counsel y III. FROn- Clerk of the Beard TO.- County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDEEL By unanimous vote of the Supervisors present: ( This Claim is rejected in full. { } Other: I certify that this is a true and coo rect copy of the Board's Order entered in its minutes for this date. Dated: 1 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov, code section 13) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the trail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVff OF MAII.ING I declare under penalty of perjury that I ate now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: ' By: PHIL BATCHELOR Bputt' Clerk CC: County Counsel County Administrator ROBERT H.GREENFSELD GREENFIELD OF'COUNSEL SUSANNAV.PU,- N iEFFERYMI.JONES,P.C. ANGELA M.CASAGRANDA LAW F THOTAS D.PHI:ZR'S IRM July 19, 1999 RECEIVED7 �9j �� 42, CULN3OARD OF S � Gv Clerk of the Board of Supervisors County Administration Building 651 Pine Street, Room 106 Martinez, CA 94553 Re: Claim of East Contra Costa Irrigation District for Equitable Indemnity Dear Clerk: Enclosed please find an original and two copies of a claim against the Contra Costa Flood Control District. Please file the original and return a conformed copy in the enclosed self- addressed, stamped envelope. Thank you for your courtesy and prompt attention to this matter. If you have any questions,please do not hesitate to contact the undersigned. Very truly yours, 0 ,f Geina L. Crook :gc Enclosures G:/RHG Defense.!Larrur✓Enclosure It for Equitable:ndernnity 4120 CAMERoNPARK DRIvE,siJrm 402tt',.4MERt7NPARK,CAI.IFoRNIA 95682+TELEPHoNF:530.672.5770*FACSLIV=:530.672-5773 WRITER'S DIRECT E-MAIL:rgreenfield r�clarectcon.net Gauss to. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY Ms 3205 TO CLAl'iKMI A. Claims relating to causes of action for death or for injury to puson or to personal property or growing crops and which accrue an or before Deminber 31, 1987, most be presented not later than the 1006 day after the accrual of the cause or action. Claims relating to causes of action for death or for injury to person or to personal property-or growing crops and which Accrue on or after January 1, 1"8, trust he presented not later than six months after the accrual of the cause of action. Claims relating to any otter cause of action trust be presented not tater than one year,after the accrual of the cause of action. (Covt.Corte§911.2.) B. Claims must be fled with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,651 Pine Street,,Martinez,CA 945513. C. If Claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be(tiled in. D. if the claims is against more than one public entity,separate claims must be fled against each public entity. L LrAd. See penalty for fraudulent claims, Penal Code Sec.72 at the end of this form. RE; Claire by ) Reserved for Clerk's Filing Stamp EASE` CONT STA I. R UA Jnr ) DISTRICT Against the County of Contra Costa and/ or CONTRA COSTA. ELCt3D CONTROL DISTRICT District) � (Hill in Name) The undersigned claimant hereby makes claire against the County of Contra Costa or the above nained District in t1wmw#M-and in support of this claim represents as follows: excess of $101,000.00 L When did the dorrtagae or injury occur? (cavo esaet Date wad m wr) SEE ATTACHED . ""---_- 2. Where did the damage or injury occur? t Yndude City.na Courcy} _................... a SEE ATTACHED _-_____r_-___._..a_®_.......___._a-.............................. I Hort did the damage or injury occur? (Give 1a doraft use extra p:per lrregWM) .............................. ----------------- ............ d. What particular act or omission on the part of county or district officers, servants, or employees caused the Injury or damage? SEE ATTACHED (Over) Eo/told !CW AS16 AiD diSCC U6iNCC SZ.ZT 666I-6T--Inf S. 'hat are the names of county or district officers,servauts,or employees causing the damage or injury? .......................L-31.1 1H S _ZlyF ..._.,.,_._...a.____.._............................. What daneages or injuries do you-claim msulted* (Give tilt*%teat orinjt,ries ordanutgat tkimedi. An&cih t"vsKn=t=for arta tl+wttr�.� ------------------------------------------- T, Hoyt'was the above chimed amount computed? {rndude tru atln,atW amount or any grospeetdve Injury or danar p.? SEE ATTACHED S. Names and addresses of witnesses,doctors.send hospitals._ .............................. .....:._____ -- .ATTAQU.Z......................_......._..b_._.,._._....., .-----_..___._-- 9. Ust the expenditures You made on account of Ws accident or injury:. 'A.MC7�rT�T NOT APPLICABLE AT THIS TIME !8 YeltYa 8e at9r # # atia ,t me Areltl0' l, rc 1tr[ aEtewi� k1! * w rrit•lcae * re ,e * ib rc rr * fry: ,tskk # rr !lttryefr. .. Ctrs, Code Ser- 410.2 provides- "The claim roust be signed by the claimant SEND NOTICES TO. (Attorney) or by sonic person on his behalf:" s >� Name and Address of Attorney S4 t._ ,>GREENFIELD s :SAW FIR�4 41,20 Cameron Park Drive, Ste.402 (Claimant's Signature Cameron Park, CA 95582 ;3 (Address) Telephonc No. (5 3 C). 672—5770 Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who,With intent to defraud,presents for allowance or for payment to any state board or officer,or to any county,city or district board or oiflw,authorized to allow or pay the same V genuine,any false or fraradW=t claim,bill,account,voucher,or writing,is punishable ether by imprisonment in the county j 'I for a period of not more than one year, by a flue of not exceeding one thousand dollars (51,000),or by boor such imprisonment and fine.or by imprisonment in the state prison,by a fine of not exceeding tete thousand dollars(S10,000}, or by both such imprisonment and firm. i / cf i0w ?i6ta AiD HIS0:3 u8iNoo 9?cZT 666,-6T--?nr I l I Robert H. Greenfield, SBN 114500 Susanna V. Pullen, SBN 188194 2 GREENFIELD LAW FIRM 4120 Cameron Park Drive, Suite 402 3 Cameron Park, CA 95682 Telephone: (530) 672-5770 4 Facsimile: ( 30) 672-5778 5 Attorneys for EAST CONTRA COSTA IRRIGATION DISTRICT 6 7 Claim Of: CLAIM FOR EQUITABLE INDEMNITY 8 EAST CONTRA COSTA IRRIGATION 9 DISTRICT 10 11 l / 12 I 13 , TO THE BOARD OF DIRECTORS AND/OR THE GOVERNING BODY OF CONTRA 14 ' COSTA FLOOD CONTROL DISTRICT: 15 You are hereby notified that East Contra Cost Irrigation District("Claimant'), located at 16 ; 626 First Street, Brentwood, California, 94513-0696, submits this claim for equitable indemnity 17 against CONTRA COSTA FLOOD CONTROL DISTRICT. 16 On or about September 8, 1998, Willis and Sharon Lamm filed a complaint for 19 damages, Action No. C98-03774 in the Superior Court, County of Contra Costa, agains 20 Claimant East Contra Costa Irrigation District. The complaint was served on Claimant on o 21 about October 10, 1998. 22 On or about November 12, 1998, the County of Contra Costa filed a complaint for 23 equitable indemnity, Action No. C98-3774 in the Superior Court, County of Contra Costa, 24 against Claimant East Contra Costa Irrigation District. The complaint was served on Claiman 25 on February 9, 1999. 26 On or about January 19, 1999, Art Boyce, Patricia Boyce, William Martin, P. Gail Martin,( E 27 Walter Antoniazzi, Diane Antoniazzi, Marcia Hoyt, Roger Cottle, Linda Morse, and Richard 28 Robertson filed a complaint for damages, Action No. C99-00182 in the Superior Court, Count Claim for Equitable indemnity- 1 i _ f of Contra Costa against Claimant East Contra Costa Irrigation District. The complaint was 2 I served on Claimant on February 16, 1999. On or about March 4, 1999, the County of Contra Costa filed a complaint for equitable i 4 indemnity, Action No. C99-00182 in the Superior Court, County of Contra Costa, against Claimant East Contra Costa Irrigation District. The complaint was served on Claimant on i 6 March 4, 1999. 7 ; The facts underlining these complaints for damages and equitable indemnity are the 8 same. The actions are based on damages to the individual Complainants' property as the i 9 ! result of flooding that occurred on or about February 2, 1998 in the Knightsen Triangle Area o 10 = the County of Contra Costa. _ 19 € Claimant is informed and believes that CONTRA COSTA FLOOD CONTROL DISTRICT € 12 and its agents are responsible, in whole or in part, for the injuries, if any, suffered by Plaintiff 13 and Contra Costa County by virtue of their ownership, control and maintenance of aqueducts, 14 pumps, drains, drainage systems, ditches, culverts under roads, railroads and driveways, 15 drainage pipes and/or other water transmission and/or water facilities in or around the 16 Knightsen Triangle Area as well as any acts or omissions associated therewith. Claimant i 17 also informed and believes that CONTRA COSTA FLOOD CONTROL DISTRICT failed t 18 initiate proper flood control measures in or around the Knightsen Triangle Area. 19 '= By reason of CONTRA COSTA FLOOD CONTROL DISTRICT's conduct, it owes a duty 20 !of equitable indemnification to Claimant for the amount of any judgment or settlement in favor 29 of Plaintiffs' against the Claimant. Claimant contends it is not liable for the events and 22 occurrences described by Complainants in the above-entitled actions. 23 The damages claimed as of the date of presentation of this claim exceed $10,000 24 Jurisdiction of this claim rests in the Superior Court. Please send notices to Greenfield LaVV 25 Firm at the above address. 26 DATED; July 19, 1999 9FZf ENFIELD LAW FIR 27 28 ? R BERT A. G ENFIE € Attorney for EAST CONTRA COSTA IRRIGATION DIS RICT _ i Claim for Equitable Indemnity-2 i 4 W Lai 0 (D > �-, to !!AA per} pq VS r7 :�p > •1 p3 SV Y� V Yit' Ln y d 4c + r r `r:s. C 5 Cw p # Ul Ln Lo toIlk 'r1 ,C7 • LrY s- 14 C) `'sem k c� .a> CLA-M QARD QEI '1 ��`tZR C�QNTRA COSTA ?IzTIM LT RTt'T� BO�CT1 Q August 17, 1999 Claim Against the County, or District Governed by ) the Board Of Supervisors, Routing Endorsemants, ) NOVICE T'0 CLAIMANT and Board Action. All Section references, J .� The copy of this document mailed to you is your California Government Codes. w notice of the action taken on your claim by the Board of Supervisors. tParagraph IV belovO, liven pursuant to Government Code Section 913 and 915.4. please rote all "Warnings". Ni ri AMOUNT: In Excess of $10,000.00 CLAIMANT: Janice Harris ATTORNEY: c/o Merrill C. Haber DATE RECEIVED: July 12, 1999 Haber & Slljepcevich. ADDRESS: 505 Beach Street, Ste. 224 BY DELIVERY TO CLERK C>?�T: July 12, 199° San Francisco, CA 94133 Jul 10, 1999 BY MAIL POSTMARKED: L FRONE Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claire. PHIL BAT �FMLOR, Clerk Dated: July 13, 1999 $y: Deputy . ,.. II. FROM: County Counsel M. Clerk of the Board of Supervisors ( ) This claire complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: ` R a Dated: '_ f By Deputy County Counsel VT V 11LC) Clem of the Board 'I`t3: Gravnty Counsel (1) County Administrator (2) was returned as untimely with�a c'a to claimant (Section 911.3). IV. BOARD 0RDEft: By unanimous vote of the Supervisors present: This Claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PML BATCHELOR, Cleric, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claire. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. DAVIT OF MAIIJNG I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. 01 Dated: ' " f— r By: PIgL BATCHELOR BygZ::LL Deputy Clerk CC: County Counsel County Administrator =TOR J.WESTPAAN DEPUTIES: PHILLIP S.ALTHOFF i.. iba Y 'i..' �3TL. JAN;CEL AMENTA NORA G.BARLOW B.REBECCA BYRNES SILVANO S.MARCHES! tai ANDREA W.CASSIDY CH IEE ASSISTANT COUNTY COUNSEL OFFICE- �✓O T99A �„y�+d�/�T EY CC MCNIKAL.COOPER ®i—� V: OF A �'7iI4 tJ L4.fLifl G MARIK L.ESTI S MARKS S.ESTIS SHARON L.ANDERSONMICHAEL D.,ARR fJiN,iS''RATsICJit: LT{,s71 G :. 4 LILLIANT FUJI: ASSISTANT COUNTY COUNSEL PI' !E.5t � ( OR DENNIS C.GRAVES JANETL HOLMES MA TI34� a t ��Q€� �tl r�36� 229 KEVI,vi KERR GREGORY 4/+,HARVEY BERNARD L.KNAPP ASSISTANT COUNTY COUNSEL EDWARD V.LANE,JR. SEX,.TRICE LBU MARY ANN MASON GAYLY MUGGL� PAUL R MCMV JrF"E MANAGER VAL ERIE J.RANCHE STEVEN R.RETTiG DAVID F.SCHV,16T PHONE(925)335-1800 DIANA.S RR VVE'��TLIFFE FAX(925)646-11378 JACCUELINEYWOODS NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Merrill C. Haber, Esq. Haber& Slijepcevich 505 Beach Street, Suite 224 San Francisco, CA 94133 RE: CLAIM OF: Janice Harris Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ ] L The claim fails to state the name and post office address of the claimant. ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ j 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ 14. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known, j 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000),the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [ j 6. The claim is not signed by the claimant or by some person on his behalf. Page [X 7. Other: The claim fails to describe any duty or obligation of the public entity and any action giving rise to the claim. **** The Contra Costa County Board of Supervisors is not the proper body for assertions of claims against Central Contra Costa Transit Authority. **** VICTOR.J. WESTMANI, County Counsel By: r v- eputy Count ( OU6 CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 1013a,2015.5;Evidence Code§§ 641,664) 1 declare that my business address is the County Counsel's Office of Contra Costa County,651 Pine Street,Martinez,California 94553;1 am a citizen of the United States,over 18 years of age,employed in Contra Costa County, and not a party to this action. 1 served a true copy of this Notice of insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. 1 certify under penalty of perjury that the foregoing is true and correct. Dated: July 13, 1999,at Martinez,California. cc: Cleric of the Board of Supervisors(original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,910.8) Page 2 HABER&SLIJEPCEVICH 505 BEACH STREET,SUITE 224 SAN FRANCISCO,CA 94133 415474-6211 Fax:415 474-75$4 RECEIVED JL July 8, 1999 Clerk Of the Beard of Supervisors Room 146 County Administration Building 651 Pine Street Martinez, CA 94553 Re: Harris vs. CCCTA To Whom It May Concern: Enclosed please find completed Claim Forms for my clients, Walter John Harris and Janice Harris against the Central Contra Costa Transit Authority. Please file and return file-stamped copies to me at the above address. A self addressed stamped envelope is enclosed. Thank you for your assistance. Sincerely, Merrill C. Haber 4 Claim to: BOAR'S OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRU ()N TO A. Claims relating to caws of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100* day after the accrual of the cause of actions Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988,must be presented not latter than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not latter than one year after the accrual of the cause of action. (Govt.Code§911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,551 Pine Street,Martinez,CA 94551 C. N Claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity,separate claims must he filed against each public entity. F. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this forst. RE: Claim by "anJ ce Harris ) Reserved for Clerk's Filing Stamp 3 RECEIVED a Against the County of Contra Costai JUL � 1999 or 1RK 6 p DO CON'rRA 00 CO ° Central Contra Costa Transit Authority District) (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Crista or the above named District in the surra of S and in support of this claim represents as follows: Claim is over $10,000.00. Jurisdiction lies in Superior Court 1. When did the damage or injury occur? (Give exact Date and Hour) 5/93-6/99 ------------------------------------------------------------------------------------- 2> Where did the damage or injury occur.? (Include City and County) Concord California ------------------------------------------------------------------------------------- 3. How did the damage or injury occur? (Give full deta"-use extra gaper of required) Claimant was sub,, ected to Sexual 'Harassraent, Sexual discrimination, defamation, retaliatic marital discrimination and constructively discharged. 4. a What particular acct or omission on the part of county or district officers, servants, or employees caused the injury or damage? See number 3 above. Over) S. What are the names of county or district officers,servants,or employees causing the damage or injury? Rick Ramacier, Cobert Patrick (former General Manager)Tom. Brush(Former Employee. 6. What damages or injuries do you claim resulted" (Give full extent of injuries or damages claimed. Attach two esametes for sato damage.) Lost wages, emotional distress, attorneys fees. Medical Expenses 6_ - How was the above amount computed? (include the estimated amount of any prospective injury or damage.; --_ 7. s Amounte is not computed. Damages are ongoing 8. Names and addresses of witnesses,doctors,and hospitals, N/A-- There are numberous witnesses, including those named above. 90 _List the eWnditurr- you made on account of this accident or injury. DATE MEMA AMOUNT Not calculated to date, sa �ean ,eaaeaa aca tsa * a a: * at * ,e * ,t * a >< to * a sae ,e ac * aea # n Gov. Code Sec.910.2 provides: "The claim roust be signed by the claimant SENA NOTICES TO: (Attorney) or by some person on his behalf..." Name and Address of Attorney -�- Merrill Co Haber > Attorney For ;anice Harris Haller & Slid epcevich (Claimant's Signature) 505 Beach Street, She 224 San Fra:�ncisco, CA 94133 05 Beach Street, Ste 224, San Francisco CA 94133 (Address) TelephoneNo. 415 474 6211 Telephone No.415 474 6211 NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or for payment to any state hoard or officer,ler to any county, city or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account,voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand dollars(S1A00 ),or by bath such imprisonment and fine,or by imprisonment in the state prison,by a fide of not exceeding ten thousand dollars (S10,000}, or by berth such imprisonment and fine;. Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUC`I'It1 S 1Q- A. Q A. Claims relating to encases of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not latter that the 10e day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which acerae on or after January 1, 19S8, must be presented not later than six months after the accrual of the cause of.action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt.Code 4911.2.) B. Claims must be filed with the Clerk of the Berard of Supervisors at its office in Room 106, County Administration Building,651 Pine Street,Martinez,CA 94553. Ca If Claim is against a district governed by the Board of Supervisors, rather than: the County, the name of the District should be filled in. D. If the claim is against more than one public entity,separate claims trust be Bled against each public entity. L Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim by Janice Harris ) Rmrved for Clerk's piling Stamp RECEIVED Against the County of Contra Costa s orF 8080Fi Central Contra CostaTransit Authority District} (Fill in ?dame) The undersigned claimant Hereby makes claim against the County of Contra Costa or the above named District in the sum of S and in support of this claire represents as follows: Claim is over $1.0,000.00. Jurisdiction lies in Superior Court 1. When did the damage or injury occur." (Give exact Date and Hour) 5/93-6/99 ------------------------------------------------------------------------------------- 2. Where did the damage or injury occur." E Tnewde C4ty and C'aursty 3 Concord California ------------------------------------------------------------------------------------- 3. Rove did the damage or in jrtry occur? (Give ltztt detsiia,use extra paper Itmqutred) Clamant was sub;ected to Sexual Hara8S—Ment, Sexual discrimination, defamation, retaliatic marital discrimination and constructively discharged. 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? See number 3 above. (Over) i k Cfj � fir. Lon oc 0 4V o0cW COE { 4'Q cD cco tz a 0 0 10 10 CLAIM RD of S1TYJMS Q S QE cQNIRA STA-CQ=s r c A BOARD ACTIQI August 17, 1999 Claim Against the County, or District Governed by } the Berard of Supervisors, Flowing Endorsements, 1 NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV belovo,, given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: .Ln Excess of $10,000.00 CLAIMANT: Walter John Farris ATTORNEY: c/o Merrill. C. Haber BATE RECEIVED: July 12, 1999 Haber & Slijepcevich ADDRESS: 505 Beach St. , Ste. 224 BY DELIVERY TO CLERK. ON: July 12 1939 San Francisco CA 94133 BY MAIL POSTMARKED: July 10.L1999 L FROM: Clerk of the Board of Supervisors T`O. County Counsel Attached is a copy of the above-noted claire. PHIL BATCHELOR, Cler4 Dated: July 13, 1999 By: Deputy IL FRONT: County Counsel W. Clerk of the Board of Supervisors ( This claim complies substantially with Sections 910 and 910.2. (' This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated I3y;d : 1eputy County Counsel 5 f TIL TNI+ Clerk of the Board TLS.bounty Counsel (1) County Administrator (2) ( ) Maim was returned as untimely with notice to claimant (Section 911.3). BOARD ORDER.- By.unanimous vote of the Supervisors present: This Claim is rejected in full. ( ; Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, ByDeputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF I4IAL�G I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By: PHIL BATCHELOR By .Deputy Clerk CC: County Counsel County Administrator VICTOR J.WESTMAN COUNTY Y Cat € JANIC{E L A�UENTA NORA G.BARLOW B.REBECCA BYRNES ILoJAt C3 B.MARCHES! DY ONTRA COSTA STN ANDRE .W.COOPER OiVlKA L. S? CH PEF ASSISTANT COUNTY COUNSEL p� 3p� p COU t#� f► pp���+ VCCK;EL.0AWE$ 0FF14,.rE FT E 1 OUN 0UNSEL MAR KES EST$ SHAROW—ANDERSONx£33#riSt�#STRAF�t3'$U#Li{3:,'.. LILLIAN T.'UJ:{ ASSISTANT COUNTY COUNSEL �i � ��� �, � �� � DENNISC.GRAVES JANET L.HOLME.S MA�t'�WE4,, AJM FF ��"#229 KEV;NT-KERR GREGORY C.HARVEY BERNARD KNAPP ASSTS TANT COUNTY COUNSEL BEAAR^,V LANE,JR. EA:R;CE LiU MARY AVN MASON CAY v L': PAUL R.MUvIZ VALERIE J.RANCHE OFFICE MANAGER STEVEN r RETT;G DAVIC SCH Wr-, PHONE 1,925)435-1.9030 BARBARA{N.SUTL 4FFE FAX(525)645-1075 JACQUEL'NEYWOOOS NOTICE OF INSUFFICIENCY ANL?/OR NON-ACCEPTANCE OF CLAIM TO: Merrill C. Haber, Esq. Haber& Slijepcevich 505 Beach Street, Suite 224 San Francisco, CA 94133 RE: CLAIM OF: Walter John Harris Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ j I. The claim fails to state the name and post office address of the claimant. j 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ j 3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4, The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [ j 6. The claim is not signed by the claimant or by some person on his behalf: Page I LX 1 7. Other: The claire fails to describe any duty or obligation of the public entity and any action giving rise to the claim. **** The Contra Costa County Board of Supervisors is not the proper body for assertions of claims against Central Contra Costa Transit Authority. **** VICTOR J. WESTMANCounty Counsel By !z it tputy County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 1013a,2015.5;Evidence Code§§641,664) I declare that my business address is the County Counsel's Office of Contra Costa County,651 Pine Street,Martinez,California 94553;I am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Dated: July 13, 1999,at Martinez,California. cc: Clerk of the Board of Supervisors(original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,91,0.8) Page 2 HABER&SLI,tEPCEVICH 505 BEACH STREET,SUITE 224 SAN FRANCISCO,CA 94133 415474-6211 �+ y Fax:415 474-7684 RECEIVED JUL 12 1999 G1 ERK BOARD OF SUPERVIS0R5 r NTRA OSTA C July 8, 1999 Clerk Of the Board of Supervisors Room 106 County Administration Building 651 Pine Street Martiniez,CA 94553 Ike: Harris vs. CCCTA To Whom It May Concern: Enclosed please find completed.Claim Forms for my clients, Walter John Harris and Janice Harris against the Central Contra Costa Transit Authority. Please file and return file-stamped copies to me at the above address. A self addressed stamped envelope is enclosed. Thank you for your assistance. Sincerely, Merrill C. Haber a cn Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 1000' clay after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six mouths after the accrual of the cause of action. Claims relating to any other cause of action must be presented not Tater than one year after the accrual of the cause of action. (Govt. Code§911.2.) B. Claims trust be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,651 Pine Street,Martinez,CA 91553. C. If Claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity,separate claims must be Illed against each public entity. E. fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE.• Claim by ) Reserved for Clerk's Filing Stamp Walter John Barris 1i -- RECEIVED- Against the County of Contra Costa JUL 12 1999 or G"L ERIK BTARJ 0p SJr fRV1SCR5 Central Coi,tra Costa Transit Authority District --- - (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sum of S and in support of this claim represents as follows: Claim is over $10,000.00 Jurisdiction lies in Superior Court 1. When did the damage or injury occur? (Give exact Oate and Hour) 1/28/99 ------------------------------------------------------------------------------------- 2. Where slid the damage or injury occur,? (Include city and County) Concord CA, Contra Costa County -------------------------------------------------------------------------------------- 3. How did the damage or injury occur? (Give full details,use extra paper if required) Wrongful Termination based on discrimination and retaliation Defamation.. 4. What particular act ror omission on the part of county or district officers, servants, or employees caused the Injury or damage? Claimant was wrongfully terminated. by Rick Rama C4 Manager (Over) 5. What are the names of county or district officers,servants,or employees causing the damage or injury? Hick Ramacier ------------------------------------------------------------------------------------- 6. What damages or injuries do you Claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for aatodamage.) Lost Wages, emotional distress, attorneys fees , medical expenses 7-- . How was the above claimed amount computed" (Include the estimated amount of any prospective injury or damage.) Amount is uncomputed. Damages are on--going. ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses,doctors,and hospitals. N/A-- There are numerous witneses to the events leading to the termination. ------------------------------------------------------------------------------------- 9. List the expenditures you trade on account of this accident or injury. DATE ITEM AMOUNT Not calculated to date. Gov. Code Sec.910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney -- Merril' C. Haben ' Attorney for Walter John Harr3 Haber & Slij epcevich �f -0 505 Beach Street, Ste 2.24 (Claimant's Signature) San Francisco, CA 94133 505 Beach Street, STe 224. San. Francisco CA 94133 (Address) — Telephone No. 415 474 62-11 Telephone No. 415 474 6211 � a � * aaa * � a � * x � aa * tray * a � * aaa * * aa * x * aa * * ate * aa * at3a * xa * * * t * NOTICE Section 72 of the Penal Code provides: "Every person who,with intent to defraud,presents for allowance or for payment to any state board or officer,or to any county,city or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim, bill, account,voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ( 51,000 ), or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exuding ten thousand dollars ($10,000 ), or by both such imprisonment and fine. o a , LA tz -00 CLAIM BOARD QE SIM)MMS OF CY?r''v'TRA COSTA-QQ=a CAI TF'Q`1+t 10ABD AlC1I1L AltiiL � 99 Claim Against the County, or District Governed by � the Board of Supervisors, Routing Endorsements, NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this documt mailed to you is your California Government Codas. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV belovO, given pursuant to Goverrrrmrit Code Section 913 and { V 915.4. Please note all "Warnings". ..:: AMOUNT: $1.0,000.00 s . . . S. i CLAIMANT: Lawrence L. Hughes w .* ATTORNEY: { 7A�TE RECEIVED: Judy 22, 1999 ADDRESS: Martinez Detention Facility BY DELIVERY T4 CLERK ON: July 22, 1999 C-Module, Room 10 901 Court Street BY MAIL POST AARXED: July 21, 1999 Martinez CA 94553 L FRONL• Clerk of the Board of Supervisors 70.- County Counsel Attached is a ropy of the above-noted claire. PHIL BATCHELOR, Clerk r ; Dated July 22, 1999 $y: Deputy . �9 1� x { s' .1 IL FRONT: County Counsel 1Xk Clerk of the Beard of Supervisors ( ) This claire complies substantially with Sections 910 and 910.2. , } This claire FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. 'The Board cannot act for 15 days (Section 910.8). ( Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's aright to apply for leave to present a late claim (Section 911.3). tach 3 4-4 Dated: ' L - _ a By: putt' County Counsel 1131 IRbbi Clerk of the Board 7yr unty Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: A Ibis Claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Yll Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 13) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional 'Warning See Reverse Side of This Notice. AFFIDAVIT OF MAn'1~liG I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Carder and Notice to Claimant, addressed to the claimant as shown above. Dated: �By: PHIL BATCHELOR By "puty Clerk Y CC: Coumty Counsel County Administrator VICTOR'J.AVE aTMAN DEPLIT1ES: COUNTY GOEJ€ SELJA'ICE L AIVENTAr NORA G.BARLOW S.REBECCA BYRNES SIVANO 8.MARCHESI /�p��+ /� �} o� ANDREA W.CASSIDY y'� CONTRA, i„a OST-P9 W;VTI MONIKA L.COOPER CH F-E ASSISTANT COUNTY COUNSEL ViCKPE:DAWES OFFICE OF THE CONN OLINSELi MARKES.EST:s SHARON L.ANDERSON NILLAN FUjI:D. R ,3£Fr%'R(SNi1N;S-AATtCYE�E�L.'�Et'ka", E.iLL A�,�'T FUJI' ASSISTANT COUNTY COUNSEL € F�1 E. C t ET DENNIs C.GRAVEs p� JANE HOLMES MART N84 CA�.(FC3�A�tJ.653- ��J KEVIN KERR GREGORY C.HARVEY BERNARD L.KNAPP ASSISTANT COUNTY COUNSEL EDWARD V.LANE,JR. BEATRICE LiU MARY ANN viASON GAYLE MUGCL: PAUL R.MUNIZ L7LF9^vE MANAGER VALER;=J.RANC IE TEVEN P.RET':IG DAVID F SCHMIDT DiAA .ERPHONE{92b�335-1800 BARBARA N. SL3TLI.FE FAX(925)546-1073 Acr�uELINEY.woCDs NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Lawrence L. Hughes Martinez Detention Facility C-Module -Room 10 901 Court Street Martinez, CA 945533 RE: CLAIM OF: Lawrence L. Hughes Please Take Notice as Follows: The claire you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ ] I. The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. 3. The claim fails to state the date,place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000),the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000),the claim fails to state whether jurisdiction over the claire would rest in municipal or superior court. Page 1 6. The claim is not signed by the claimant or by some person on his behalf. [X. 7. Other: The claim fails to describe any duty or obligation of the public entity and any action giving rise to the claim. VICTOR Y. WESTMAN, County Counsel B � eputy u4C�uKselr l CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 101.2, 1013a,2015.5;Evidence Code§§641,664) I declare that my business address is the County Counsel's Office of Contra Costa County,651 Pine Street,Martinez,California 94553;I am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Dated: July 22, 1999,at Martinez,California. e cc: Cleric of the Board of Supervisors(original) Risk Management (NOTICE OF-INSUFFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,910.8) Page 2 Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 10& day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By \i Reserved for Clerk's filing stamp )! RECEIVED- Against the County of Contra Costa or JUL 2 2 1999 k w ' _ # z;R:. 1rJtrfct� �L jL 8r,I { tit Er 1�+vi�1'7y A r•tviA Cts. (Fill in name)---.-...t a The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of 5 > < and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) { .: f # l € h f.�• � i. y fG,4 f 4 od A # �' 4� x y,4 { � .t �'v� {� {e 4F {.9 .. .'.5 } 2. Where did the damage or injury occur?(Include city and county} 2 1y,L { { i x. �. Y ) .a c .v o .. # a k - p rY^ck f .# o { .. ,..:; ..�. ..: ::.:: -f v VH >k{Y; F .. .... ........ ................ .... k S 3. How did the damage or injury occur? (Give full details;use extra paper if required) , .:{.. i i k F S: 8 1 ,¢ > f J7 c ( : x 4 What particular actor omission on the part of county or district officers, servants, or employees caused the injury or damage? 5. What are the names of county or district officers, servants, or employees causing the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) #.t ¢ j S 7. How was the amount claimed above computed?(Include the estimated amount of any prospective injury or damage.) t. t . t ny: $ a S.t Names and addresses of witnesses, doctors, and hospitals. t 9. List the expenditures you made on account of this accident or injury. DATE TME AMOUNT Gov. Code Sec. 910.2 provides "The claim must be signed by the claimant or by some person on his behalf." SEND NOTICES TCS. Attorne Name and Address of Attorney ) r : (Claimant's Signat tr$$e) }/ (Address) Telephone No. }Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand($1,0000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. r 4 �s r c r 'e. CLAIM BQAED C FST�P'F_, RVISOR CQMA COSIA QbCAM CATEDRM BOARD Ano AUGUS I`17:. 999 Claim Against ft County, or District Governed by } itis Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to } The ropy of this document mailed to you is your Wfornia Government Codes. , <, »; > of the action taken on your claim by the of Supervisors. !Paragraph lY belovO, given f: rsuant to Government Code Section 913 and 5.4. Rease note all "turnings". AMOUNT: Jurisdiction of Superior Court CLAIMANT: Mli.chael B. Jardin ATTORNEY: c/o Hunter Pyle BATE RECEIVED: July 15, 1999 Siegel & Yee ADDRESS: 499 14th Street, Ste. 220 BY DELIVERY TO CLERK ON: _- - July 15, 1999 Oakland CA 94612 BY MAIL POSTMARKED: Hand-delivered L FROM: Clerk of the Board of Supervisors fid.- County Counsel Attached is a copy of the above-noted claim. PHIL BA R., Clerk Dated:_ __-- July 19, 1999 $y: Deputy .� IL FROINAL County Counsel M. Clerk of the Board of Supervis s ( ,4 This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). { ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: 46 Dated: By: County Counsel III. FRONT: Clerk of the Board TO:. County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IVa BOARD ORDE3L- By unanimous vote of the Supervisors present: This Claim is rejected in full. ( ) Caber: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: . PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See:Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional Warning See Reverse Side of This Notice. AFF3DAVIT OF AlAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressers to the claimant as shown above. d � Dated: ; ?9 / By: PHIL BATCHELOR By pu ty Clerk CC. County Counsel County,!Administrator DAN SIEGEL, SBN 56400 HUNTER PYLE, SBN 191125 2 1 SIEGEL & YEE 499 14th Street, Suite 220 !.'Oakland. CA 94512 {{ Telephone: 510.839.1200 4 11 Telefax: 15 10.444.6698 5 i Attorneys for Claimant `�ttp %V1�ORS Michael B. Jardin ` 6 7 CLAIM AGAINST TIME DANVILLE POLICE DEPARTMENT I g 1. Claimant in this matter is Michael B. Jardin, whose address is 7095 Ann Arbor Way, i i Dublin, CA. 3 to 2. Notices regarding this matter should be sent to claimant's attorney, Hunter Pyle, whose 11 business address is c/o Siegel & Yee, 499 14"' Street, Suite 220, Oakland, CA 94512, s 12 3. This claim arises as a result of the actions of Officer E. Glasser of the Danville Police i I 13 Department. On April 14, 1999, Officer Glasser arrested Mr. Jardin without probable cause, in a I 14 manner that violated his rights under the federal and state Constitutions. s E zs 4. As a result of the conduct mentioned above, Mr. Jardin has suffered humiliation and I 16 emotional injuries. 17 11 5. The name of the public employee responsible for the actions giving rise to this claim is 3 as 1 Officer Glasser. 19 S. The amount claimed as compensation for the claimant's injuries falls within the I 20 jurisdiction of the superior court, 21 ' I Elated: July 12, 1999 SIEGEL & YEE 22 i I; - {w 23 I By: 2 i f F3xlnter Pyle , i; 1 3 H Att4neys for Claimant i 25 iMichael B. Jardin ! i i � f f i PROOF OF SERVICE 1, Chloe A. Satterlee, declare as fellows: 3d I am a legal assistant employed by Siegel& Yee Law Offices. I am not a party to the within 4 , action. My business address is 499 14'h Street, Suite 220, Lapland, CA 94612. On July 12, 1999, I served codes of the following documents: } d Claim Against the Danville Police Department 7 on the parties to this action by placing true copies thereof in sealed envelopes, addressed to the parties named below, with first class postage thereon fully prepaid and depositing the same in the United ` States Mail at Oakland, California: 5 i Sherifrs ice—Complaint �i � 51 Fine Street, '?6 Floor i Martinez, C.A. 94553 j a I declare under penalty of perjury that the foregoing is true and correct. Executed on 4 ; July 12, 1999,. at Oakland, California. i 1 6 Chloe A. Satterlee i t Legal Assistant to Hunter Pyle 2 0 t 21 ' 22 t 221 24 i 25 f 2 6 1, t 27 2 8 ! 1 : DAN SIEGEL, SBN 564€I0 HUNTER PYI.E, SBN 191125 2 SIEGEL & YEE i 499 14th Street, Suite 220 ? Oakland, CA 94512 Telephone: 510.339.``=_200 j 4 ;�T-,iefax: 510.444.6693 5 Attorneys for Claimant Michael B. Jardin 7 CLAIM AGAINST THE BASVILLE POLICE DEPAR'TMEN'T" 8 1. Claimant in this matter is Michael B. Jardin, whose address is 70395 Ann Arbor Way, 9 i1 Dublin, C.A. I iC 1 2. Notices regarding this matter should be sera to claimant's attorney, Hunter Wyle, whose business address is c/o Siegel & Yee, 499 14'' Street, Suite 220, Oakland, CA 94512, 12 i 3. This claire arises as a result of the actions of Officer E. {Masser of the Danville Police I 1 Department. On April 14, 1999, Officer Glasser arrested Mr. Jardin without probable cause, in a 14 ii :manner that violated his rights ander the federal and state Constitutions, 15 4. As a result of the conduct ;mentioned above, Mr. Jardin has suffered humiliation and ! �4 16 t;emotional injuries. 7 17 11 5. The name of the public employee responsible for the actions giving rise to this claim is :s Officer Glasser. � t9 6. The amount claimed as compensation for the c'laimant's injuries falls within the { 20 s jurisdiction of the superior court. 2i 'Dated: July 12, 1999 SIEGEL & YEB 22 j 1 2� ' By. r , 2 ! rater Py�ie Atto�neys or Claimant 25 Michael B. Jardin 4i j PROOF OF SERVICE 211 I, Chloe A. Satterlee, declare as follows: 3 I am a legal assistant employed by Siegel& Yee Law Offices. I am not a party to the within ! 4 i action. My business address is 499 14"` Street, Suite 220, Oakland, CA 94612. j } { 5 3 On July 12, 1999, 1 served copies of the following documents: 6il i { Claims Against the Danville Police Department -711 1! i 8 1i on the parties to this action by placing true copies thereof in sealed envelopes, addressed to the parties 3. named below,with first class postage thereon fully prepaid and depositing the same in the United States Mail at Oakland,California: i Sheriff's Office--Complaint 651 Pine Street, 7'h Floor Martinez, CA 94553 �3 i j, I declare under penalty of pe.jury that the foregoing is true and correct. Executed on JJ'} July 12, 1999, at Oakland, California. l 16 �. Chloe A. Satterlee 17 ! Legal Assistant to Hunter Pyle sg 3 } 2 C !; 21. 22 2 3 tj { 2 4 25 i i 26 i 277111 2 CLAIM vy .�� AUGUST 17, 1999 Claim Against the County, or District Governed by } ft Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to } The copy of Ws document mailed to you is your California Goverrmnt Codes. } notice of the action taken on your ciaim by the Board of Supervisors. (Paragraph IV belov 1, given pursuant to Goverment Code Section 913 and 915.4. Plan note all "Warnings". t�bfl. AMOUN`r- $25,000.00 s; CLAIMANT: Antonio Johnson ATTORNEY: DATERECEIVED: July 14, 1939 ADDRESS: 2555 Churen Lane BY DELIVERY TO CLERK ON: July 14, 1999 San Pablo, CA 94806 BY MAILPOSTMARKED: Unreadable L OT*L- Clerk of the Board of Supervisors TD: County Counsel Attached is a copy of the above-noted claim. PML BAT I I,QR, Clerk4 Dated: July 14, 1999 By Deputy 7/ F IL FROM- County Counsel Tt Clerk of the Board of Supervisors {` # This claim complies substantially with Sections 910 and 910.2. This claire TAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 91(3.8). ( Claim is not timely filed. "The Clerk should return claim on ground that it was filed late and send warning of claimant`s right to apply for leave to present a late claim (Section 911.3). { ) Other: Dated: Deputy County Counsel ` V, r M. tOn- Clerk of the Board M 'C9uhty Counsel (1) County Administrator (2) ( ) Crim was returned as untimely with notice to claimant (Section 911.3). TV. BOARD ORDEFU By unanimous vote of the Supervisors present: } This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:�n LA4 kff I'IIIL B ATCIELflR, Clerk, Hy `�� Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the slate this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *Por Additional Warning See Reverse Side of This Notice. I declare under penalty of perjury that 1 am now, and at all tithes herein mentioned, have been a citizen of the united States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Bated:Lt ` ., 9 By: PHIL BATCHELOR lay Deputy Clerk Cc. County Counsel County Administrator _. Claim to' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 144 'day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing craps and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any ether cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 146, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County,the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or P ri e JUL 14 1999 M( e. C.f District) CLERK BOARD OF SUPIrtlWORS (Fill in name) ) 'f3h1TRA 00SIA kQ, : < The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 51 and in support of this claim represents as follows: 1. When did the damage or injury occur?(Give exact date and hour) i ri�C �L� �,.......�.. fit ; . 2. Where did the damage or injuryoccur? (Include city and co`unt'y)' 4. 21� �. v> rna c 3. How did the damage or injury occur?(Give full details,use extra paper if regdired) n 64 n. CC,, rn_or-Lr,,>n_ k t A v �. $$ � i -_ _.... _... .. .__.... .........__. .._... __ ...... ....... ........ ........ ........ ......... ....... ..... _. ............ _._....._... 4. What particular act or omission on thepart of county or district officers, servants or employees caused the miury or damage? : } 1 ' zkevirc- bL +N�> 4f� trs,)or 0�olaf t +tit.5 faci ay oe -+sd"•._N' :. <.:, c x.....,.: a.. '�t,:+w 4vr a: 5. What are the names of'county or district otcers, servants, or employeecausingthe damage or injury. w s..:: .:idc' 9f '�u.u.'�,.w.>: . ...;.,.,,, .. a Kv'..a.,,,,< :. •E .k°aon X � ...b k..,... _ ..::' xx f d. Whatamage or injuries do you claim resulted? (give full extent of injuries or damages claimed. Attach � r two estimates for auto damage.) .:> 7. How was the amount claimed above computed? (Inc nude the estimated amount of any prospective injury or ` $ •) n . dame a M , '" prA t dQ �C> � ): y ° ., ataict � w .. k } � P � , ° : 4 :� 8. Names andaddresses owitnesses, doctors, and hospitals. a XJ : w4rlq :L -#J 1:..5 n:os-r °° 9. List the expenditures you made on account of this accident or injury. 42e. - .r -i,ci DATE T� AMC3UNT ) Gov. Code Sec. 910.2 provides"The claim must be ) signed by the claimant or by some person on his behalf" SEND NOTICES TO: (Attorney Name and Address of Attorney ) • i J J f ) (Claimant's SignAifure) (Address) Telephone Nn �4, ' �)Telephone No. NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand($1,000),or by bath such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. p S 3 1 A �" _ _ t ={ CLACIMr BOARD ACTS[Ifs AUGUIST 17, 1999 Claim Against the County, or District Governed by } the Board of Supervisors, Routing Endorsements, NOTICE TO CLAIMANT and Board Acton. All Section references are to } Mr copy of this cent railed to you is your Califo rria Government Codes. } notice of the action taken on your claim by the Board of Supervisors. {Paragraph IV beiov4, given h _ pursuant to Gojverrment Coale Section 913 and 915.4. Pisase nate all "Warnings". AMOUNT: None Specified CLAIMANT. Virginia Lee ATTORNEY: DATE RECEIVED: July 14, 1999 ADDRESS: 120 California St. BY DELIVERY TO CLERK ON: July, 14, 1999 Rodeo, CA 94572 BY MAIL POSTMARKED; July__12, 1999 L FROft Clerk of the Board of Supervisors Zai} County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Cl" Dated: July 14, 1999 By: Deputy 'f 'gY S ' IL FROM: County Counsel TO: Clerk of the Board of Supervitors z This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant, The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was fled late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �. 4 : i ;, $yDeputy County Counsel i i S M. FIt{3M Clerkthe Board 3D: '.#unty Counsel (1) County Administrator (2) ( } Claim was returned as untimely with notice to claimant (Section 911.3). IV BOARD ORDEM By unanimous vote of the Supervisors present: This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: � ,' ,. i PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the snail to file a court action on this claim, See Government Code Section 945.6. You may :.eek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AT"FMAVIT OF Ai41 .3NG I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: t 1— � � By: PHIL BATCHELOR By Deputy Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 140th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County,the name of the District should be filled in. D, If the claim is against more than one public entity; separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp Virginia Lee �RECEI Against the County of Contra Costa e a or JUL 14 1999 The Housing Authority of Contra Costa (District) ,ONTRA Cr"qTAnfl (Fill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of$ and in support of this claim represents as follows- ,7 I When did the damage or injury occur? (Give exact date and hour) 2. —Where did the damage(k injury occur? (Include city and county) X, 3. How did thO damage or injury occur? (UivJf_ull details; use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? clmform j 5 ........ ............. ................................................... . ...................................................................... ............................................................................................................. S. What are the names of county or district officers, servants or employees causing the damage or injury? b. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attached two estimates for auto damage.) 7 How was the amount claimed above computed? (Include the estimated amount bf any prospective injury or damage.) .:.. .,}. �Lg g' Namds aid addres es of witnesses, doctors and hospitals. =' 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICE TO: (Attorney) or by some person on his behalf." Name and Address of Attorney ` ti Claimant's Signature) s (Address) d r Telephone No. Telephone No `: 4✓ ` s.,. ' NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim,bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000) or by both such imprisonment and fine." cimform !•' 1'a>1.1,,".�`,a��� f`,S V.b`r,I.d'I� � � � ..ts'f.,.r�,.e:✓'� -"^-'� �,.rg,.��;n ""-/ /''�'a `�.r�'. r.+• 1•j4 ;1450 ... ., .•"" `.n. , �-- terse' ,,.,at:,� �+:. r' �. ,�,✓ "'> '. id o 3 r/ -rtifi,. yy .r p 4 a' o R K AN {t f{ Y f i { r 3 �f t CLAIM BEARf) AAG"Ttt)t AUGUST 17, 1999 Claim Against ft County, or District Governed by � NOTICE TO CLAIMANT the Board of Supervisors, Routing Endor err�ents, � and Board Action. All Section references are to The copy of this docurnent mailed to you is your Caiiforr a Goverwent Codes. notice of the action takers on your claim by the Board of Supervisors. {Paragraph IV beloW, given # 3 pursuant to Covesnrrent Code Section 913 and w : s 915.4. Piesse note all "Warnings". AMOL�h"ra $5,000,000.00 x } G CL.AIMANrr: Rickey R. McNeal ATTORNEY: DATE RECE]1-M. July 27, 1999 ADDRESS: Martinez Detention Facility BY DERRY TO CLERK ON: Juin 27, 1.999 F11-1,0 901 Court Street BY MAIL POSTMA ME€3: _ _ LL.-L ahl Martinez CA 94553 L FROM: Clerk of the Board of Supervisors TO. County Counsel Attached is a copy of the above noted claim. PHIL,BATC .LOR, Clerk Dated: July 29, 1999 Byo Deputy 7 ;r IL F1tO4NL- County Counsel TO: Clerk of the Board of Supervisors 0-) This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). Claim is not timely filed. The Clerk should return claim can ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ) Other: t« Dated: t Bputy County Counsel 7 1 RO"'I Clerk of the Beard M 49ity Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). TV. BOA= ORDEi: By unanimous vete of the Supervisors present: ( `Phis Claim is rejected in full. ( ) Other; _ I certify that this is a true and erect copy of the Board's Order entered in its minutes for this date. Dated: P7 i IWPHIL BATCHELOR, Clerk, By ;" Deputy Clerk WARNITNG (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally sued or deposite+ in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFI]DAVIT OF NIAnXiG I declare under penalty of perjury that I am novo, and at all bines herein mentioned, have been a citizen of the United .States, over age 18, and that today I deposited in the United States Postal Service in Martinez, California, postage futile prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Datedt h By. PHIL BATCHELOR Byp ' Deputy Clerk M (".++phot}C uml County Ait`3 uinistrator Claim to t bad 07 fD'MISOILS OF CONTRA COSTA C»OMMy '!'SIITO I A.,, Claims r*latinj to causes of action for death or for injury,/ r or to personal property or growing crops and which accrue on c+rember 11., 1987, mutat be presented not later than the 00til after the accrual of the cause of action* Claims relating to cap of action for death or for injury to person or to personal pro *rt or growing craps and which accrue an or after January 1, 1888, must bee presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Cade 511.2. ) X. Claims must be filed with the Clerk of the board of Supervisors at its office in Room 108, County Administration Building, 151 pine Street, FArtinet, CA 94553. Cg If claim isagaainst a district governed by the board of dupitrtrisors, rather than the County, the name of the District' should be filled in. D. If the claim is againstsore than one public antity, separate claims must be filed against each public entity. Slee penalty for fraudulent claims, Penal Cade See. 71 at the end of this form. Claim S Reserved for Clark's filing stamp D } RECEIVED Against the County of Contra Costa) Maj or p: a JUL 2 7 1999 e a !w $ District) CLERK BOARD OF 9Ji PPVIS R5 • (Fill in name) �' - COs4,A COSTA a , The undersigned claimant hereby makes claim against the Co= )X of Contra Costae ar the above=naamed District in the suss a5f S � tE k. and in support of this claim represents as follows: I. When did the damage or injury occur? (Give exact date and ho m 2. inhere did the damage or injury occur? (Include 0city -and county) 9. Now did the damage or injy occur (Cave full details; use extra paper if required) V t € � = c ZAN 4. 'khat JArticular a t or caissiOn On the part of county or +dixtrift oaffir eraac, servants or,,q�fe6 play�e+e rycausa th ,i rijuzyppfa[S��os dy«ay�mage'?irS�° 'L.a.'9 S Y 6 .� tw.'w�) �M..§ 'W 4 i�. S °`4„`•"(� `i.3 4 f' ! '�+✓�' 3 'r 4 `eo L:3 (aver) Y S. What are the names of county or district officers, servants or Omployoima causing the damage or injury? r 7—o t � was 17—oiqO'Xk C' r r kcu -n 6. what damage or injuries dti you claim resulted? (Give full extent of injuries or damages. claimed. Attach two estimates for auto damagj.) -11-- e 1-bv'4 _ � ` coat Tot6�1 � F P � s ke'.t'cr_;O.1C4 ` taI tic Pail V, 3 7. Now vas the amount claized Bove computed? (include the estimated amount of 4MY pros *at ' •injury,or daueag Mf- .k, a. Names and addresses of` wi?tnesses, doctors and hospitals. S. List the expenditures you made on account c� this accident or injury. o i Sr y v"3c Gov. Code Sec. 910.2. provides ) 07be claim must be signed by the 3 claimant or by some person on his Name and address of Attorney . 12, (Claimant's Signature) .. 0 �e (Address) Telephone No. Telephone NO LL'c9 33'-02 1 Suction 72 of the penal Code provides: fveery Person Vbo, Frith intent to defraud, Presents for allowance or for payment to any state board or officer, or to any county, city or district board or +officer,. Authorised to allow or pay the sauce if Genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not nor* than one year, bWrisonment fine of not exceeding one thousand ($1#000) # or by both such and fine, or by imprisonment in the state .prison, by s fine of riot exceeding ten thousand dollars ($101000, or by both such imprisonment and fine. STATE LSF CALIFORNIA STATE BOARD OF CONTROL F. w. Box 3035 Sacramento , CA 95812_3035 (916) 323-3564 A`: SS 473 -3564 June 3, 1999 RIrKY R VCNEAL 901 COURT 5T MA T NEZ9 CA 94553 Re : i"CNEAL f BACK 1 R Claim Numaara 6345428 Code: Your claire was presentea to the State Board of Control (Board) on May ZC, 1999 We have reviewed the claim and determined that the board has no jurisdiction to accept the claim for consideration for the following reason(s) : The :entity that you allege caused the damages or injuries is a State Government Agency. The Eoard will take no further action on your claim. Sincerely, Government Claims Division Stag Board of Control (15 No jurisdictio^) Jacob Rosenberg , M . D . Em COW 10m TO: Pt bli.c Defenders Office FAX 925y-335.8010 COURT DATE: 03/11/99 CILENT: Richard McNeal FROM Jacob A. Rosenberg, M.D. DATE: 03/09/99 A total of three ( 3) pages are being faxed with this cove: sheet. 2299 Bacon St., Suite #6 • Concord, CA 94.520 . Phone 925/69;-9$06 < Fax 925/69:-9807 d Jacob Rosenberg, M.D. Board CerC fiedl Pars Nianagernent and Anestheriia March 9, 1999 RE: PATIENT: RICHARD MCT IRAL near Sirs: This letter ;s regarding Richard McNeal who apparently has a court sate on Thursday, March 11, 1999. I have been treating Mr. McNeal along with Dr. David 'Wren for low back pain as a result of a Workers' Cos rpe3:sat.I.on injury which occurred last year. Mr. McNeal haA 2-level disc disease and requires a 2--.level lumbar fusion for his low back pain and radicular pain down his leg. This has boon demonstrated on both MRI scare (an x-ray test) as well as or, disco- graphy (an injection test.) which reproduces the patient's pain by injecting into the disc. believe that currently Mr. McNeal is having enor;nous social problems that are at least partially as a result of his workers' Compensation injury. The history that bath I and Dr. Wren have obta4ned from Mr. McNeal is that he had a significant alcohol problem eight years ago with some drug abuse at the sane time. He is quite clear, however, that he has been clean and saber for over five year:. When I first saw Mr. McNeal several months ago, 1 noted that he was quite depressed. At least a significarit Portion of the depression is because he was having difficulty in his marriage arra he felt that his wife was; unwilling to help h.m deal with his ruin and disability. He was suffering from a significant loss of self-esteem because* he could no longer work and he felt largely irr e}eva,nt in the house. He told me that the host impor- tant thing to him at that time were his children and his +aiff--, and he was very concerned that his marriage was going to end as a result of his physical impairment. In the time that I have known Mr. McNeal, I have never seen his wwfe nor have T had her express any concern, despite the fact that he was looki,na at having a major surgical procedure so that he can return to some stmt of employment. After the discography was performed on him some two weeks acv, Mr. McNeat. returned home and was apparently asked to leave his houee. This, comhined wit-1i his previous depression and indeed with his past history of drug and alcohol abuse, led him to relapse with drum and alcohol abuse. ZZ99 8aecrr St. Suite #G • Cor,,cord, CA 94520 . Phc;se 92S/6,,i-B OG • Fax 925/69'-9807 Re: Richard McNeal March 9, 1999 'age 2 At the current time, what Mr. McNeal needs is .to undergo a behavioral management program aimed at controlling his drug and alcohol problem. He has already been through an acute detoxifica.. t ,on by being placed in jail and, its fact, really needs very little of any sort of acute detoxification work. He does, however, need behavioral management and Workers' Compensation has refused to pay for this. It is my understanding that he does have Kaiser insur- alnce and that. this will corer tl w problem. In summary, the history that I have for Mr. McNeal is that he has been clear and sober for the last fire years, working quire dili- gently and raising a family. He was injured about one year ago and since that time has had significant problems in his marriage at least partially because he was no longer able to bring in any income or only a small income on Temporary Disability. Because of this, his marriage has continued to deteriorate, leaving the patient extremely depressed because he has felt that he Would not have access to his children and because of the sense of failure that he suffered because he was not being a "breadwinner" any longer. This culminated in :is wife asking him to leave their house and that .resulted in a relapse for drag and alvohol. At this Point, T feel the roost compassionate course for this gentleman and In fact the most effective course for society could be to enroll him in a behavioral management program. If you have questions, I would be happy to answer them, and I can be reached on Marci: 2.1, at ;5101) 523-4040. I declare under penalty of perjury that the information accurately described the information provided to me and except as noted herein that I be-Lieve it to be true. I further declara under penalty of perjury that I nave not violated the provisions of California Labor .ode Section 139. 3 with regard to the evaluation of this patJ.ent, the preparation of the report or the dictation of any procedure. Sincerely, J oh A. Ros terg, m.D. "rAR:+'m c v�`�*rr'¢ "3 is �_ � .y� 4 r +. s * � •,� ry � ��+Y` 'h+�gi���� �.�`*`1�'"��(; ` d•"h� s �' � Y._z �...• r, has ,..`*� 'a�•�^�a;� ',.{sc •. a to �`� r` � .r'�u�vr, ac "`5°9','.1 }"t•�V'a 5:�`-' l xW.t ,., i - F'tkiW .nt } �Y. , f, � F-s s-�" ,��f•si�•'a{ ","''tom T-?i -$ h •h y,r �� r �'kc�} -•�,��, .. �,y`� x' $'+-. M . 'yA_,. /} .� x�t rf•• �,� X -. k '♦s w ��, c,,,'s ,ty�. �: ! r3�a^-, v.•r* r } k .+fG•>9�},,,{ � T� i+�, .xa ,.,,;� N ,v, a ^^�' kih'.2 ',?�i'4i y� � .r #A$•,'-' TT � �� 'u'�<a�r�a� L"3 -; �{!r x.�• �, �s +, <tL"+ '^Sz z�x { a. ieL r � � �� 'XG��` » � <��+ y,,4}„rra � 1,fi',"Sf F{ � i• y"f `�.� *� c t } ,a6�r1vY. •L�n,� � � {. ;-� a Y .3 � s•L*f L9 b.X+a'+-L s a >y' fe 4.✓ � d`�`�' ? 'n`' :h � ii "::v f.,t$.:t �,'{-!; " r YS - -�,c _ � f .�'�.}•..� a�f�r. "..0� $�s �``N�a �' d ;� .. a � r,z b w J f{-,�+�%i' .' v• �Y .• a fr �'� �` � n• @!�.:. ���L. 4'� tS Yy xt T �.s'$ d.�Yn, d •2u n...$! � a T '.vXs1 1��'r Yh`�v T}}_ - \4.i�i. �{. > � {l' � '4 a.. ^v "°'• •}°'. ^�' }S'{F"'}�, ..� r V? ? 3 �. 4>i.4. .'JF?Y•'• T OMAN - wLfra;?+n+f 5 � -� v. �s�, f.�i4 �`�� 'rfia � a.'v,, s ;••...° S\ d.. t r {riY � :(� �,y a a a .a TL d � .c.,... �f' �, r�,. _'x a '�$9' •,i o04> '.A z� sY •`GXi �-✓/ - `' s `*L}R' /a'2 .1 a ,r - i.a ',y' v�• Y,y ?, r •� a ��.. "� �-.' r x � 14 .rr .: y r � �'^ aY5''�,.. CL�_ a � "r�'�•fw'ir�t. r $'a oa wvsaj ,pS as "s-r ^�i�fi r'•{ �. x f y„ _. � .�- `hf rz•$ < ��{,�' 'k"x<t c�r yS. � -a-� �T\ s�' �� a ,a_ ,. h k 'eWi.'-Y-N �� - L a } ,♦ {,f `fir d �r L{ } +Lp a S ..� a'"* :meq � S i" .tP'�''r°���•`is �s4•eY .• \,` � •, ., _ .as'•.. f.- .,: Via._ .W.. .,.yam x } Y.. too-,'r „u •{t .s.-f .;:.s'' :+La: L,.L"t'•.j.§° {�`N L'n jt i�''vf.. F•`- a - r is :".. f -' t`�^ -;r 'x?� i a '{/r � �, /•Tyr �''�Ar m *a � e< �,f?r E �" , � -, _ �. '.. 2� ,;� 5., .r • {�' �4 L y a r '�31't-r a�hft`' �r a. r 777 yy+ :- iMn•+`c a'3AS. a'-t`s'i�k+'' uy't rT+ .� � ,� ��•i� �. � €s� F ods ,,�z}� c•L< a .: rta Tf�.' 3'�. L x�' ,,;4''x xt f �•'.� L -�' 'k' r .. k q l Av i" {x{ r+;x e xu- �,S*'}..w ueY.r -r.+. .4.y: A sours.!r �+}�•ad^p..,'^ ♦ ..ix. .y f.? "'} '?- _<t o yyr ;+ r.Z.X> 'frm.} 'z��' y. tiTf.-: E�xdyi� K'fi`+w ?rte!-?Ck i> n .�• 'r"o ,s` {i• .�,, = ;,,. 3 i-' y'/...{�` �v v ac`/.5�'. '-.r'�'."f{" `{� 5j A ; .�[4+n' `){h. � �^...�. {'3r 4< � $�;. ,�rF�d � - � �.y t. d t,� - wx� t;rr{ .£_ .c•� • WCis y�/ Yyltr .i n vi}3 F3 aa� Y lA +x h ..`� ` �� {}. � ��rf>4 X{ ? ti f�� _ + �}{' Su+rA'�,'f•�{s r j,h .v .� dM;aZ to f+v hti• 4r �' �,r +�^ �rif Y f.}+RY4.. l/ryW A ;: ; �� .. d� w }r� $ *Y/!Y 5 ?' >� { •ate..''. f t 3,v K MOW / ...ny{1.+x; +J4fN,�`! � .. /..dLYYA :.+".. � y .::?^•. f `•:• .: CY*e fr� rz•:+ �•3w �,'..r Yfi,.. !S: S '�. r �' Sa ", j "...,,�ftyi�Y 3co r''�;''ti} y�.W'f`<. H+ { - } fT:l} Yf > 3� J' y,i, +�`Yv+''• Ni=sY�. 44ti - i• :" � c - � >' h�yw+� ;al< F 3{c�* }t ,+ K .r}, _ � ., p a.�1 �.-. _.> "" A_ tf•� }ySS+,.t++'"r�r � ?� 'wn rbc.} s 9'.� s z- a -o sr. w .:R:Rcv..,Z •a{t»'Mf' Yaa{>•,"Sa ... • o0 r { r ee}}��.. ,}. V Y � 'w7 w• .ew z g.,t{ +xc. "fes rwY•� , s!%- .�, .� ,moo•.. » � e�y i F .g. w.S� to '�' .r, w v A•�` 'vr £i 3+ :� �.l*''.:, . i #`-�`�•`t;4�°"�, a 'v ✓ S v� Y VXu 3 x�+Y.,.r•, h�� '.Fr 3 .' +c 5... �r� 'n rNu•3: 'Y.S.2. Yf}t' � F ^Y`� r A>} U�•:J't a +�Cy.. { "",;:,tfi; � a .�; a� ,� ,�.. r:: c a A' r�k / v� >F%' �"�'` ".. j � �,•. r �'"f syrr„<. .vJ v,� ryt: �vf' r °� }� aak• ?' {�. ? > - o�'� 9 -{�_r�r�c ,�;. � ...•"�.. ."- <�'» r � < .: ��� ._.:. ,' ,may �. � � ' i 4"�<�`x��r".�5,.���'•, 5, ,�y}�,k�+_ � £ -`.{v 2r„ ,+ t•,.5r<. .'Y s _ tl�,C�ke y> s ? f.<�:s`� '£ t<`^ > •kYa'. ,fin, t A,} fin 'a' •�,R r r � '.. `a rY >�.. � ,<� 'T+f �• � ♦ YA'SYrt�k i�� wvk� � w� 3w ) <�J a,�i.+fwot'a� Ir+�*� `,�r � �: 5. i - '� Y"",� _ �,•'s �it;.• S <hb ..fc 1'. �.�<r Y Y':'{ �^ 'wa 'ti y u{<4 N t:2¢#r� ,.9� .N _ .t•.� '''. _ �. <, as' c{+��� fT,} x a xa, ,, f 's> rt,� ��.un ,�S.r� .. ,rer. 7:a r s` -°"+rt r t 3u 'ef•cf�, • r�J' a t r s A k�4Sy: yr .rrG},e.. r oo �• r" .,'d»".+ 3dbl.Yn m'• ,.,wA sAJ> '� -.. 4 ,.,.a.a.� � - r ,A L y ,.i• a .L.• ::.f. }vr3�+,r `j��y� +.r.{. R 3 .c,.,,.i �l ✓ sR 4,T.Y a,Q� solo.TVA � .�� s � �i•- 2 .o-7r. a `ns `�A i3 1��.7v'�rr�v. .-r g ✓Y- .�'`y 1'�. .Y �+�i� - � � �a t eta {, � r,. � ,;.' �•r: -«. •� �rEs >T e _ n� k > 1 i Oi' 1 rn ``r}'t„`M ;. e r= r'"�' 1� ,t2bpv r.. 4 V t si i 5 Y�y- �r•'L{ '�',? ,.> 4 f a .'.'K¢ h+� {.tri`[> t � �� s � '�� .�• Ytr r r, 1 '1r {• � t a { v { _ {k YFi r x••r �• z x{ ,�..:.r ..+ ,y •fdk�' +. : R - S� A .rr ,y .r{ � ,:.w 1 ',ic � , • .{>�,A �� _�� �� '' ^h'2� r £, a�5 � w -� a �T 4� � �r>'a'' .> w. >u't, '''fit• v w- :(err '. t,,yv kr� < t^7i",•. X.•? <+{. { *{ .rr. F ��. �'� i � � tt5 1�.'r�Y.• F+<x n Y � .�"�'rs x+��� ,y i i r '�< �'�.�, t '"� '""` � +`''�"• ".{q.. a. ^"Y. iF r ,,.amu .{ 10. v�"a•�yr�+w' a �.+� •, •. � }xii •. : -:{rac < x;'{Ci "f+.{ >x xr#•xv•'�'ku} "Cr' +,''4 »�+ y tr +Yr{ n }�• fir.'Yom,y, `_. -I""�ya•�F`--� .. - '' x a _ vx x { ,e•------ ca rte.:±f s✓y `� ( .Y Ul cc �y# o ��s...sh LS �r,�•:tLS .;fin •h*' � y' TIM {> s••s-f fi{'k `..ti C .��i, .,o,. �' ` <z' r* , *' r..;,xx .�..• _ ' x>�^ Q •.+..,fes.- .aY' `t, C_ ,F �,-'�d ��.- �.a „3� _s' t.. 4 a''c a.e:�. !`r ..� k t° }+,_ ar tr,Y -�"'.o t t.,.�•- p r.. ''. �'a`�' � a.£,.'+3!- �, "�'�`� ✓'F"�m xn gyp. '.? � xy �`'�., � < � -''4:'2 � '5 � ��r, k » e� �i, '!�' � ^Cc�^.pgt t +� -'` iaY v i '� �,tS4n �it `""� 3^> e ''�` tr rs3, �, *..,''e! a! � -rr`' ".;wry .iSk� 4 ` �,� �•-�. { '.{ �r ✓ ! c a.,y. �.+ rs w.a+ ww .'v,.y +.W d. ,, �� ay'�. -..�� r� .tr •�,tA`T �'S •� .+�{ :� F {yx � s': wr�� y��� 4:'�''x .rs?vrT. -t hyo wtr Y : r 'p✓s- >� ��, 4trx� � i�''d ��# `C 9�s 5„ is -'.� <. y, t �r. rw�.,i�✓,� :� .c�G tact ?. l ¢. f � -: s k�� Y tr tr M. '2 d�fM4 as: •i-' '� �. '"3� � sr y �! �x-� <kr��f^` £ d1. s ct Ji.�. L.i �..iw+ � _ 6.3 may+ aa�•••�j�� X $ liw u_I CD i f CD E, r . rrCL' CA C i Ib N. it Z > tooo 00 OD 51 C) ' � . r�. ' 7 E t Z I LIN a t { CMD # i • (b CD LD3 Mv CD ea,�sr= :� " x. ``. wi F:� t�,N,z•. �;y �'_ k„x,� „�.,t .r., � a. .d .y. r� �',7 ^.'�^; r g r e g ;l L-1 — A� .. r _ ; i f 7XV `7r� ` •e -� G-rr `tom 3 AA A r ' INMATE REQUEST FOR INFORMATION � ME€ IC REQUEST 4C C.Al- To: P Z6te; Housing Assignment heck One: )'Request Grievance ) Appeal { ; Other I mt--A r :5L 14 41 i l r r - o- }• ec'd B ' t Routed Tse. VY x. AN R: . 4 } AR 'R 7v E7 ' ) DENIED-(state reason) By: gate: 1 Pink:Ke t by Inmate Yellow:Reply to Inmate White:To Booking _.-. __RE C38dRM_71Pf _ -------. rnCj J4 , rLU Av Ice til. y �� � s� K ;, �:3 +� •�, �: � 'yam � V+' h zr I IL .. �.. LL f46mFz ,. I 4W- s i Y ti G e ' a cc ~- Fc TA V � -17 car co 0 cc Cw iL �- v k, v - v- -is r .o era ate... • .,.:. ;,;. .: .-.,,F .a:,... .. ;. - l +. Y ,ti• .,4 � .:. 1. , J , r Y r a S w Facility: WC Page 1 Date: 03/ 16/99 15 : 19 39850 ANDERSON CONTRA COSTA COUNTY DETENTION FACILITY Incident Report Incident Number: 3070015096 incident Date/Time: 03/16/99 14 : 00 incident Type (s) : OUT OF BOUNDS iNTERFER W/STAFF DUTIES RECLASSIFICATION Participants: Last Name First Name COIN Booknum Inv Fac Mod Sec Rm. Bed MCNEAL RICHARD 070083558 99203901 M WC 4 01 B Incident Occurred > Fac: WC Module: 6 Section: A Location: OTHER 6A Action Taken: IR-MOVED TO 4 Disciplinary? Y Inmate Violence? N CS Violence? N Contraband"? N Fac Damage? N Sett . Action: Waiver: Findings : 0 Adjusted Type (s) : Submitted By > OID: 5342" Name: OSPITAL Date: 03/16/99 Updated By > CID: 00000 Name: Date: 01/01/01 Approved By (Sgt) > OID: 39850 Name: ANDERSON Date: 03/16/99 Approved By (OD) > OID: 00000 Name: Date: 071/071/0 Narrative: SYNOPSIS : I-MCNEAL (592039071) REFUSED TO STAY ON BLDG 6A. NARRATIVE: I WAS WORKING AS THE 6A DAYSHIFT DEPUTY. AT 1400 HRS MCNEAL CAME TO THE DEPUTY STATION AND FOLD ME HE WAS "ROLLING" UP HIS PROPERTY AND GOING TO THE CLASSIFICATION OFFICE. MCNEAL TOLD ME THAT HE WASN'T GETTING PROPER MEDICAL: ATTENTION FOR HIS BACK. I ASKED MCNEAL IF HAD USED THE PHONE TRIAGE SYSTEM (I INITIALLY TOLD HIM TO USE IT AT 07830HRS THAT MORNING) TO SET UP AN APPOINTMENT. MCNEAL WOULD NOT ANSWER MY QUESTION AND KEPT RAILING ON ABOUT HIS BACK. I ASKED MCNEAL TWICE MORE WHETHER HE HAD MADE A CALL ON THE TRIAGE PHONE. MCNEAL WOULD NOT GIVE ME A YES OR NO ANSWER. I ASKED MCNEAL IF HE HAD THE APPOINTMENT SLIP TO PICK UP HIS BACK MEDICATION (HE TOLD ME HE HAD A 13307HR APPOINTMENT FOR MEDS) . MCNEAL DID NOT PRODUCE THE SLIP. MCNEAL TOLD ME THAT HE WOULD NOT STAY HERE ANY LONGER, GATHERED HIS BELONGINGS AND WALKED OUT THE DOOR. I TOLD MCNEAL TO KEEP WALKING PAST THE CLASSIFICATION OFFICE TO BLDG 4 . ESCORT 3 ESCORTED baci__ty . WC Page 2 Date. 03/16/99 15 : 19 39850 ANDERSON CONTRA COSTA COUNTY DETENTION FACILITY Incident Report Incident N=u*:iber: 300015095 MCNEAL TO BLDG 4 . SGT. PARSER WAS NOTIFIED OF THE MOVE. MEDICAL HAS NO RECORD OF A 1330HR APPOINTMENT WITH MCNEAL FOR MEDICATIION. NURSE JEFF TOLD ME THAT THE ONLY HARD COPY RECORD IS TIME ONE THEY GIVE THE INMATE. NFI. *** End of Report ** Zl ' 5 V� ¢�f d rw l I ar SCJ � O Claim tot SOUD CSI BVPZRVISORB 07 CONTRA COBTX COUNTY Maims relating to causes of action for death or for injury or to personal property or growing crops and which accrue on D6aamber 31, 19878 must be presented not later than the .100 � after the accrual of the cause of action. Claims relating to +ca .of action for death or for injury to person or to personal propart or growing crops and which accrue on or after January 1, 19gg, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other *aures of action must lee presented not later than one year after the accrual of the ,cause of action. (aGov•t Code $11.2.) S. Claims must be filed ari.th the Clerk of the board of Supervisors at its office in Room 106, County Administration Building, 951, Pint Street, Martinez, CX 94553. C. if claim is -against a district governed by the board sof Supervisors, rather than the County, the'name of the district should be filled in. D. ° if the claim 3s against more than one public entity, separate claims must be filed against eeacb public entity. B. rZ.. bee penalty for fraudulent Cl,aixs, Penal Code Sec. 72 at the end of this form. +a,er•a�:eea*t��tt��,r�t�rr�,rrr�t�#a�ra��s:,t�#,ter,ta+t#srt�re�trk,rae�rte�#rt,erta,�,�aaa�+efs,�+�as Claim By _ Reserved for Clerk's filing stamp 5 ' RECEIVED Against the County of Contra Costa) , t ° �. t% (%�- �- JUL 2 7 1999 t-J:«( - Skcj�q* District) CLERM-ARD OF SUPERVISORS (Fi.11 in,naze) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the CountX of Contra Costa or the above-named District in the sum of S f and in support of this clams represents as follows: 1. When did the damage or injury occur? (Give exsect date and hour) x 2. Whore slid the damage or injury occur? (Include city and county) kr Cosvc#�Co_ 3. Bow did the damage or injury cceur (Give fall details; use extra paper if required) JA t e. 'khat J>articular &dt or omission on the part of county or district officers, servants jos emg�l^^.cye+e caurre ,t ► jury o damage? d". t A t + CifCa( Je"rotCC. S9IUA e uro�,���ta Fe, 6 'c � JCYWrCtS (over) r �y CJ sr- LU z �. .... ....:........ ...... w.. . ........ ........ .......: :. ............................................ ... . " � ....... . a RECEIVED .. :..... : t `..... :.::...... : .. .........Ju l-.' �M: .- ..:: . :: CONTRACOST cv. x ----------------------------------- .......................... ................................ .............................................................­.­...........­­........................ d r-- DO) ....................... /iv I ......... --- .............. .. .... }. ... .. ......fix` �... .... ...... s. .... .. v ...::: ------------------------------------- ............................... ---------n.. .......S.1.111,11--t-&-ca--t . ... ........�'. ` . .:: .... ....:.: .....:: �r�� I � .. ...... . .# € E..:: #. r f t _( } "LAL a ,gS [/�, �e _ ............................................. ......... . Jt �gy,'f`'�i r`FY'' F,/��),;/�,i{I� 5�h,J( [ftp if`.! !`�i � k i t t art........ ......4.rK.L:-1 -.}.v :. .... "..... - ........: ...~ .. .: . .... .. -- ................. .... . � ...'. .... . '�......: ..._ ....: w ...... �.... ...... ...... ..... ..........G.!p _ .:: . .... . ---- ...: .. _ �.�.. : . . . - .. .. _ F . : . E.... ..::: ; .. . .. .....�:: , .... °.� .............................................. .x .::. ....... .... .... .....: ..,.� ..... :. ........ }.':i�......:.�+. .. :.fi ..... ........ _:- ' ^: ....:. Tom.:.:.:"^'... -----------------------------------------------. iii sa ' �p } ::.. ... � ....: .5,,...{..l;�,..,.... .. '.. ... .... ....... V 5 ... ................. ......... ......... . 3 .,.. ......:.: ......::: ...... . .. . .. .. --- ------ ....: ..... . .. .. --- }y n r)t C_lcl s k E1125 4i 162" " _ :: . ................................................................................................................................................................................................................................................................................... `-- lzu ....... ........ ........ ........ ............ ........................................................................................... ...... ......... ......... ......... ......... BOARD OF 51 Dt SO M OF CO:h� COSTA CO NTY, CAL PORN A BOARD AC71AUGUST 17, 1999. Claim Against the County, or District Governed by } the Board of Supervisors, Routing indorsements, } NOTICE TO CLAIMANT and Board Action, All Section references are to } The copy of this document maned to you is your California Governnnent Codes. ) notice of the action taken on your claim by the Board of Supervisors. {Paragraph IV belovA, Oven 4 j fi pursuant to Goverrimnt Code Section 913 and 515.4. Please note all "Warr ngs". AMOUNT": $84,312.70 CLAIMAN-r.- Yolanda PalTerin >3>: `ZY ATTORNEY: c/o Michael D. C,oforth DATE RECEIVED: July 13, 1999 C,oforth & Lucas ADDRESS: One Concord Centre BY DELIVERY TO CLERK ON: July 13, 1999 2300 Clayton Road, Ste. 1460 Concord, CA 94520 BY MAIL POSTMARKED: Hand-delivered L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATOT 0R, Clerk Dated: July 14, 1999 By: Deputy IL FROIvt County Counsel TO: Clerk of the Board of Supervis6rs This claim complies substantially with Sections 910 and 910.2. This claim T'AIL'S to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( } Other: Dated:—'--/ 3,��.dY .;� i{ iii✓1,..�'s�i�� � e� r �.� o„�.� fix.. z C yn- .�„� �" !,/< my Counsel UL FROND: Clerk of the Board M County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORD1 EL By unanimous vote of the Supervisors present: This Claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: ` } t PFUL BATCHELOR, Clerk, By Deputy Clerk WARDING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. SeeGovernment Mode Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDA'V'TT OF hL4ELJ NG -- - I declare under penalty of perjury that I am now, and at all times hozein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: - By: PHIL BATCIELOR By puty Clerk CC: County Counsel County Administrator �i I CERTIFICATE OF SERVICE VIA HAND DELIVERY 2 The undersigned, at Concord, California, certifies to be 3 true, under penalty of perjury under the laws of the State of Q California as follows : 3 5`' That I am a citizen of the United States, and employed in 6R Contra Costa County, California, over the age of eighteen (18) 1, 1 years and is not a party to this action or proceeding. My business address is Goforth & Lucas, One Concord Centre, 91 2300 Clayton Road, Suite 1460, Concord, California 94520; ` 10 telephone number being (510) 682-9500 . l That I served a copy of the attached: o2 CLAIM AGAINST THE COUNTY OF CONTRA COSTA � o � zL Uby placing said copy sealed in an envelope addressed as 0 14 follows: iZ acx U 15 5 " � o d ° 161 Contra Costa County Board of Supervisors 0 '1 o 1 651 Bine St . 1f;` rm. 106 Hi Martinez, CA 94553 Via hand delivery. d ,: 19 _z 20 € s, By Abri ,0. Lucero 211 2211 2311 .�e - EE � 1 24 25 € JUL 1999 80 AP,-cr sv�o 2 `sem G03? ;s 28; 3 i 3 R � CLAIM AGAINST THE COUNTY OF CONTRA COSTA 2' E ! TO: COUNTY OF CONTRA COSTA 31: ATTN: Contra Costa Beard of Supervisors 431 1 Pursuant to Section 910 of the Government Code, claim is 5 presented to the City of Pittsburg, California, as follows : 61 (a) The name, mailing address and phone number of the claimants 73 Yolanda Palmerin, 1325 Columbia Street, Pittsburg, CA 94565, f (925) 473-9256 c/o Law Offices of Goforth & Lucas etc . (b) The date, place, time, location and other } circumstances or transaction which gave rise to the claire 1V asserted: i Date: 01-08--99 Place: Contra Costa Health Services, Pittsburg Health Center, 550 School street, Pittsburg, California 3 c� 0 12 � N On or about January 8, 1999 claimant Yolanda Palmerin, who w 13 ' Was suffering from "flit syndrome" , Was examined at Pittsburg 1 Health Center on an outpatient basis . The responding physician q ^ ✓Z 14 found that claimant' s right ear was occluded with wax and elected •. 0 "4 o a to irrigate the right ear with warm water and hydrogen peroxide. 3: 15 The January 8, 1999 chart notes do not indicate that the 00 0 claimant had a rupture of the right tympanic membrane. 16'3 0 1 In claimant' s follow up visit of January 15, 1999 the right 1 17; perforation of the tympanic membrane was noted and on January 20, 1999 Lorre T. Henderson, M.D. impression was "traumatic right 181tympanic membrane perforation. " 191 Pittsburg Health Center was negligent in its care of claimant because it caused severe injury to claimant' s right ear. A Following the said negligently perforated irrigation the claimant experienced intense and increasing ear pain with decreasing 21 hearing. l 22'1 As a result of the above said traumatic tympanic membrane rupture, which measured approximately 1 . 5mm in diameter, claimant 23= was forced to undergo tympanoplasty with fascial graft from the W right temporal scalp. 243 (c) Nature of claimant' s injuries: 25 As a result of the above said 'tympanic membrane rupture, 261E which measured approximately 1 . 5mm in diameter, claimant was 1( forced to undergo tympanoplasty with fascial graft from the right 27`i temporal scalp. Claimant sustained hearing loss . 28 1 1 1 E� If` (d) The amount claimed as of the date of presentation of the claim, including the estimated amount of any prospective 2 injury, damage, or loss, insofar as it may be known at the time of the presentation of the claim, together with the basis of 3 computation of the amount claimed: E 41, 1 . Special Damages (attached) . . . . . $ 9, 312 . 70 E �g 51E 2 . General Damages . . . . . . . . . . $ 75, 000 . 00 1 TOTAL. . . . . . . $ 84,3:12 .70 7 I declare under penalty of perjury under the laws of the 8 State of California that the foregoing is true and correct . 3 9i Executed at Concord, Califorq},&on ly 13 , 1999 . E 16 a GOF'ORTH & LUCA c 12 MIQ�IAEL D. OFORTH, ° Attme claimant n�_ A 'ALMERINp 13 a _. y 14 _— E "�, IN 0 zz6 1557 d Z Oe 0 U 16 E 0 80 L) � ' 17 � 18 c 19 € rR 20'1 F 22 23� 24 263 �p 27 28, i TABLE OF CONTENTS RE. Yolanda D. Palmerin DOCUMENT EXHIBIT Contra Costa Health Services Billing . . . . . . . . . . . . 1 Contra Costa Health Services Records . . . . . . . . . . . . , . . . . . . . . . . .����.. --- . . . . . . . . . . . . . . . . . . . . . . . . . ._� ( \� K ( � [ ( K \ � { [ { [ { { [ \ \ ( ( ( ( r [ [ r � [ ` ( [ [ t ( � [ / ( ( ( [ [ E ( ( � [ : ( ( ! \ � r WILLWA,B. WALKER, M. D9 PATIENT Acco NT1NG ' HEALTH SERVICES DIRECTOR 595 Center Avenue, Suite 300 Martinez, California 94553 CONTRA COSTS Ph(925)393-6500 Fax(925)373-6599 HEALTH SE VICES June 23 , 1999 Law Offices of Goforth & Lucas 2300 Clayton Rd. , Suite 1460 Concord, CA 94520 Re : Yolanda D. Palmerin URN# 480109-8 Dear Attorney: Enclosed herewith please 'Lind a copy of billing on the above- named patient in accordance with your request for the same . Yes No in addition, this patient has received care from providers other than Contra Costa County Health XX Services . Due to the patient' s involvement in the Contra Costa Health Plan, these providers were reimbursed for their services by the Health Services Department . Any settlement received for this patient should provide for full reimbursement of all services rendered and paid for,-by Contra Costa County Health Services, 2500 Alhambra Avenue, Martinez, CA 94553 . Please inform us when litigation is settled. Thank you for your assistance in this matter. CONTRA COSTA HEALTH SERVICES Debra Ferrara Account Clerk III Enc : **The enclosed charges total $9, 312 . 70 . Contra Costa Community Substance Abuse Services . Contra Costa Emergency Medical Services . Contra Costa Environmental Health Contra Costa Hea',th Plan . . Contra Costa Hazardous Materials Programs .Contra Costa Mental Health . Contra Costa?ublic Health . Contra Costa Regional Meoical Center . Contra Costa Hea to Centers Patient Accounting 595 Center Avenue, + 300 Martinez, CA 94553 Date . 06/23/99 RE: Yolanda D. Palmerin UA 480109-8 Contra Costa County Health Services are divided into several clinic areas . The information enclosed is from xx Martinez Health Center/Centra Costa Regional Medical Center 2500 Alhambra Avenue, Martinez, CA 94553 Richmond Health Center 38th and Bissell, Richmond, CA 94805 xx Pittsburg Health Center 550 School Street, Pittsburg, CA 94565 Concord Health Center 3052 Willow Pass Road, Concord, CA 94520 Brentwood Health Center 118 Oak Street, Brentwood, CA 94513 Oakley Health Center 260 Main Street, Oakley, CA 94561 West County Older Adult Clinic 11720 San Pablo Avenue, Suite C, El Cerrito, CA 94530 Antioch Health Center 3505 Lone Tree Way, Suite 4 , Antioch, CA 94509 CCCMHC 2025 Part Chicago Highway, Concord, CA 94520 RMH C 256 24th Street, Richmond, CA 94805 AMhC 2400 Sycamore Drive, Antioch, CA 94509 George Miller Center West 2801 Hilltop Drive, Richmond, CA 94806 if you believe additional treatment was obtained at any location other than the one marked above, please request this information and/or billing from that center. Thank you. STOP • The following 56 pages are medical records. Do not print or distribute without written consent from County Counsel. ID-. PA1186--02 CONTRA COSTA REGIONAL MED CTR DATE: 06/21/9 USER: PA. LEE1 Combined Transaction Detail TIME: 10:05.2 Pat#; 4367291-4 Name : Vip. Y MR#s 4857515798-19-0111 Cyc Sry--Date Itm Code Description Most Dte Btch# Qty Amount C 1 6/15/99 41717463 ACETAMIN/COD 3OM 5/16/99 053131 145 6. 15 TRLR: 2 0506565 C 1 6/15/99 405205544 OPERATING RM 1 H 6/16/99 4O212 1 800. 00 TRLR: 1615--1722 C 1 6/15/99 4020 5692 OPR RCM EA ADL 1/ 6/16/99 40212 1 350. 00 C 1 6/15/99 40286155 MISC 6/16/99 40212 1 1865. 00 TRLR: 69631/rt tympanoplasty C 1 6/15/99 40211054. ANESTHESIA 1 HOU 6/16/99 4575229 . 1 400. 00 TRLR: 1610-17305 C 1 6/15/99 40211104 ANES EA ADDL 1/4 6/16/99 405229 2 200. 00 C 1 6/15/99 40219990 MISC ANESTHESIOL 6/16/99 40229 1 153. 00 TRLR: 69631-30 C 1 6/15/99 40277055 OP REC RM I N I T 1 6/16/99 402 50 1 4050. 00 C 1 6/15/99 40277063 OP REG RM ADD 1/ 6/16/99 40250 5 5100. 00 C 1 6/15/99 40580409 EAR/ULCER SYRING 6/16/99 40264 1 105. 50 C 1 6/15/99 40599961 FRAM ER SUCT 105E 6/16/99 40264 1 19. 27 C 1 6/15/99 40596884 SKIN SKRIBER 6/16/99 401264 1 3. 19 C 1 6/15/99 40215014 GEN W/ENDOTRACH 6/16/99 401264 1 . 00 C 1 6/15/99 40592636 SPONGE ;FRAY DET 6/16/99 40264 1 4. 01 C 1 6/15/99 40592 099 TRACH TUB HI-LO7 6/16/99 40264 1 10. 39 C 1 6/15/99 40596454 NEEDLE COUNTER L 6/16/99 40264 1 10. 50 C 1 6/15/99 405593790 SPONG LAP STRL 6/16/99 40264 1 9. 91 C 1 6/15/99 4O599268 'VAGINAL PKING 2X 6/16/99 40264 1 19. 514 C 1 6/15/99 40 593659 IV STRT PK W/A18 6/16/99 405264 1 12. 50 C 1 6/15/99 40593493 IV SET EXT 6/16/99 40264 1 4. 50 C 1 6/15/99 4O5970 68 STOPCOCKS 4 WAY 6/16/99 40 0'x+4 1 7. 00 C 1 6/15/99 405935.35 IV TUB CF21NJ SI 6/16/99 405264 1 14. 51 C 1 6/15'/99 40593543 IVSET-SECON#2C74 6/16/99 40264 1 6. 77 C 1 6/15/99 40590945 CIRC BREATHING A 6/16/99 40264 1 9. 65 C 1 6/15/99 40596215 SUTURE PACS'. #2 6/16/99 40254 1 130. 00 C 1 6/15/99 40549974 SUR CASE CART 11 6/16/99 40264 1 816. 00 C 1 6/15/99 40596108 ELECTROSURC COAG 6/16/99 40264 1 26. 00 C 1 6/15/99 40599698 YANKAUER SUCT HA 6/16/99 40264 1 2. 98 C 1 5/15/99 40596033; LINER DISP 15OOW 6/16/99 40264 1 11. 00 C 1 6/15/99 40288066 ENT-COMPLEX 6/16/99 40264 1 . 00 C 1 6/15/99 40593964 MA K -ANEST MED O 6/16/99 40264 1 22. 00 C - 6/15/99 40598765 TUBE CONNECT 6 F 6/16/99 401264 1 2. 49 C 1 6/15/99 40599698 YANKAUER SUCT HA 6/16/99 405264 1 2. 98 C 1 6/15/99 40592057 ELECTRODE, PEDI 6/16/99 40264 1 2. 27 C 1 6/15/99 40590218 AIRWAY, SMALL 6/16/99 40264 1 1. 75 C 1 6/15/99 40598419 SYRINGE 5 ML 6/16/99 40264 1 1. ,51 C 1 6/155/99 405591364 CATH SUCTION 14F 6/16/99 40264 1 4. 00 C 1 6/15/99 40598443 SYRINGE 301 ML 6/16/99 40264 1 1. 52 C 1 6/15/99 40598427 SYRINGE 105 ML 6/16/99 40254 1 1. 00 C 1 6/15/99 40593493 IV SET EXT 6/16/99 40264 1 4. 50 C 1 6/15/99 40597239 OXISENSOR N25 6/16/99 40+264 1 71. 77 C 1 6/15/99 405561177 KIT IVSTART PACU 6/17/99 05410 1 41. 24 C 1 6/15/99 41715087 PLASMALYLE A 100 6/17/99 05410 1 50. 09 C 1 6/15/99 40570020 MASK OXY ADULT 6/17/99 05410 1 3. 22 C 1 6/15/99 405594970€ ELECTRODES -- SUR 6/17/99 0 5410 1 4. 75 C 1 6/16/99 40574765 MICROSCOPE 6/17/99 055408 1 150. 0505 C 1 6/16/99 40594046 MICROSCOPE DRAPE 6/17/99 0.3408 1 125. 00 TOTAL. . . . . . . . . 6292. 56 CONTRA COSTA COUNTY HEA LTH SERVICES PAcsrus. . TY ILL DATE OF U.J. ,� � 2500 ALHAMBRA AVENUE FINAL MARTINEZ,CALIFORNIA 94553 l ' (510)313-6500 AO PATIENT NAME PATIENT NUMBER S€% ' AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED -- PAIMERIN, YOLANDA D 43471408 Fj 48105/24/99105/24/99 1 INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOLANDA PALMERIN NAME 1-325 COLOM3. A STREET AND PITTSBURG, CA 94565 ADDRESS i PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' DATE OFDESCRIPTION OF S€ CE TOTAL EST.COvERAGE EST.COvERAG€ EST COvERAG€ PATIENT SERVIC€ G1! so"CE SERVICES E CODE CHARGES INS.CO.NO.4 INS.co,NO.2 INS.CO.NO.3 AMOUNT 00524 9 1 ECG 4110001. 1.32 . 00 s ** TOTAL EKG 132 .00 E 05249 1 'COMPREHENSIVE I—EST —7,8400227 97 . 00 i 05249 1 TX—ROOM COMP I EST 5846022 11.7 .00 * TOTAL ENT/AUDIOLOGY 214 . 00 SUPS—TOTAL CHARGES 346. 00 j TOTAL -LIABILITY 346. 00 i i c i s c E s s E s i I l r 3 i s s s s E i p t 4601098-05-0107_ PATMW NUMBER PLEA&F P"MA TO PASS NT ADOMONAL PATINNT s LLMO MAY!Y NEC€9BARY FOR ANY NUN ER ON ALL Nt"luN& CRAM"$NOY FMNO WREN TM SILL WAS PREPARPO,OR a 43471402 AND CbRRE&PONa&NG&. AMOUNT&ONOWM UNDER &TIMATED sureURANCE CMItAoe. PLEASEIF INSUKANCE CAMSU 00 NOT PAY ANY FAPff OF THE SAY THIS AMOUNT Mate checks Payable to:CONTRA COSTA COUNTY HEALTH S'rRMCES,595 Center Avenue,Suite 300,Martinez,CA 94553 4L �. CONTRA COSTA COUNTY HEALTH SERVICES PACE NO. TYIE OF DATE Of 8" -� 250th ALHAMBRA AVENUE FINAL MARTINEZ,CALIFORNIA 94553 OCT (510)313-5500 AO .0 PATIENT NAME fWnENF`NUMBER SEX I AGE E AomismoN OATS mocHARGE DATE I DAYS AMOUNT ENCLOSED PAT,MERIN, YOLANDA D 4292B614 E 47104/05/99 04/05/99 1 � INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOLANDA PAT M„.R T N NAME 2325 COLOMBIA S'T'REET AND PITTSBURG, CA 94565 € AOORIESB i € ; PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' OATS OF DESCRIPMON OF SERVICE '1 OTAL EBT;COVERAGE EST.COVERAGE EST.COVERAGE PATIENT SERVICE r 3Y HOSPITAL SERVICEIS CODE CHARGES 3NS.CO.NO.1 INS,CO.NO.2 INS.CO.NO.3 AMOUNT i 04059- 1 CARDIO STRESS TEST 41-1000313 43.4 . 00 ** TOTALS EKG 414 . 00 04059 € 1 EXPANDED CONSULT 58400326 82 . 00 04059 1 TX—ROOM EXPANDED CO 58460329 91 . 00 = * TOTAL ENT/AUDIOLOGY I 173. 00 f SUB—TOTAL CHARGES 587 . 00 TOTAL LIABILITY 587 . 001 € i c p € 11€ € f i € f i I 3 E i i i € f I 480-1098-05-0143 #'AT1E3EF NUMBER FLEAii REFER TO QUW6r ABOMONAL PAVNNf SP-LINO ANY EE NECESSARY FOR ANY - ftB”R ON ALL PATIENT CNAROSS NOT FOOTED WHEN TM N&L WAl FREFARED,OR 4 2 9 2 8 614 AND aoRREsroNDENCE. oNAMOUNTS i°NtOWN e�gb WS RANC*COVIRAoa PLEASE PAY THIS AMOUNT € 3 y Make checks Payable to CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,Suite 3413,Martinez,CA 94553 a CONTRA C©STA COUNTY HEALTH SERVICESTY*E OF ©ATF OF» 2540 ALHAMBRA AVENUE FINAL MARTINEZ,CALIFORNIA 94553 (510)313-6500 AO O PATIENT NAME PATIENT NUMBER I SEX I AGE ADMISSION CATS DISCHARGE DATE DAYS AMOUNT ENCLOSED PALMERTN. , YOLA DA B 42.305789 k 47102/04/99 02/04/99 1 INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOLANDA PALMERII NAME 1325 COLOMBIA STREET I AND PITTSBURG, CA 94565 ADDRESS I , c i PLEASE RETURN TCP PORTION WITH YOUR PAYMENT ' DATE OF DESCRIPTION OF SERVICE TOTAL EST.COVERAGE EBT.COVERAGE EST:COVERAGE PATIENT SERVICE HOSPITAL 8ERVtCEB CODE CHARGES INS,Co.NO,I INS.CO,NO,2 INS.CCI,NO.3 AMOUNT t ( � t 02049S 1 BRIEF CONSULT 15840030 63.00 02049 1 ``X—ROOM BRIEF COINS 5846030 78. 00 I * TOTAL ENT/AUL7TOLOGY 141 . 00 013[]SU RY OF CHARGES BY DEPAR MENT ENT/AUDIOLOGY 141 .00 SUB—TOTAL CHARGES 141 . 00 TOTAL i I ABTT-ITY 141 00 E i � t i f f 3 i i s E c e 4 8011798-05-01 0 PATIENT NUMBER J PLBAS&RWLgtTo PATOW A=ffMSMAL PATISW"LOW NAY Rtl NNUONSARY FOR ANY - NUbNI6R*WALL OWUMISS CHARGES NIT POST90 WMEN THIS HILL VMS PRNPAMB OR 4 2 3 0 5 7 8 ANB coRR�sroNss�Nce. AMOUNTs sH u" NDER 00 NW€ISTiNA�INS PART cR aaYMPAaa. PLEASE PARI THIS AMOUNT f Aftk*Checks payable to:CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,Suite 300,Martinez,CA 94553 CONTRA COSTA COUNTY HEAL=TH SERVICES PAGE NO' Tyk OF DATE OF RILL / 2500 ALHAMBRA AVENUE FINAL 4 MARTINEZ,CALIFORNIA 94553 (510)313-6500 AO O PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED PALMER N, YOLANDA rJ 42144543 F 47101/20/99 01/20/99 1 s INSURANCE COMPANY NAME GROUP NO. I P013CY NUMBER GUARANTOR YOLANBA PALM ERIN NAM€ 1325 COLOMBIA STREET AND P-'`TSBURG, CA 94565 ADDRESS c E E I PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' DATE OF DESCRIPTION OF SERVICE TOTAL EST COVERAGE ESTCGvERAGE EST;COVERAGE i PAT104T SERVICE Ci7'l HOSPITAL SERVICES CODE CHARGES 3N$.CO.NO.t INS.CO.NO.2 INS,CO.NO.3 AMOUW i 012109 1 EXPANDED CONSULT S64003261 82.00 01209 1 TX—ROOM EXPANDED CO 58460320 91 < 00 * TOTAL ENT/AUDIOLOGY 173. 00 L'�3.DOS`s �,ARY OF CHARGE'S BY DE PAR MENT ENT/AUDIOLOGY 173. 00 SUB—TO'T'AL CHARGES 173. 00 E TOTAL LIABILITY 173.00 E E s i E E 3 I E 3 � 4801098-0 5-00 9 PATIENT WM$ER PLEASE REFSR TO PATIENT ADDITIONAL PATMOT 83LLINO MAY ES RSOEESARY FOR ANY I - NuMSSR ON ALL INoummB CHARO88 NOT POSTED INNBN TM WU MR8 PREAMMO,OR f AND CORRESPONDENCE. IF INSURANDS CARRIERS DO NOT PAYANY PART OF TfIE PLEASE PAY THIS AMOUNT E 421 4543 _ ; AMOUNTS SNOWN UNDER E57IMl7E0 INSURANCE COVERAGE. Make checks payable to.CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,Suite 300,Marhnoz,CA 94553 CONTRA COSTA COUNTY HEALTH SERVICES PAGE NO. wpi OF I DATE OF BILA (510)313-6500 - 25t7 ALE AMBRA AVENUE FINALMARTINEZ,CALIFORNIA 94553 1%0 y;. PATIENT#AME PATIENT NUMBER SEX AGE I ADMISSION DATE I DISCHARGE DATE I DAYS AMOUNT ENCLOSED PALMERIN, YOLANDA D E 72987886 E 47101/1- 8/99 01/18/99 ' Is INSURANCE COMPANY NAME GROUP NO. ..UMBER GUARANTOR YOLANDA PALMDR T N NAME 1325 COLOMBIA ST AND PITTSBURG, CA 94565 E ADDRESS s i s PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE DESCFtfPT3Ct7 D€ SERVICE TOTAL EST.COVERAGE EST:coveRAGE EST;COVERAGE PATIENT SERVICE ; HOSPr 4L SERVlCEe CC4ARtEg INS.CO.Nfl.1 INS.CO.#O.2 i#S.CO.NA 9 AMOUNT I OI189 1 EMERGENCY ROOM 4530002 95.00 01189 1 ER LIMITED Vi SIT 4552440 50.00 *X TOTAL EMERGENCY ROOM VISITS 135. 00 F-i-00SUMNLARY OF CHARGES BY DEBAR ME NT EMERGENCY ROOM VISITS 135. 00 SUB—TOTAL CHARGES 135. 00 TOTAL LIABILITY 135. 00 E k III ' s s E i 1 ' E E E e i I i G I 6 � 4801098--02--00 8 PATIENT NUMBER PL94AS R6f6R TC PAroff ADDITMI"PATIENT OLLMO MAY SS HBCFSSARY FOR ANYkl#A7 A ROMOSON PONWWOIL S IF NfURRANCE MOT MFRS DOE"NOT PAIN°riiL MAS"Y PART OF om'OR PLEASE PAY THIS AMOUNT 3 72987886 , AMCUHT!SHOMYY7 UMOlR IWIMATRO IMSU'RAMCE COMMOL y,; Make checks payable to:CONTRA COSTA COUNTY HEALTH SERVICES,595 Canter Avenue,Suite 300,Martinez,CA 94553 CONTRA COSTA COUNTY HEALTH SERVICES BILI. PAGE NO. TYPE£s� ®A-E e £ �' 2500 ALHAMBRA AVENUE AN .L MARTINEZ,CALIFORNIA 94553 U0 T (510)313-6501' O O PATIENT NAME PATIENT NUMBER SEX AGE I ADMiSS£ON OATS DISCHARGE DATE DAYS AMOUNT ENCLOSED PALMEEcTN, YO AN DA D 43433353 ik 48 05/25/99 0 /25/99 1 i INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER i GUARANTOR YOLANDA. PALMERIN NAME 1325 C^vLOM-131A STREET ; AND PITTSBURG, CA 94565 ADDRESS i PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' OATS O€ O.y DESCRIPTION OF SERVICE € TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE i PATIENT SERVICE MOS14TAL SERVICES CODE i CHARGES INS.CO.NO.I INS.CO.NO.2 INS.CO.NO.3 i AMOUNT i E t ; E E € i 06019 2 VENIPUNCTURE 4363035 NIC j 0601. 9s I URIN PRk.G TEST 4363044 27 .50 t t 06019 _ HEM HEMGRM/PLT/DIS 4363057 38 . 00 € € ** TOTAL LAE—CLINICS & UBLIC Hl, 65. 50 € 052598 1 EXPANDED VISIT—NEW 58420068 55. 00 052599 1 DTAG AUDIO EVAL 5342227 71 .50 B 052590 1 IMPEDANCE TESTING 5842230 32 . 00" 05259 1 TX—ROOM EXPANDED NE 5343006 91 . 00 * TOTAL ENT/AUDIOLOGY 249. 50 SUB—TOTAL CHARGES 315. 00 j 'T'OTAL LIABILITY � 315. 00 € i € 6 € 4801098-10-01 3 PA'F SNr NUMBER MSAS®rjw" 0 PAT£BNT ADWIONAL f%'r0 t 81"INO fAY 89 MROUBARY FOR ANY muhs"ON A"INCHAR lS ONAR.a..NOT POSY.®WHEN THO R&L WAS Pnftmo,IDK 4.�48 3 5 3 AND OO£CitESPaNOiNCB. Aa�ta�Nca a fHrnwW a iin ae ru"ax ffiY ANY PART tici acsr eAa . PLEASE PAY THIS AMOUNT y MR)*checks POYabie to CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,Suite 300,Martinez,CA 94553 PAGE NO. i CONTRA COSTA COUNTY HEALTH SERVICES r— WPE OF WLLA- o ELL i' x 2500 ALHAMBRA AVENUE F'INA 887' MARTINEZ,CALIFORNIA 94553 (510)313-6500 AQ G PATIENT NAME PAmENT NUMBER SEX AGE ADMISGION DATE DISCHARGE DATE.. DAYS AMOUNT ENCLOSED PALM ERIN, YOLANDA D 60940442 F 48 05/05/99 05/05/99 ' s INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR YOLANDA PALMERIN NAME 132: COLOMBIA STREET I ANO PITTSBURG, CA 94565 ADDRESS 9 PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' DATE OF DESCRIPTION OF SERVICE TOTAL EST COVERAGE ESI.COVERAGE W.COVERAGE PATIENT f SERVICE QTY HOSPITAL SERVICES CODE CHARGES INS.CO.NO.I INS.CO.NO.2 INS.CO.NO.3 AMOUNT 05059s 1 MANLMMOGRAPHY SCREEN 4141098 1.29.00 ** TOTAL X—RAY 129.00 ' 000SU MARY C' CHARGES BY DE PAR MEN T X-RAY 1-29.00 SUB-TOTAL CHARGES 129.00 TOTAL LIABILITY X29.00 I i i t' E i i 0 I I s s I i i f i 4801098-10-01 6 Ii PATIENT NUMBER PLI AU Wflt Tb FATMW ADWKWAL PATNINT 90-LLW MAY W NIIQN68ARY FOR ANY N+JME,ON ALL MQS9IRAS CN0.ARORG NOT POMO W 2N TM WLL Vaa PPM%XJ as i 4 2 AND caRlvr:raNarsNcoz. NaelNetvaeg"u Yi Ria ANY PARTTM PLEASE PAY THIS AMOUNT y; Make checks POYANO tDr CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,Suite 300,Martinez,CA 94553 A CONTRA COSTA COUNTY HEALTH SERVICES PAGE No. TY"OF DATE OF L >-' 25M ALHAMBRA AVENUE t FI NATf MARTINEZ,CALIFORNIA 94553 i (510)313-6500 AO O PATIENTNAME PATIENT NUMBER SEX AGE AOMISSION DATE DISCHARGE DATE I DAYS AMOUNT ENCLOSED PALMERIN, YOLANDA D 43124981 is 47 04/22/35 04/22/99 1 INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER t GUARANTOR YOLANDA PALMERIN i NAME ; 1325 COLOMB?A STREET AND PITTSBURG, CA 9456: ADDRESS i 1 ` ` I PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' GATE OF QTY. DESCRIPTION OF SERVICE TOTAL ear COVERAGE EST.COVERAGE EST.COVERAGE � PATIENT sr"C€ HBSPITAL SERVICES CODE CHARGES INS.CO.NO.i INS.CO.NO.2 M.CO.NO.'.3 AMOUNT s i s 04229 100 CHLORPHEN 4MG-1070 417308 9. 00 i 25 165800 04229S 17 ALBUTEROL iNH 17GGM 4174281 29.24 E 25 165799 I 04229S 100 PSEUDOEPHIRD 60MG-10 4174936 12. 00 25 165801 i * TOTAL PHARMACY 50.24 3 04229S 1 DETAILED VISIT—EST 5182020 60. 00 04229 1 TX ROOM—DETAILED—ES 5i880205^10. 00 ? ' x TOTAL FAMILY PRACTICI 110. 00 SUB—TOTAL, CHARGES 160. 24 TOTAL. LIABILITY 160.24 C E s c a s s s 3 4801038-103-01 4 PATIENT NUMBER K.fAMI NEPER TC PATIOW ADWMNAL YATNW SILLM O MAY of NfCifSAlCY PCN ANY NUMER ON ALL MiOMMS CNARAES wn PbSTEC WNEm T"W.L WAS ARfMTfLO.oft 4 3 81 ANC!a ,sir oawr`"MS SHOW °M�r=Y c is aAraf PLEASE PAY THIS AA40l1NT Make Checks payable to.CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,Suite 300,Martinez,CA 94553 A(` CONTRA COSTA COUNTY HEALTH SERVICES PACE"O A . ' '` 2500 ALHAMBRA AVENUE IFINAL MARTINEZ,CALIFORNIA 94553 (510)313-3500 0 PATIENT NAME PXnENT NUMBER 8EX AGE ADMISSION DATE DISCHARGE DAT- DAYS AMOUNT ENCLOSED PFiLMERIN, YOLANDA D 42898221 F1 47 04/01/99 04/01/95 INSURANCE COMPANY NAMECROUP NO. POLICY NUMBER I i i IGUARANrOR YOLANDA PALMERIN NAME .1325 C1-/—IBIA STREET AND PITTSBURG, CA 94565 j ADDRESS i 1 PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' ORM OF DESCRIPTION OF SE€tVrCE TOTAL EST.COVERAGE EST.COVERAGE EST.COVERAGE i PATSENT SERVICE Off' HOSPITAL SERVICES CODE CHARGES INS.CO.NO.r INS.CO.NO.2 INS.CO.NO.5 AMOUNT E ! I 04019S 100 ACETAIMINOPHEN TABS 41.73176 9.00 8 1.62554 ** TOTAL PHARMACY 9. 00 i 04019S 1 BRIEF V-SIT—EST 5182016 30. 00 0401.9 1 TX ROOM—BRIEF—EST 5188016 50. 00 * TOTAL FAMILY PRACTICE ' 80. 00 i SUB—TOTAL CHARGES 89. 00 TOTAL LIABILITY 89. 00 o 1 E a E i = c ' i a s I f i! I 4801098:- 10-01 2 PATIENT NUMBER PLUM RIVER TO PATOW AOOr MML PATIENT MLLING WYN9 MIZOS99ARYPOR ANY - - - m$11"It ON ALL mwR1*8 CHAP490 NOT POs Y80 WHIM Tfo ELL Vat PRlPAREO,OR 8 - r r AMO CORRUPOOMWef. IF AMO "1%,PAYN uPRAT OF�RAwe. PLEASE FLAY THIS AMOUNT ,; Make checks payable to.CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,wife 300,Martlnea,CA 94553 CONTRA COSTA COUNTY HEALTH SERVICES PAGE-NO. s LOg DA`TEOFRILL % � 2500 ALHAMBRA AVENUE � E -NA, , v MARTINEZ,CALIFORNIA 94553 �77r— (510)313-6500 PATIENT NAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOSED j PALMERIN, YOLANDA D 42452649 E 47 02/19!99 02/19/991 s INSURANCE COMPANY NAME CROUP NO. POLICY NUMBER i GUARANTOR `!OLANDA PALMERIN i NAME I 1325 COLOMBIA STREET j I AND P.ITTSBURG, CA 94565 i ADDRESS I PLEASE RETURN TOP PORTION WITH YOUR PAYMENT DATE OF DESCRIPTION OF SERVICE TOTAL EST.COVERAGE 6ST COVERAGE EST.COVERAGE PATIENT # 4 MCS ; Q.Y. HOSPITAL SERVICES CODE CHARGES INS.CO.I I INS.CO.NO.Z INS.CO.NO.3 AMOUNT 021991 70 ACYCLOVIR 800MG CAP 4173984 275. 10 14 155279 I 021999 60 CHLORPHEN 4MG-24 41749241 5. 40 30 155278 ** TOTAL PHARMACY E 283. 50 j 02199 1 EXPANDED VIS':T EST 5182018 42.00 021991 1 TX ROOYI-EXPANDED-ES 5188018 50. 00 ** TOTAL FAMILY PRACTIC j 92 . 00 i ; SUB-TOTAL: CHARGES 372. 50 i TOTAL LIABILITY � 372. 50 3 i E i 3 E i i i i 3( 6 I i j i s I : 1 E i 4801098-1C-01 � PATIENT" #ICAU ABffR To►Amir 1AMTiYI AL M INT SILL MO AIRY$&,!=IfB/tRY i�CRANY AND CO�R�it�iM OEIiGft ALL �� CmArA ams NOT �na NOt PAYNYY PART OF THE OR PLEASE PAY THIS AMOUNT 452649 ANOUR"SMOWN tMSR srsxHAUM MUR MCr CMRAOC. , y,x Mak&ChOCks PaY&bk to.CONTRA COSTA COUNTY HEALTH SERMCES,595 Center Avenue,Suite 300,Martinez,CA 94553 CONTRA COSTA COUNTY HEALTH :SERVICES ` pAG€o L DATE OF ISL ;-' �' 25W ALHAMBRA AVENUE T. L MARTINEZ,CALIFORNIA 94553 (510)313-6500 F2ALMERIN, PATIENTNAME PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATEDAYSAMOUNT ENCLOSER Y'JL.xLNDA I} 421138548 47101/15/99101/15/99 1 INSURANCE COMPANY NAME GROUP 140. POLICY NUMBER GUARANTOR YO---.,ANDA PAf�ME R I N NAME 1325 COLOMBIA ST i AND PITTSBURG, CA 94565 ADDRESS 3 i PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' DATE OFDESCRIPTION OF SERVICE TOTAL EST COVERAGE EST COVERAGE ES7 COVERAGE PATIENT SERYICE QTY. HOSPITAL SERVICES COBE CHARGES INS.CO.ND.I INS.CO.NO.2 INS.CO.NO.3 AMOUNT 01159 60 NAPROXEN 250MG # 4173132 NIC 30 149517 0.11.59 20 TRIMET/SUL?'AIM DS # 41743367 13. 40 g 10 149516 I ** TOTAL PHAR_MAI CY 13. 40 3 01159s 1 EXPANDED VISIT EST 51820181 42 .00 01159s 1 TX ROOM—EXPANDED—ES 5188018 50. 00 * TOTAL FAMILY PRACTICI 92 . 00 c SUB—TOTAL CHARGES 105. 40 ' TOTAL LIABILITY 105. 40 I I E I t 48G1098-10-0017 fi PATIENT NUMSER rL&A26 R3r8R TC PATIENT AC1fi% 2" PATl"T RU-11O M1Y 8'A RiCC$BARY FOR ANY _ W,JWUVR(W ALL INGUWAS EIiAIRi#18 NO2 tiSETj Wj TM FILL Ws.E F"FAMD,DR 0 8 5 4$ AND aORREsraNtitxcE. Ar�u14=woo:°°sT�T�1mu cff C THN RA PLEASE PAY THEA AIi'Ii7U�I f y,; hfafslea checks payable to.CONTRA COSTA COUNTY HEALTH SERMCES,595 Center Avenue,Sulto 300,Martinez,CA 94553 CONTRA COSTA COUNTY HEALTH SERVICES PA(iENo. ,SILLTYPEOF DATE uF sem. %' '' 2500 ALHAMBRA AVENUE PIN Ai MARMNEZ,CALIFORNIA 94553 (510)313-6500 AO 0 PATIENT NAME PATIENT Nttmom SEX I AGE 3 ADMISSION DATE DISCHARGE DAM DAYS AMOUNT ENCLOSED � PALMERIN, YOLANDA D 42079939 K 47101/13/99101/13/99 1 $ �I INSURANCE COMPANY NAME GROUP NO. POLICY NUMBER GUARANTOR Y O LAN EA PALM E R I N NAME 1325 COLOMBIA ST AAAI PITTSBURG, CA 94565 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' DATE DP DESCRIPTION OF SERVICE TOTAL EST.COVERAGE EST.COVERAGE EST.CDVERAGE PATIENT SERVICE $TY HOSPITAL SERVICES CODE CHARGES ## .CO.# .4 INS.CO.NO.2 iNB.CO.NO.3 AMOUNT s i i I 01139S 10 ANTIPYRINE/HENZOCAI 4173184 19. 90 7 149055 01139 30 AMOXICILLIN500MG CA 4174250" 13. 80 10 149054 * TOTAL PHARMACY 33.70 E 01139S 1 EXPANDED VISIT EST 51820181 42. 00 01139 1 TX ROOM—EXPANDED—ES 5188018 50. 00 * TOTAL FAMILY PRACTICE 92. 00 i i SUE—TOTAL CHARGES 125.70 TOTAL LIABILITY 125,70 j i E 4801098-10-0046 PATIENT NUMBER. PLEAlE RwIlm TO PATENT ADOITU)NAL IEMT SILLDIO WAY IM N90848ARY FOR ANY HUNA R ON ALL IYOW UN GHARO"NOT POWT60 rM TNRi RIiL Hill FREPAR$O,OR . ANDCOPANPONOEMCE. AAS Aw.4 xRrA T"p�`yaPAY NYINStu«O THN'II AaE. PLEASE PAY THIS AMOUNT r Make cheeks payable to.CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,Suite 300,Martinez,CA 94553 CONTRA COSTA COUNTY HEALTH SERVICES PA6gNO. fLE DAM 8kd. a 2500 ALHAMBRA AVENUEFINA MARTINEZ,CALIFORNIA 94553 (510)313-5500 0 PATIENT NAME 1, WiT NUMBER I SEX I ACE ADMISSION DATE DISCHARGE DATE DAYS AMOUNT ENCLOBED PALMETERIN, YOLANDA D 60794690 F 99 01/08/99 1 INSURANCE COMPANY NAME GROUP NO. POUCY NUM8ER GUARANTORY 0LA:'N DA PAT.E R..I N NAME 1325 COLOMBIA ST AND PITTSBURG, CA 94565 ADDRESS i PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' DATE OF DESCRIPTION OF SERVICE TOTAL EST.COVERAGE EST COVERAGE EBT.COVERAGE PATIENT BE#RVMCE O� HOSPITAL SERVICES CODE CHARGES ENS.CO.NO.! INS.CO.N0.2 INS.CO.NO.S AMOUN' 01089S 100 ESTROGEN/EST 0. 625M 4173143 27 .00 1£30 107937 X* TOTAL PHARMACY 27 . 00 i 3 000SUNMARY OF CHARGES BY DE AR 'MENT S PHARMACY 27 . 00 i SIOS-TOTAL CHARGES 27 . 00 TOTAL LIABILITY 27 . 00 1 E s c i s s i s s 4801098-10-0015 i PATIENT N iMrlER NUMBS ON A L iMTi g AUOITICIIAL PATWXT N"INO MAY W N@Cd@4ANY PCR ANY NUMBER ON ALE.INA1pRfL°3 CHAR"N NOT P0111D YM@N THO BELL VAS PREPARED,aft _60794t ANDaoRREEPCND@NC$. } @ vNoert°i@�F aFf©IN�"YsuPARTcE O-00 ttawa@. ALAE PAY THIS AMOUNT ANKWW.>> Make checks payable to.CONTRA COM COUNTY HEALTH SERMCES,5435 Center Avenue,Suite 300,Wortinez,CA 84553 %� rs CONTRA COSTA COUNTY H=ALTH SERVICES PAGE NO. oATeO€BILL o. ,�-' � . . 25001 ALHAIUIBRA AVENUE � E� ' T. MARTINEZ,CALIFORNIA 94553 (510)313-5500 O O PATIENT NAME PATSEw NUMSER SEX AGE ADMISSION DATE OISCHARGIE HATE DAYS AMOLINT ENCLOSE( i PALMERIN, YOLANDA D 42028464 471,01/08/99 01/08/99 1 E INSURANCE COMPANY NAME GROUP NO. POLICY NUMSER E y GUARANTOR YOLANDA PALM ERIN NAME ` 1325 COLOMBIA ST ! AND PITTSBURG, CA 94565 ADCRESS c i 3 i PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ' VA'MOF i O,t. OESC€if€MON OF SERVICE TOTAL EST COVERAGE E8T.Ct7VERACs€ EST.COVERAGE PAMEW. mcs HOSPITAL SERVICER COOS CHARGES INS.CO.NO,# fN$,CO.N0.2 INS,CO.NO., AMOLW- I I 01089q 1 CHEM HGBAIC 4068101 26. 00 ** TOTAL: CLdNICAL LAB 26. 00 01089 30 TRIPRO/PS UDO "ABS 41.73060 3. 00 30 .14815" 010891 30 DIPHENHYDRAMINE 50M 4:173094 NICi 30 148150 01089 100 IBUPROFEN 600MG #I 4174479 22. 041 33 148153 01.0899 60 FLUOXET HCL20MG TAB 4174684 157 .20 60 148154 01089S 30 ACETA.M/COD CT30MG # 41748.53 14 . 10 30 1461^2 ** TOTAL PHARMACY 196.30 01089s 1 VENIPUNCTURE 4363035 N/C ** TOTAL LAB—CLINICS & PUBLIC Hill 01089s 1 EXPANDED VISIT EST 5182018 42.00 01089s ? TX ROOM—EXPANDED—ES 5188013 50. 00 ** 'TOTAL FAMILY PRACTIC - 92 . 40 s SUB--TOTAL CHARGES 314 . 30 TOTAL LIABILITY 314 .34 I ` 4801109.8-10-00T4 I PA'E?ENT N4JM8ER PLEASE RSF8R Y0 FAY'N9ff ADWMHAL FAT$Wt YfLLNNG MAY 88 1486$SSARY FOR ANY NUM08 SPQ Nq$ W R`A NOT R20"rRMFAYANYFAm�or HE °" PLEASE PAY THIS AMOUNT 2 8 4 6 4 AMOUN"$MOWN UNOSR MIWATIM WSURANC9 OOY$RA68. y Msk6 Checks PAYOble to.CONTRA COSTA COUNTY HEALTH SERVICES,595 Center Avenue,Suite 300,Martinez,CA 94553 z �^ :«��� � _.���� �~: ��� ~. \ \ ° \� ! � f \ \ t \ \ \ \ / \ e \ . \ \ \ \ � ¥ % \ \ � \ \ \ % f � \ \ \ \ \ \ � { \ \ \ � x { { f ................................................ .................... ..................................................................... CONTRA,, DECLARATION OF CUSTODIAN OF MEDICAL RECORDS COF-TA' C0614TY CONTRA COSTA CUSTODIAN OF MEDICAL RECORDS: Tina Thompson HEALTH SERVICES RE: Palmerin,Yolanda D. MEDICAL RECORD# 4 8 - 0 1 - 09 - 8 CASE# SSN: 519-21-1010 DATE SUBPOENA SERVED: says as follows: That the declarant is the duly authorized Custodian of Medical Records of Contra Costa Health Services and has authority to certify said records, and 0 That the copies of the original Medical Records attached to this declaration are true copies of all the records described in the 7 Subpoena Duces Tecurn E-1 request as indicated below and have been released for documentation on microfilm to the deposition notary That the copies of the original Medical Records attached to this 0 Igdeclaration are true copies of all the records described in the ilf - =�Q -1 Subpoena Duces Tecurn CK request as described below: F g No exceptions. CL K 'm E❑ Except those portions of the record which come under the -1 C*10 C3 0 ' 0 provisions of the Welfare and Institutions Code § 5328. 0 1==;;. CL. a --4cD —= % E-1 Except those portions of the record which come under the MWVo =' 'a , Em provisions of 42 C.F.R§ 2.3 et seq. 402 ;-"cro aZ;g 50=n 7 Except those portions of the record which come under the = provisions of California Health& Safety Code§199.20-199.22. ❑ Other exceptions: =0 L CK Billing information will follow under separate cover. cr� a C 7 Diagnostic imaging films will follow under separate cover. That the records were completed by the personnel of Contra Costa Health Services, staff physicians,or persons acting under the control of either, in the ordinary course of REPLY TO MEDICAL hospital and health center business at or near the time of the act, condition or event. RECORDS AT: Contra Costa Regional I declare under penalty of per ury that the foregoing is true and correct. Medical Center Contra Costa Health Centers 544" 2500 Alhambra Ave. Signature of Declarant Martinez, CA 94553 9251370-5220 Executed on date: June 17, 1999 at Martinez, California. Contra Costa Health Services is divided into several clinic areas. The information enclosed is front. (1) Contra Costa Regional Medical Center ❑ EarlyPeriodic Screening,Diagnosis&Treatment Contra Costa Health Centers (EPSDT),Children's Mental Health 2500 Alhambra Avenue,Martinez,CA 94553 2450 Stanwell Drive,Suite 200,Concord,CA 94520 (925)370-52213 FAX 370-5275 (925)646-5097 FAX 646-5115 ❑ Tom Powers Health Center(Richmond Health Center) ❑ Intensive Intermittent Intervention Program(I3P) 10038th Street,Richmond,CA 94805 Children's Mental Health (510)374-3071 FAX 374-3024 2450 Stanwell Drive,Suite 270,Concord,CA 94520 ❑ North Richmond CenterforHealth (925)646-5118 " FAX 646-5115 1501 3rd Street,North Richmond,CA 94801 ❑ Summit Center,Children's Mental Health (510)374-7327 FAX 374-7328 204 Glacier Dr.,Martinez,CA 94553 ❑ Pittsburg Health Center (925)313-2900 FAX 313-2921 550 School Street,Pittsburg,CA 94565 ❑ Hospital&Residential Program (925)427-8075 FAX 427-8313 Children's Mental Health 0 Concord Health Center 2425 Bisso Lane,Suite 235,Concord,CA.94520 3052 Willow Pass Road,Concord,CA 94520 (925)646-5240 FAX 646-5662 (925)646-5506 - FAX 646-5505 ❑ Conservatorship/Guardianship Program ❑ Brentwood Health Center 624 Ferry Street,Martinez,CA 94553 118 Oak Street,Brentwood,CA 94513 (925)646-2791 FAX 646-2853 (925)634-1102; 427-8628 FAX 427-8639 ❑ Detention Facility,Mental Health Services ❑ Bay Point Family Health Center 1000 Ward Street,Martinez,CA 94553 215 Pacifica Ave.,Bay Point,CA 94565 (925)646-4702 FAX 646-4712 (925)427-8296 FAX 427-8304 ❑ Mental Health Crisis Services ❑ Antioch Health Center 2500 Alhambra Ave.,Martinez,CA 94553 3505 Lone Tree Way,Suite 1,Antioch,CA 94509 (925)370-5700 FAX 646-5716 (925)427-8586 FAX 427-8581 ❑ Forensic/Criminaljustice ❑ Concord OlderAdults Clinic Conditional Release Program(CONREP) 3052 Willow Pass Road,Concord,CA 94520 10 Douglas Drive,Suite 140,Martinez,CA 94553 (925)646-5506 FAX 646-5505 (925)313-1150 FAX 313-1163 ❑ Antioch OlderAdults Clinic ❑ East County Adult Mental Health Clinic 3505 Lone Tree Way,Suite 4,Antioch,CA 94509 550 School Street,Pittsburg,CA 94565 (925)427-8775 FAX 427-8779 (925)427-8110 FAX 427-8117 ❑ El Cerrito OlderAdults Clinic ❑ East County Adult Mental Health Clinic Annex 11720 San Pablo Avenue,Suite C 2400 Sycamore Drive,Suite 18,Antioch,CA 94509 E1 Cerrito,CA 94530 (925)427-8700 FAX 427-8707 (510)374-3629 FAX 374-3294 ❑ East County Child/Adolescent Mental Health ❑ Martinez Detention Facility,Medical Module 2400 Sycamore Drive,Suite 33,Antioch,CA 94509 1000 Ward Street,Martinez,CA 94553 (925)427-8664 FAX 427-8645 (925)646-1647 FAX 646-4272 ❑ West County Adult Mental Health ❑ West County Detention Facility,Medical Module 100 38th Street,Room 2400,Richmond,CA 94805 5555 Giant Highway,Richmond,CA 94806 (510)374-3061 FAX 374-3068 (510)262-4380 FAX 262-4399 ❑ West County Child/Adolescent Mental Health MENTAL HEALTH CLINICS 303 41st Street,Richmond,CA 94805 0 Central County Adult Mental Health (510)374-3261 FAX 374-3857 1420 Willow Pass Rd.,Suite 200,Concord,CA 94520 ❑ Intensive DayTreatmentProgram (925)646-5480 FAX 646-5622 256 24th Street,Richmond,CA 94804 (510)374-3467 FAX 374-3927 ❑ Central County Child&AdnlescentMental Health C—) West County Crisis Service Oak Grove Rd.,Suite 11,Concord,CA 94518 256 24th Street,Richmond,CA 94804 (925) 646-5468 FAX 646-5102 (510)374-3420 'FAX 374-3927 AB3632 Program,Children's Mental Health 2425 Bisso Lane,Suite 280,Concord,CA 94520 ❑ West CountyMedical Records (925)646-5665 FAX 646-5685 256 24th Street,Richmond,CA 94804 (510)374-3658 FAX 374-3927 If you believe additional treatment was obtained at any location other than the one indicated above,please request that information and/or billing from that center. MR459 (3-99) CONTRAtCO TA HEALTH SERVICES PATIENT REGISTRATION r* EMERGENCY DEPARTMENT Financial Class Code AU A0 Med,Serv. Patient# E/R 4801098-02-0098 Work Related? Td Dr's 1 st Patcom Type Voluntary Clerk/Con Medicare? N St.Facts? 072987886 E ADM.CABEZA Insurance? N H Plan? y PATIENT'S NAME Medi-Cal? N Vet? PALMER I N z OLANDA D SID? M/Y/$ Previous Change Race Coverage#1 BAC ELIGIBLE WFIITE HISP Policy# Sex D.O.B. Age Information 88400 HPAO F 5/13/1951 047 Coverage#2 Soc.Sec.# I.D. M. Status Policy# 5,19-21-1010 X - SEPAE Information Maiden Name 'Mother's Maiden Name Coverage#3 Policy# Language How Arrived Information SPANISH, Cher Insurance Address/Phone Nate: .595 CENTER. AVE Patient's Mailing Address MARTINEZ CA 1325 cbLOM13iA' ST PITTSBURG ,- CA 94565 Pt.Employer Day Phone Night Phone (925)473-9256 Occupation Local Address mployer's Address RESPONSIBLE PARTY PALMERIN YOLANDA Resp_Party's Employer D.O.B. Relation Sex U14EMPLOYED SE — SEL Resp. Party's Employer's Address Soc. Sec.# I.D. 519-21--1010 00000 R.P.Address ubscriber 1325 COLOMBIA ST A 41W .Sec.# Employer rITTSBUPG CA 94565 000-00-0000 Day Phone Night Phone EMERGENCY CONTACT ALEJANDRA LEDESMA PRIMARY CARE PROVIDER&CLINIC Relationship DA — DAUGH F I HEL, CA FNP PITT - PITT S Day Phone Night Phone Admit Date Time Pre-Admit E.D.A. S/P 1/18/99 14: 18`. Address 92 --- SELF—REFER 14: 05 5 - NO ADVANCE DIR i NEXT OF KIN Relationship Room Bed Med Sery Acc.Cd. Day Phone Night Phone Smoke Religion Inquiry Address Last Admit Date Place NOTES Patient Unable to Sign Consent to Service P 0 rQ8 Co t to Service Signe Consent to Service on file dated (Si alure of iiegiSiration Clerk) Discharge Date: Time: AC7MT-£7i (12l97) CHART M.D. CONTRA COSTA HEALT VICES (SERViCIOS DE SALUD DE G�ATRA COSTA) YOL AND A ,. PALiKER19 11 COWENTIMIENTO PARA LOS SERVICIOS.Y PITC 92S 473-92 a6 CONDICIONES DE LOS MIEMOS Y DE LA AUMISION I` ' S ► CIS- 13 8� (Consent to Services and Conditions '4 '8n j 0 q of Services and of Admission � ' 13/ 10" I � C2 E /R f. 1 i I £t/q cl CONSENTIMIENTO PARA TRATAMIENTO MO-DICOJOUIRURGICO: t La persona firmante da su eonsentimlento para recibir cuatquier =t:~.",,1* tratamiento mAdico,Incluyendo parrs no iimitedo a ex6menes con reyos X,procedlmlentos de laboratorio,procedimlentos mddicos Patient to quir6rgicos,Inyecclones y transfuslones de sangre,considerados aconselables o necesarlos par at mbdtco do cabecera o por otra persona del plantel medico del hospital,Incluyenda m6dicos residentes y contratados independlentemente,y ademis esti de acuerdo con to estipulado on el reverso de este formularto. PROGRAMA DE ENSENANZA: El suscrito entiende qua Contra Costa Health Services,Contra Costa Reggional Medical Center y Contra Costa Health Centers,son instftuciones de ensetlanza y que los residentes,internos y estudiantes en at Campo do la salud,pueden proveer atencic5n m6dica y/o de salad bajo la supervisl6n de personal pro asional. CONSENTIMiENTO PARA LA EXONERACt6N DE INFORMAC16N Y t NV10 DE ETIQUETAS DE MEM-CAL:EI suscrito autoriza at Departamento de Servicios Sociales del Condado de Contra Costa el exonerar toda informaci6n relacionada al estado on at qua se encuentra Is solicitud de Medi-Cat del paciente,y envier las etiquetas de Medi-Cal a Contra Costa Health Services Department.TambiLn autoriza a la``Agencia indicada arriba que envfe una Carta de Autorizaci6n a Contra Costa Health Services,para permitir que todo servicio medico qua he recibido an una institucibn del condado que acepta mi cobertura de Med;-Cal,sea lacturado a Medi-Cal. ACUERDO FINANCiERO:EI suscrito promete reembofsar al Condado de Contra Costa todos los servicios de atenci6n hospitalaria y/o m6dica que se hayan prestado al paciente en cualquier momento dentro de los 365 dial a partir de la fecha indicada a continuaci6n,si esos servicios no estuvieran cubiertos pot Medicare,Medi-Cal o cualquier otra compatlia de indemnizaclon de gastos de atenci6n do la salad,a los honorarios establecidos pot la Junta de Supervisores del Condado de Contra Costa.El suscrito acuerda ademAs utilizer todos los dartos o indemnizaciones pagados a o an nombre del paciente Como resultado de la tesi6n o enfermedad qua requiri6 esta atenci6n a reembolsar at condado hasta to cantidad facturada, pero sin exceder los honorarios fijados pot la Junta de Supervisores. EI suscrito renuncia durante un perfodo de 10 arlos a is ley que flja los t6rminos de preseripcibn relativos a este cuesti6n. Este acuerdo y renuncla es obligatorio para el suscrito,sus herederos,cesionarics,administradores y aibaceas testamentarios. ASIGtNACION DE BENEFICtOS:La persona firmante,ya sea comp agente o tomo paciente,autoriza el pago directo al Condado de Contra Costa de cualquier beneficio pot seguro que seria de Otto forma pagadero a o pot el/la paciente pot esta hospitalizaci6ny/o estos servicios err consultorios externos,incluyendo servicios de emergencia si se han provisto,an un monto qua no exceda los cargos Corrientes Jet Condado.Una fotocopia de esta autorizaci6n sera considerada tan efectiva y vdlida tomo at original. La persona firmante autoriza a instruye at abogado, encargado de reclamaciones, compaMia de seguros, y a to persona o personas, Compania o corporaci6n que pueda efectuar un ajuste o pago de cualquier reclamo pot dartos o indemnizaci6n que el/la paciente haya presentado pot is herida o enfermedad qua requiri6 is atenci6n hospitalaria y/o los servicos an consultorlos externos,a deducir el importe de los cargos de esos servicos de cualquier suma adeudada al/a la paciente y a pagar esa cantida directamente al Condado de Contra Costa y pot este medio asigna esa cantidad a Condado de Contra Costa. DIVULGAC16N DE INFORMACtt3N PARA REEMBOLSO: La persona firmante acuerda que,para determinar la responsabilidad pot el pago y para obtener reembolso,el Condado de Contra Costa puede reveler partes del historial del/de to paciente,hasta at punto qua sea necesario,incluyendo sus historiales medicos yy psiquiatricos,a toga persona o corporaci6n que sea o pueda ser responsable pot todos los gastos o cualquier parte de estos incluyendo pero no limitado a compaNas de seguros,planes de servicios do cuidados de la salud,compaNas de indemnizaci6n a trabajodores, la Administracidn del Serguros Social,y orgenizaciones paritarias de examinaci6n, La persona firmante cirtifica que ha teido ambos tados rte este documento, ha recibido una copla del mismo,y que es elAa paclente, su reprontante legal,o que tie utorizacfdn dei/de Is paciente Como su agents general para ejecutar este documento y aceptar sus tIrmi $. l =FECHA(Dale) FIRMA DEWDE LA PACIENTE O DE SU REPRESENTANTE(Signature) SI ES DEL/DE LA REPRESENTANTE, RELACION CON EULA PACIENTE G LA FIRMA(Wit ss to Signature) (Raiationship/Patiant's Represemativa) If patient unable to sign,STATE REASON: Date: By: DECLARACION DE DATOS,PACIENTE DE MEDICARE (Medicare Patient Statement of Facts) n El/la paciente tiene aAos de edad. []Esta visita no es at resultado de ninguna cfase de accidents. i_]El/la paciente no estA empieado/a. C) Ninguna otra persona es responsabte pot las cuentas madicas def/de Is ❑El/la c6nyuge dei/de Is paciente no estd empleado/a. paciente. 0 El/la paciente no tiene cobertura de indemnizaci6n a los ❑PACIENTE HOSPITALIZADO: He recibido Is Notificacibn de Medicare Trabajadores, del Programa Pulm6n Negro(The Black Lung titulada"Un importante mensaje de Medicare." Program),ni de un plan de salad de grupo. ❑PPS d EXEMPT Cerfifico que todas las declaraclones anterlores son verdaderas. FECHA(Date) FIRMA DELIDE LA PACIENTE O DE SU REPRESENTANT£(Signature) Sf ES DEL/OE LA REPRESENTANTE, RELACION CON EL/LA PACIENTE TESTIGO DE LA FIRMA(Witness to Signature) (Relationship/Patient's Representative) MR 463A-1(else)side t ORIGINAL-CHART COPY t-FINANCIAL/PATIENT ACCTG, COPY 2-PATIENT CONTRA COSTA REGIONAL MEDICAL CENTER t YOt NDA,: EI�t1ERGENCY DEPAR NT ❑ FAST TRACK y. { r f . ..f;; .:' F PITT �} 473-9256 All DATE: ' s c TRIAGETIMIf AGE: r' SEX?, ARRIVAL VIA-- 0 WALKING 0 W/C Cl GUERNEY CI AMBULANCE 0 CARRIED ❑POLICE Q 510, t4 C 13/ 1c351 FISHEL . CA FISP Q TRANSFER 1 REFERRAL---o ADVICE NURSE" p t"' 2 E/R " VISIT TYPE: INITIAL 0 SCHEC}RETURN 0 APPT Cl UNSCHEDULED RETURN c 48 HOURS , LOCATION: 0 LOBBY 0 ROOM: TRIAGE STATUS. r ih CHIEF COMPLAINT f HPI: {t' r }+ PAST MEDSGAL HIST{}RY: © HTN © DIABETES ©.CV 0 ASTHMA/COPO" d SEIZURE Cl CARDIAC{LIST}: [3 SUBSTA USE(LIST): EIitES(LIST}: OTHFR: �01C-Eo D INTERPRETER INTERVENTIONS: El MASK ❑COLLAR D 0 NPO µ SIGNATLIR C LABS X-RAY /A C:I TYLENOL OTHER jar LMP-G P MEDICATIONS: ALL S: CONTRACEPTION 'y' ✓ LAST TETANUS OTHER: WEIGHT z� KG INITIAL ORDERS ©NII MEDS -WA PktFA ©MONITOR ❑EKG TIME` IT TYPE � P P R 7 TYPE BP P TYPE BP P D O2 ©ABG's PULSE OX 0 PEAK FLOW 2 ^_ ©CHEM WG Q BREATHELIZER I,a HISTORY AND PHYSICAL EXAMINATION' d Ev TE TIME!N AM RATE:: � _D _ TIME SEEN BY `'''"����'` ©UTA O C&S O UTOX A 1 � 0ER PREG ©PREG U 7fME NURSE 0/0 0 CBCD 0 CRP Q ESR 0 PTIPTI`" ©CARP El LFP El CRP _._. .w..._.M __,__. " _.. _._. j/��• " .. "' � ". _ __..., _..__ 0GLU13DUN©CREATINE 0AGP "►�J /J ©TYPE 6 SCREEtoROSB X _._..__�• I__ _._ /L .Ww k.:t l-- ?` _,__. __., _ __._: ©ALC CJ SAL 0 ACET 0 HIV GEN E � C�CULTURE SITE U� _,__-,,EY 21 0 THROAT 0 ASS _ s.". y . � _.: I ._. ✓ + G-. ..� ._. �.. _.. C INIT AA IM 7E ORDERS 171 _ Td BOOSTER PCXA Me F L++ ` . .._. ©SEE ADDITIONAL RECORDS DISCHARGE:DEAGNOSIS: y.... � +-- �,. ,¢. FICATION: C.�CORONER 0 POLICE CI CPS ®OTHER DISCHARGE CONDITION: RI'&AMB. DISPOSITION: ME©IN CUSTDDY D MHOS SIGMA 4 �� �� O ADMIT CI OTHER: t/U'j t t ,.-`•l-�, ... .M.D./FNP MR 689-8 (9188) CHART EMERGENCY DEPARTMENT RECORD CONTRA COSTA REGIONA1 ,MEDIC:AL.CENTER E.D. NI IRSING RECORD TIM£ (�© NEUROLOGIC PSYCHOLO T CARDIOVASCULARESPIRATO ABDOMEN I GU MUSCULOSKELETAL ©NIA TO C/C El WA TO ❑N/A TO C/C �NIA TO NIA TO C/C 0 N/A TO CIC tibENTAL STATUS BEHAVIOR SKIN SIGNS LUNG,SOUNDS �Abno story #art Age Approp#ate ormal Color ❑ Dy []clear ❑B.S.Present [j Abnorttat Gait rlentad Cakm U rm Hot ❑ Coo# © Whaaztng`L—R ®B.S.,Absent ❑ C-spine precautions Lethargic C1 Restless❑ Anxious ❑Cyanotic ❑Pate "I_E ❑Soft ❑ Swatting ❑ Deformity 0 Confused ❑ Cy#ng Inapr. ❑Clammy []Flushed [j Rales —L_ R ©Non-Tender 0 Discoloetion ❑Unconscious [J Uncontrolled 0 Diaphoretic ©Rhonchi —L--R ©Ted 0 Redness SPEECH L7 Agitated E]Jaundiced Q Decreased—,L R ❑Tender © Abasion ' herent 0 Combatike PULSES ❑ Cough�,,P—NP 0 Distended ❑ Rash ❑ Paranoid (?SStron JVD PATTERN C} Bmes#s ❑ Rash ❑ Bun Incoherent 0 Hallucinating g © © Diarrhea Neuro-Vascular Check ❑Slurred C1 g Regular ❑Pedal ❑ Regular ❑ Labored ❑ Vag Bleed i,7 Normal ❑Ahnormai GRIP STRENGTH ❑ Delusional ©irregular 0 Edema © Accessory Muscles © \Ag DIC Location ❑ Non-\§rbal Equal ❑ Threatening CAP REFILL ❑ Nasal flaring Cry: © Strong❑ V�6ak Q Unequal ❑N/A . 0 Pressured Speech E;Nornal Q Abnormal PUPILS PERRRLA []NIA DESCRIBE ABNORMALITIES: C wr`-n xaL^ GLASCOW Q N/A Scale C]Temors VISUAL ACUITY I L i R I0 CORRECTED SIGNATURE: LV N TIME TYPE B/P P R T Other TIME REASSES MENT/EVALUATIONS .. lNtTtAts cam- — twos' b 0i 1zr .Su —`0 # TIME INTERVENTIONS INIT. BELONGINGS: ❑ HOME ❑ TO UNIT F1SEE ADDITIONAL NOTES MEDICA"Ptt7NS SITE/ AMT. ❑ Oa LITERS: VIA: TIME MED I SOLUTION DOSAGE~ 'ROUTE ABSORBED INIT. ❑ EKG ❑STAT<10- ❑ ROUTINE ❑ NEBULIZER TX ❑ RT CARDIAC MONITOR RHYTHM ❑ X-RAY: TYPE: ❑ PCXR I RETURN; �D- IV## SITE: El l SL TYPE: 0 PARAMEDIC START ❑ IV#2: SITE: ❑ SL TYPE: ❑ PARAMEDIC START ❑ BLOOD SPECIMEN DRAWN L R T B ESC SITE: ❑LAST ❑FIELD DRAW ❑ URINE SENT 0 CC 0 CATH 0 BAG W',: ,INTAKE OUTPUT ?` O° IV URINE EMES#S/NCiT .', &HER ❑ NG TUBE fn ❑ LAVAGE ❑ IRRIGATION 0 Lac 0 Wound 0 E e 0 Ear I J I GEN PROBE SENT O E e Q Gu ad LV ( ' N 5 Stb I I+ IL 1 DIP-UA Prl sg " 9 C> i' beLG 8 b�.3 i i.JO hj0 , f 0 LEUKS,., 3 NIT ©UAO 0 PRCI ❑GLU BLD 0 KgT_____O BILI f v0XV101 ADDITIONAL SIGNATURES IMT. �Il �3117�d 7�y K,. i MR387-2!2/981 CHAR T-r '., of WORKISCHOOL RELEASE PATIENT NAME `i ADDRESS TIME OFF ALIT jD FROM: [ '1NSTA3CTIONS 3N SPANISH [� PE. SCHOOL -, o_� ❑ INJUW �.0 Sig: Dlsp: DUE TO: ❑ ILLNESS 5 �� � J -0 v Q VOID: COPY ONLY FROM: �.r ,cs a-.- -4 --o RETURN DATE: l om fQ Sig: Disp: RESTRICTIONS: IC}NS: o a is � + otu n 3 D VOID: COPY ONLY ; rte", 411 .� <[ m E-04>1 45 t !I w o v FROM: sem-11.) sty h Slg:ye', Disp:Uj ..0 0% x.. 0 z 00 It VOID: COPY ONLY sIGNATURE: g .3 4 X } SIGNATURE ❑TRANSMIT-AL ORDER DATE: ! • . 1r'},r FNP OTHER �.. OTHER 1�GIVEN: �i:�'"'�w-`'I'•"" WORKING DIAGNOSIS: ✓ ; J' � '`" DO NOT DRIVE HOME FROM THIS VISIT. 0 { MSTRUCTIONS ON REVERSE OF PAPER: PRINTED INSTRUCTIONS GIVEI-� I---�� ��--77 ❑WOUND CARE L.J SPRAIN 1 FRACTURE n VOMITING/DIARRHEA ❑UTI ❑ASTHMA t COPD t 1 X-RAY L SCREENING NURSE ❑HEAD INJURY 0�CASTS I SPLINTS ❑COLDS/FLU El EARLY PREGNANCY 11-1--I EAR INFECTION READINGS ❑DRIVING CAUTION 0 t- ❑EYE INJURY I_1 BACK/NECK INJURY ❑FEVER CONTROL ❑VAGINAL 13LEEDING i 1 ABDOMINAL PAIN ❑LABORATORY ❑REGULAR PROVIDER OTHER INSTRUCTIONS: TESTS 0 /I 11L4 FOLLOW-UP APPOINTMENT: CONTACT APPOINTMENTS FOR FAMILY PRACTICE APPOINTMENT IN DAYS I WEEKS ©RETURN TO EMERGENCY DEPARTMENT IN� DAYS ❑APPOINTMENT SLIP GIVEN, f.. ❑ SPECIALTY APPOINTMENTS: L}� MESSAGE LEFT AT APPOINTMENT UNIT.YOU WILL BE CONTACTED 4 ABOUT YOUR APPOINTMENT WITHIN TWO,WORKING DAYS. IF YOU *CLINIC* DAYS/WEEKS, HAVE NOT BEEN CONTACTED,CALL APPOINTMENT UNIT AT 846-47.1 S. APPOINTMENT SCHEDULED-- 0 CHEDUCEI7.,, „❑NOSOTROS HEMOS DEJADO UN MENSAJE EN`LA UNIDAD DE CITAS, CLINIC/PROVIDER SITE DATE m—e UD.SERA CONTACTADO DENTRO DE 2 DIAS HABILES.Si NO HA SIDO CONTACTADO,LLAME AL 646-4715. CLINIC!PROVIDER SITE DATE TIME STAFF INITIAL SIGNATURE ❑ YOU NEED TO PICK UP I UNDERSTANDTHESE INPTRUC•T`IONS(Patient Signature) i REMAINDER OF I1 IT /j PRESCRIPTION t L-[turd✓L ii �I'C c. `+ TIME DISCHAR ED �. HO4V._DISCHARGED l FNP INTERPRETER L d�L ALKING O W/C O CARRIED Q GURNEY E]OTHER: ADDITIONAL NURSING NOTES/DISCHARGE TEACHING: 7PT/GUARDIAN VERBALIZES UNDERSTANDING OF INSTRUCTIONS Cj PT/GUARDIAN GIVEN ER PRINTED DISCHARGE/RX INSTRUCTIONS -pip, Q GIVEN RX TO BE FILLED CJ STARTER DOSE ©HEALTH CARE SYSTEM NURSING N U Q DSG ©ORTHOPEDIC DEVICES 0 DIET ©RESP'DEVICES C]SELF-EXERCISES MR 474A-5 (6/98) CHART ~' .EMEFi... l NCY DEPT DISCHARGE INSIRUC QNS CONTRA COSTA HEALTH SERVICES MR# : OOOOOOMOO4801098 Contra Costa Regional Medical Center NAME: PALMERIN, YOLANDA, D Martinez Health Centers DOB: 05/13/1951 2500 Alhambra Avenue, Martinez, CA 94553 SPECIALTY NOTE DATE OF SERVICE: 01/20/1999 The patient comes in today with her daughter who provides for translation. The patient has a history of having had her right ear irrigated approximately one week ago. At the time she experienced pain in the right ear as well as in the right side of the throat and neck area. The patient became very vertiginous and states that she fainted. At this time she is on. Bactrim. and Naprosyn 500 mg tablets . Examination of the ears finds a central perforation in the right tympanic membrane that is approximately 1. 5 mm in diameter. The edges are clean and slightly elevated, indicating a relatively normal healing process. The left tympanic membrane and canal are within normal. limits. IMPRESSION: Traumatic right tympanic membrane perforation. PLAN: I advised the patient to keep the ear dry. Should she have drainage from the ear she is to come in for follow-up. The patient is to return in six weeks for a follow-up visit and an audiogram at that time. Lorre T Henderson, MD CC: Pittsburg Clinic Martinez Clinic Carol J F.ishel, FNP LTH:EDiXll027 D: 01/20/99 14 : 39 T: 01/21/99 07 : 49 DOCUMENT: 990120223745820300 SPECIALTY NOTE GLines : 31 Page 1 of 1 Original i CONTRA COSTA HEALTH SERVICES MR# : OOOOOOMOO4801098 Contra Costa Regional Medical Center NAME: PALMERIN, YOLANDA, D Martinez Health Centers DOB: 05/13/1951 2500 Alhambra Avenue, Martinez, CA 94553 SPECIALTY NOTE DATE OF SERVICE: 02/04/1999 Patient comes in today with history of having pain in her right ear, followed by drainage. The drainage has subsided at this time. She is putting no drops in the ear at this time but is on a multitude of medications for the ear infection. The pain is better in the ear, though she does have some tinnitus in the ear. PHYSICAL EXAMINATION: Finds the left tympanic membrane and canal to be normal . Examination of the right ear finds a central perforation that is healing and measures approximately 1 . 5 mm in diameter. The external canal and middle ear space are dry, with no signs of discharge. IMPRESSION: Acute otitis media of the right ear, followed by perforation, PLAN: The eardrum is healing well . I have advised the patient to keep the ear dry and to return in approximately three to four weeks for follow-up visit. Lorre T ' erson, MD CC: Carol J Fishel, FNP ti Pittsburg Clinic LTH: EDiX11063 D: 02/04/'95 17 : 37 T: 02/08/99 09: 30 DOCUMENT: 990205013520820200 SPECIALTY NOTE GLines 28 Page 1 of I Original CONTRA COSTA HEALTH SERVICES MR# : 00000`OM004801098 Contra Costa Regional Medical Center NAME: PALMERIN, YOLANDA, D Martinez Health Centers DOB: 05/13/1951 2500 Alhambra Avenue, Martinez, CA 94553 SPECIALTY NOTE DA'Z'E OF SERVICE: 04/05/1.999 SUBJECTIVE: The patient is status past a right otitis media which resulted in a spontaneous perforation of the drum. She still has decreased hearing at this time. OBJECTIVE: Physical examination finds the drum to be clear with a crust occupying approximately 3/4 of the central part of the drum and covering where the perforation formerly was ., It is unclear at this time whether or not the perforation is still present or not . PLAN: I have advised the patient of the findings via translator, and she is to return in six weeks for follow-up visit. Lorre T Hende s n, MD CC: Carol. J Fishel, ENP Pittsburg Health Center LTH: EDiXll250 D: 04/05/99 16: 47 T: 04/06/99 1.8 : 16 DOCUMENT: 990405234602820200 M SPECIALTY NOTE GLines 23 Page 1 of 1 Original. CONTRA COSTA HEALTH SERVICES MR# : OOOOOOM004801098 Contra Costa Regional Medical Center NAME: PALMERIN, YOLANDA, D Martinez Health Centers DOB: 05/1311951 2500 Alhambra Avenue, Martinez, CA 9.4553 SPECIALTY NOTE DATE OF SERVICE: 05/24/1999 HISTORY: The patient is seen today with a Spanish translator who provides for translation. The patient states that she has decreased hearing in the right ear which has not. changed. PHYSICAL EXAMINATION: Examination finds the perforation in the central part of the right tympanic membrane to be unchanged. ItR ;:A. measures approximately 1 . 5 mm in diameter and has smooth, fresh edges, and the middle ear mucosa is clear. There is' a scant ` } amount of material on the lateral aspect of the drum, but there are no signs of infection or problems . PLAN: After a lengthy explanation of the procedure and the / n risks, the patient has consented to a right tympanoplasty wit. fascial graft from the right temporal scalp. A transcanal approach will be used to minimize surgical insult. In additi rn the patient is to obtain an audiogram in Pittsburg, preoperatively. Lorre THe / cin, MD l' CC: Carol J Fishel, FNP Pittsburg Clinic LTH: EDiX11035 M D: 05/24/99 17 : 43 T: 05/24/99 19: 35 DOCUMENT: 990525004133820300 SPECIALTY NOTE Page 1 of 1 Original f CONTRA COSTA HEALTH SERVICES MR# : OOOOOOM004801098 Contra Costa Regional Medical Center NAME: PALMERIN, YOLANDA, D Martinez Health Centers DOB: , 05/13/1951 2500 Alhambra Avenue, Martinez, CA 94553 OPERATIVE REPORT DATE OF OPERATION: 06/15/1999 PREOPERATIVE DIAGNOSIS: Right tympanic membrane perforation. POSTOPERATIVE DIAGNOSIS: Right tympanic membrane perforation. PROCEDURE: Right tympanoplasty. SURGEON: Lorre Henderson, MD ANESTHESIA: General . ANESTHESIOLOGIST: Paul Kwok, MD COMPLICATIONS: None. FINDINGS: Small central perforation in the tympanic membrane. DESCRIPTION OF PROCEDURE: The patient was placed on the operating table in the supine position, placed under satisfactory general anesthesia after orotracheal intubation. The right ear was prepped and draped in the usual fashion for microscopic ear surgery. One percent Xylocaine with 1 : 100, 000 epinephrine was infiltrated about the tragus on the right ear and in an endaural fashion. The ear canal was irrigated with copious amounts of normal saline solution, removing some ceruminous and squamous debris . The margins of the perforation were freshened sharply with a Rosen needle and cup forceps. The middle ear space was noted to be dry, and the middle ear mucosa was very healthy. Curvilinear incision was made on the posterior side of the tragus. This was carried down to the level of the perichondrium. The subcutaneous tissue was elevated off of the perichondrium. The perichondrium was incised, and the round knife was used to elevate the perichondrium. A small perichondrial flap was then harvested and prepared and placed on the back table for later use. The incision was closed with two Monocryl 5-0 sutures in an interrupted fashion. A curvilinear incision was made parallel to the fibrous annulus with the round knife. A small posterior tympanomeatal' flap was elevated in the usual fashion, carried down to the fibrous annulus, which was identified, preserved and elevated. The middle ear space was entered. Noncompressed pieces of Gelfoam OPERATIVE REPORT Page 1 of 2 Original ........................................................................................................................................................ ............................................................................................. MR# : OOOOOOMOO4801098 NAME: PALMERIN, YOLANDA, D were placed in the middle ear space for medial support. The perichondrial graft was then fashioned and placed into the perforation and moved about so that good coverage was obtained of. the perforation. Several small pieces of Gelfoam were then placed over the incision as well as on the lateral surface of the drum. The patient was awakened, extubated in the operating room and taken to the recovery room, having tolerated the procedure without difficulty. Lorre T Henderson, MD CC: Pittsburg Clinic Martinez Chart Nurse Practitioner Bichelle LTH: EDiXll063 D: 06/15/99 17 : 15 T: 06/15/99 19: 55 DOCUMENT: 990616001202820100 Page 2 of 2 OPERATIVE REPORT Original ............ ........ ......... .............. .................................................................. ,mantra Costa Health Services is divided into several clinic areas. The in,"ormation enclosed is'From; _ Con:raCosta RcgionalMedia Center Ince-isi•rclntermictentInrc^re:t :0nPr00-ram(I3P) , Coricr.i Costa Health Ccncers Children's%lrncal Health 2500 A:. ainbra Avcnuc. Marrinez, CA 94553 2450 Scanwel Drive, Suite 270,Concord,CA 94520 (?25) 370-5220 FA's 370-5275 (925)6116-5:18 F -K 646-5115 Tom Powtrs Health C-nter(RiLkmond Health Center) _ Sumnmit Ce:ncer,Children`s: len cal Health 1C;0 38th Sate,, Richmond,CA 9405 204 Glacie-Dr.,Martinez,CA 94553 (�10) 371-3071 FAX 374-3024 (9:5) 313-2900 FAX 313-2921 Pir,sburg Health Cencer HosoitalLk Residential Program 550 Schco' Street, Pittsburg,CA 94505 Children's Mental Health (925) 427-9075 FAY 427-9313 24-75 Bisso Lane,Suite 235,Concord,CA 94520 Concord Health Center (925)646-5240 FAX 646-5662 3052 Willow Pass Road,Concord,CA 94520 Conservatorship/Guardianship Program (925)646-5306 F.A_X 646-5505 624 Ferry Street,Martinez,CA:94553 BrenrvoodHealthCenter (925)6_6-3791 FAX 6-36-2853 118 Oak Street,Brentwood, CA 94i 13 Detention Facility,"vtenral Health Services (925)634-1102, 47-7-8628 FAX 427-8639 1000 Ward Scree,,Martinez, CA 94;53 - (925;646-==742 F A-K 6-=6-17`12 _ Bay Point Communicr W ellness Center _ 215 Paciaca Ave.,Bav Point.CA 9-565 Mtntai F- exlth C risis Se^tics (925; a_2 7-S206 F.A.X 427-8304 2 500 Alhambra Ave., Marti:ez CA,94553 -- (925),370-5 700 F.�X 6416-5716 35G5 Lone Tree�A ar,_Suite .,Ancioc-'n, CA 94509 _ FarNnsic7C i n nal justice (925) =27-8586 F _X _27-8581 Conditional Release Pro;tar_ (CONREEP) Concord CJlderAdultsClinic 10 Douglas Drive,Suite 140.�lartiz:ez,CA 94553 3052 Willow Pass Road,Concord,CA 94520 (925)313-1150 FA`{ 313-1163 (925)646-5535 FA -X 6.36-5505 __ East CouricvAdult!+IentalHealth Clinic yAntioc Older Adults Clinic 550 School Street,Pittsburg,C. 94565 3:05 Lone Tree Wav,Suite 4,Antioch,CA 94509 (925)427-9110-8110 FAX 427-8117 9251 42 7-8775 F a _2 7-3779 East Countr. dult tilental Health Clinic Armes El Cer..to©lderAcults C znic 2=00 Svca-nore Drive,Suite 18 Antioch,CA 94509 11720 Sar:Pablo Avenue, Suite C I,— X27-8'00 F.A.-K 4274707 ElCerrim,CA 9.3530 v East Count.Child/AdoiescencMentalHealth (510)374-36:9 FAX 374-3294 2=00 Sycarnore Drive,Suire 33,Anrioch,CA.94509 IartinezDe,entionFacilits. Iedicalyloduie :925)427-3664 F.X, 427-8645 1000 Ward Scree,,Martinez,CA 94553 _ West Coun^rAduic Menta.I Health (925) 646-1647 FAX 646-4272 10.0 38th Street,Room 2400,Richmond,CA 94805 ti�'estCountrDeteitionFxclity,Vledica�lNIodule _ CIN''1-5 6= FAX 37--3068 5575 Giant Highwa,.,Richmond,CA 94806 _ 'A'est Courrr Child/-.dolesc,-ncdental Health (510? 26----'380 FAX 262-4399 303 11st Scr t,Richmond,CA 9=805 MENTAL HEALTH CLINICS 374-3261 FAX 374-33,57 ,- Cental Cour.CVAdule Menral Health I:;e^sive Da> reacnient roa am 3 2_th Sweet,Richmond,C.�9-SC 34 026 Oa Grote R .,Suite 12,Concord,CA 94518 5i^)3-1.3_67 FAQ 374-3927 (925)6110«5450 FAX 646-5622 EL e;tCounnvCrisis Sem:ce C�...ralCountrChild&Adoles,-encMentalHealth ., CA91St?1 1,Concord CA 9 3518 roc_-tl S=-:!:'Richr-on--, zC2a Nati Croce Rw.,Suite 1 1 j 371-34-10 !_X 37_-3927 (9_5) 646-5468 FA: 646-5102 ' �sr'cst Counw,tileditia Record= A.3-Io-12 v�Program,Children s.NfenralHealch _ �; � th St~-er R chr^o. C a 4=504 7!:'z Bisso Lane, `ui: 2SO,Concord, CA 94520 (9-25) i-'r-.�0- �C, .1 '77 _ -5665 FAX J 6 F.A.�,. .�, -39� Eat:.'PeriodicScreen;ng,Diagnosis4 T"reacment .j,Cntic t 1 s'`le^t.:c is.Lith �JGi:�..3C E ;on al 2atr".e: c was obtained at anY E YJ D 2 ,:.0 5%anv'.'ell Driv;.-,Strict, 203,Concord,CA 9 1452 red above,"l'iSe request (91 6 C-5097 i'A:� 646-5115 ....,. ;i:.,.,.,,:71 nth. rhi ,,froiti._.at:.trirer. } 4' CONTRA COSTA HEALTH SERVICES MR##.... M004801098 CONTRA COSTA R30IONAL MEDICAL CENTER Name: PALMERIN,YOLANDA D CONTRA COSTA HEALTH CENTERS Ph #: 925 .473-9256 DOB: 05/13/51 Sex F CARDIOPULMONARY DEPARTMENT Loc: SCN Acct# : M042928614 STRESS 'TEST REPORT PCP: Fishel,Carol,F.N.P, PCC: Ordering MD: Fishel,Carol,F.N.P. ORIGINAL Order Date: 04/05/99 Order Time: 1430 SERVICE DATE: SERVICE TIME: HEIGHT: 62 WEIGHT: 142 CARDIAC MEDICATIONS: REFERRED BY: FISHEL DIAGNOSIS: RESTING EKG: TREADMILL: TARGET HEART RATE: 85sk 90% 154 100* ( STAGES ( MPH ( %GRADE ( DURATION ( HR ( BP ( COMMENTS Ot REST k 76 145/80 I STAGE 1 ( 1.7 10 3 ( 122 ( 170/50 ( STAGE 2 2.5 ( 1.2 ( 3 ( 133 ( 170/60 STAGE 3 3 .4 14 2 ( 264 ( STAGE 4 4.2 I 16 STAGE 5 5.0 ( 18 ( ( ( I I 1 ( I I 1 1 jRECOVERY ( 1 ( 136 ( 175/80 I ( ( 2 ( 106 i3 i94 I 1 I t 1 1 TEST TERMINATED DUE TO: TARGET HEART RATE AND EXERCISE CAPACITY REACHED. RESULTS: 1) PA'T'IENT EXERCISED 8 MINUTES ON STANDARD BRUCE PROTOCOL HER HEART RATE 164 ( TARGET 154 ) 2) NO ASSOCIATED SYMPTOMS. 3) NORMAL"-SXERCISi-CAPACITY 4).--2mm ST DEPRESSION BEGINNING AT 6 MINUTES--RESOLVED IMMEDIATELY. WITH f' RECOVERY SEEN IN 3 LEADS CONCLUSION: POSITIVE ETT--- SEVERE BY EtG, CRITERIA BUT NO SYMPTOMS RAPID RECOVERY SUGGEST MILD POSITIVE. ; EXERCISE THALLIUM ORDERED,.' y S. HINER, MD HINS :PM D&T:04/05/99 1517 STRESS TEST' Page 1 of 1 ............................................................................................................................................... ............................. CONTRA COSTA HEt6LTH SERVICES w"ft*04LU CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS P AL MF ' 114 YCLANLa AUDIOLOGY TESTING F c, 3/ 1 1;25 473-112ci6 FISVEL , CA FNP PITT SCREENING ANSI 25 1-000 2000 3000 4000 1969 25 1000 2000 3000 4000 dB ISO dB 01964 Right Ear Left Ear KEYTO RECORD INFORMATION 0 Responded at the 25dB Screening Level 13 No response 25dB Screening Level COMMENTS 155 ci,Z PEAK dapa 1 4000 H- t3. I cm 1 '2'000 Hz mT -400 dapa 0 +200 continued on reverse MR335 (12-97) Side I AUDIOLOGY TESTING .................... ............I.........1.11,...... .................................................................................. .................................................................................................................................................................. ................................................. CONTRA COSTA HEALIN SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS PAL *',( r; 1 N AUDIOLOGY TESTING F S/ 13/ 1951 925 473- 1256 rr4 " llpq _ !; A0 0 SY FIS14EL . CA FNP P I TT Air Masked Bone Masked iti Right-Red 0 ,� < E Left—Slue x 13 > FREQUENCY IN HERTZ(Hz) -10 125 250 Soo 1000 _T 2000 4000 8000 -10 0 Audiometer 0 10 ca 10 %EJ 20 20 Awflologist 30 +--ev 30 to V,&Aiy\ 40 40 0 Z 50 50 60 60 LU 70 # 70 80 80 z go 90 100 C100 110 110 120 120 SPEECH TESTS I..iv(-Voice --- Recorded i-t Y4?) FREEFIELD SPEECH RECEPTION THRESHOLD IN d8 RIGHT LEFT UNAIDED OLD AID BEST HEARING AID IN RIGHT LEFT BOTH EARS1 SRT (Spondees) SOT (Detection) with masking opp.ear MCL(Most Comfortable Level) TO (Threshold of Discomfort) Disqrimination Scare (PB) % % ivfth masking opp.ear 1 100 % i00 % AID RECOMMENDED EAR MOLD COMMENTS A 5 1 jz4, Signature Date AUDIOLOGY TESTING MR335 (12-97) Side 2 ........................................................ ............................. CONTRA COSTA HEALTH SERVICES MR#: M004801098 CONTRA COSTA REGIONAL MEDICAL CENTER Name: PALMERIN,YOLANDA D CONTRA COSTA HEALTH CENTERS Ph #: 925-473-925 DOB: 05/13/51 'x F DIAGNOSTIC IMAGING DEPARTMENT Loc: PHC a*` Acct# : M042898221- REPORT PCP: Fishel,CaroT- F.< . ; Ordering MD: Fishel,Carol,F.N.P. PCs: PITS Order Date: 05/05/99 .' Order Time: 1420 " SERVICE DATE: 05/05/99 SERVICE TIME: 1420 r'`j 2y1.�MMOGRAM r'UrNICAL INFORMATION: Screening Breast parenchyma continues to be moderately dense in appearance with no asymmetry or mass formation visible. No architectural distortion is present . No malignant calcifications are seen. Normal appearance of the nipples and areola. CONCLUSION: Negative mammogram. Recommend routine followup study. BIRADS category 1. PETER WON, M.D. 6dQt1P JMC Dictated 05/05/99 Transcribed 05/05/99 1612 DIAGNOSTIC IMAGING REPORT Page 1 of 1 ............................................................................................................................................... ...................................................... -01/13/99 CONTRA COSTA HEALTH SERVICES Page 1 0750 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services PITTSBURG FINAL OUTPATIENT SUMMARY REPORT PAT1ENT: 1PALM!-3RTtjY0L-ANDA D ACCT #: IM2j26 8 LOC: PHC U #: M004801098 AGE/SX: ROOM- REG: 01/08/99 STATUS: REG CLI BED. DIS: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHEMISTRY'-INDIVIDUAL TESTS. Day Date JAN 8 Time 1211 Reference Units ->fIGB AIC NOTES: (a) POOR CONTROL: >10% fu FAIR CONTROL: 9-10% GOOD CONTROL: 8-9% EXCELLENT CONTROL: 6-8qs n. Patient: PALMERIN,YOLANDA D Age/Sex: 47/F Acct#M042028464 Unit#MO04801091 ........................................................ ............................... <° CONTRA COSTA Hr-Aum SERVICES 4388 V Y �y f( ff��8 7 j}�� V � `r y PITTSBURG HEALTH CENTERto MANDA � ' 923 °4713 :4e-6 DAT AO I S'l4 f L CA FMp p ITT f` r Practtce Cffnlc t Chief Complain Pt.w wider #sd1 : 7 9 .sir...« t Air oe 9-44 Y - c ... r 1 cJ � .::. LMATtENT NOTES A1S y v J,. EA"00 A It I. i SEE EIC $ v9 • h '' "q ,„y n� 4= i,a a )r `� ' {� J#��''��`�� � r^�;, a t"`�` 1°raY k ti , 'r° r 47 T{1� DATE 1 �'; '`I,' 'y :"'"g j c '�` r%, t',i..� ° .t j ° � �'su. � Cyt -� '� „k#+ zy a -.� ,�.r t t x �t y C U C� S E• F }r• 5,� }ov q^ '� N i �a s q ' r )* A i u r )Ak d S M'y r p•, ¢ ! k +F h /q +�(' r { h "4-. t'� 4 ✓r K, f '' . Ff•Y t �IFFfF � + 1 4 f 1 ;. `�� `�? � iv e 1, ttt���.^�• ;.y 1W �� 4y �"�)V"'3�..4d{'M ,� ✓rn ({ J ah .l' } � s �+� � �:».�'Y �' �� 4. ��r •s1�� � � w�Y % 4 M �' 4I9 .� � �i, - ;�`��, h. -:R+ c r�,)�. T ,n -. F; _ z Cdr t t"f'e3 v°S'yaf i a ,4-d v .+ T c A, , -01 + „i., •� !"4s^p k'� �, ,r •:t ; „y." t:4 .%v i t S r .�� PATIENT NAME DATE ADDFIESS No ....� �)�, Ell,INSTRUCTIONS INSPANISH U) RFFILL - - , . v uj f y E X w OH..... SIG: y .-;' c t.. }� A[_ 3{F R }r : 1 O L A T'I D A RFFkI_!^xf ; f olsP: �. �� ' ' -' 1 `�a I 12.115 4 7 3—1^c s I ,'�, +t z NO ... r �.'")Q l� H o Z r: 1 1 1 PA cRl Tw3.l fPh rint Are st bls qn all cq es 1�- Z flf.F441. i# COST t3UANTITY U) 0 r1i 1, .. OK { ...,.,..._,_. COS7 QUANTITY Q PA f IF.N T NAME DATE ; AC?17f;L SS, z3 nr) .. i .......-�.- C11NSTRUCTiONS IN SPANIS+ito nrFit.t.. - CLu3 a x t w W$At - _ OH SIG t f i. >'E1t� t5 �+YOLLANDA NU REFILL.X % i �� �(....^ '� - l i _. 1 "7 J ! �.C?i�.J V I W -- tt I�(^�C 9r�' cep, YEA to w NO ! - ;` .... f PATI" P I.O.1 �riAf Are9 rhU31 be Fe�a�le on wilco "es ( j TT � rs� RFF41.1 --- COST QUANTITY p RE7 tLl I RX 1 O.F .` COST OUANTITV Q OK � r.!.._ ;.. RX 2 a F?E:FtI L X, F, 01.1114'. IV)p �. Eelge�ble Name R License x must t>.:{)resent on ail prescrip4ion5 O (UEA on Con4rMtec/Suhafanrrst PRINT OR STAMP: SIGNAT(MF ^- FURNtS}4IN4i C00F ..wa....r. _..__....�..__ F.N.P. PVJN67 3(to/97) GENERIC EQUIVALENT PERMITTED _ CHART - 111 2 Y ONTRA COSTA HEAVIll SERVICES # PMrSBURG HEALTH CENTER ; Tot AM)4 lv4, •, ._ r PATIENT NAME DATE /. ° ADDRESS tj 9 �>Y�{ �:`.dui_.......... i; hk7 NO 0I14STRUCTIONS IN SPANISH to REFILL Ul FIEFILL u r PAL MF IN y(3 ANpQ w OX t in in i.._...__ sIG: 11 / l 9S I5 4 �-9ZS z W 13EF11.L X �. ((""{� i DISP. 'r FI n 1 I r L? 1t J a CA FNP TT = Z 1 ' PATIrENT I.D.Im rint Area must be readabie on al[co i I- { HErILL tth 2 COST C}UANTITY 0 p a i?@FH.L Rx V ¢ t SIG i COST OUANTITY Q R Rx 2 t CC Fr�xLLX +. DISP: MD Leg ble Name&License N must be prssent on aN scrip ions Z Wn a P, E p iD A on Contrelipd Substances)PRINT OR STAMP: rI 1 TURF. - FUtiNISHING NO, DR.CODE GENERIC EQUIVALENT PERMITTED CHART �f - `w _ PATIENT NAME DATE F ... .,.., ;I ADDRESS NO INSTRUCTIONS IN SPANISH n �� REFILL 13 R � m LU OK:! ' ,.. gatSIG: LU o > v� OF.FILL X .�- DISP: 1 P 1_ 17 ! ',. y 1.JY N A Uj _...::: " � ,l.rl ..�,.,.. r •- / , .•I I �S t 925 �7�-�^"� w NO 1 z I�Nf D'l1n i r 4 {(t REFILL S readable on all cols N O r` nF.FILL COST r 1A r y _ a REP7LI.:X SIG: �... ' COST QUANTITY PIT U� Rx 2 ar DISP: MD Lgbte Name 8 License rd must be present on at;prescriptions 0 in IDEA on Comroued Substances}PINT OR STAMP: b wr TltNA�URS ' r { f FURNISHING NO DR.CODE u F.N.P. ri P ILfN01r-3(10/97) GENERIC EQUIVALENT PERMITTED CHART . i a y 3a I VL7 V �Y4 "'I � eA 4 •s �F 7 hav '.;i �✓, I P �{���yy R (y �4r V�i7IJ Aa71� MR t fflfC rxr t� �z�- ____ __ _ _ "Y.M 7tYY ¢J�$,!'h'�xY.yr,•�¢3..�,1�ftr �t_ ✓,,"S�'3:J.`..$ck'H�' �h� n 0'YP�r ..Ibl '"'44 n ii� � AAS's 08 ; alk r ryRY!iE NfOtrrp -y rr a '7 eS Sti 5�SA kp 4 �{Y•�{�,N I�a;y�h°S .r �t�` t ,��- 2 �a�.rt ��'t•+S ,i,.'�F S'�s'i^ .E%�'9 }r 5 '�'f'! �p-� � '�t tc ix _„i }.� ��},,��.r�.i ,y,,1c� ,������� v m�,���'�k`��C� err•t Y�a� ; �y� *j ,& Jy-E L� 'fi "' �`����+^� � 9�� "t �'a��{ ,5-ice'`„Z�� �, � n �x `^ �� •ii� i��� �� ������£ts,� �� �b5� a" '�.'„k� Jr , PATIENT NAME DATE ADDRESS y L A n. P li P F P fl7 N(7 .TT._).._ ._.».©iNSTRUCTI NS IN SPANISH �R 1 •�rw f,� n f' ,�'"1 ?-»y n*`�1. " . � 1 ir� " r i r {" _. sfc r F1 (.;n FA's7 PITT I FtL1 COST t� rn etr•r�l i{. !n,t,rf,.t nrr_.7,r,r r�,rn„ .;r�I:btSI�� ,:,Ir r.r,r;^- L�' Rx I (A 1 C ORI 01(ANTI eIr tans`I1A.x i u Rx 2 Di f HC NOte(J. ttr , R(r rJll(, 1"'1 { rC4 Ib(-A hr r.i tarn�. r pu r�t? v,.pn r;is;NA rURF_ DFA NO v.e:a1-r (ny9e) GENERIC EQUIVALENT PERMITTED CHART mrr c bake a NEW 1,. y Chlof oo jA 11-2 0-09 ver � sndt� i llx Atte Pit . . r n'or r t SM. � °. pwr•hat".r'ka"' i s 01 0UWA-nFw mus f hi ,J,J, i rS •M y2m a .._cv. PITTSBURG Mo# `TH CENTER OUTPATIENT NOTES -, F 5/ 13!1951 925 413 ptTT DAT! F5 f } GA TVA' �.x Sam x y. yk�vr ' t r d�.t Vdx, ai PA IENTNAME DATE .. a ADDRESS INSTRUCTIONS IN SPANISH ',f � *ri � � '} � r�)J P X 7 1 .,t C, UJI w Uj USC ° ' SIG z tir t',t t.x Olsfl w S NO t k' CIA'TWNT 1_0,irn tint Am mast be reaclabIo on ail l tes !— n 11Y'F'ILL COST `M OtSANTiTY-� -.Y� —��~ w E RFP3Ll 1 RX l 0 < I w�e ! — < X (3t£ COST QUANTITY RX 2cc a OISP: MO Leg/hie Name 6 Licmtse n must by present on as RtrE- (0EA on Cot.oiterf Substances} PRINT OR STAMP: � j rr ' f;tFATURE._..—__,._......._ RUfiN,SNiNt'a Nt?, ._.ry..ORCt7DE,___............._... .� .:t� .....,....«........_�., f,N�R. ....�. _....., � i rTJraor-3tittrs);y GENERIC EOUIVAIENT PERMITTED CHART MR-1-PHC{11/86} Side 1 OUTPATIENT NOTES S � r_. ......... ......... ......... ......... ......... ......... ...._... ......... .. ......... . ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ....... . ......... ......... .. ....... ......... PITTSBURG HEALTH CEN CA OUTPATIENT NOTES - DATE PAL REP I N YOLANDA F 4 M CA * FNF PITT 1'i! FaMi{ 277,110- He,, '.: - JAN 5-149 Chief rt��`W Pt V@Cbali4,,,. +....l �wili�iillg ofi nuai Ptii: 8P f tt spa IMw r C9Y't ` I � ff )UTPATIENT N® E r MR-i-PHC(17/86)Side 2 ,, } y� v CONTRA COSTA HEALTH SERVICES PITTSBURG HEALTH CENTER a: O!I`I'PATIENT NOTES *vjYOLxD A 04 R i..J f * CA PATIENT NAME DATE t ' ADDRESS ". q �� IP t Y NO INSTRUCTIONS IN SPANISH REFILLul VS REFILL { a 7 GK sts: u�i REFILL% r . ¢ DISP f r J n t I X ' NO f �(� r ,C _REFILL (7) PAiIEhf'CIIS rn *'u '""' n f d t REFILL j _ COST �able on aII cotsies a F i g. OUANTITYf ._ Ry i o REFIILX OX SIG: f�' l`° I COST QUANTITY RX U ! DISP/ MD __j L l9g,ble Name 8 license p must bg present bn a!1 Itre oto:�r<; G {DEA O Confrdtetl 5ubsEe Cesi PfitNT a$T ANAP . Q SI#htlRE U 't;, e*x f t FURNISHING NO. C}R.CODE 5' )� F.N.P. GENERIC PYUN07 3{10197) IC EQUIVALENT PERMITTED CHART �A r _ . , .. .... „ COME)fes` , }, Pt. Verb ai.:-_ {3: ...rte.�A`fld�t} -F- 7 N. Fl�iwil� YA{r Vl b� S 4, 4 - f ��; X MR I PNC (10-97) Site I OUTPATIENT NOTES CONTRA COSTA HEALTH SERVICES CONTRA COSTA HEALTH CENTERS AMBULATORY CARE r A y `F r G I ' Y( 1. " :p CONSULTATION F S/ 1 1/ 1951 925, 473—r3256 FOLLOW-Up 1" 1 st' � 1 1isA FNP t= l TT NOTE: This form is to be used for consultation follow-up (off-site and same-site)and for patient initiated specialty Care. CONSULTANT'S REPORT [n Self Referrals Clinic Type JAN 20 Date of Visit Findings [0 Dictated Cif so, please write diagnosis and plan below.)] � v Chart Check to PCP? r n Yes n No ;�. ( j a Consultant (please print and sign) Date original:Consult Site AlllIBU.LAICIRY.CARE CONSULTATION FOLLOW�-i CONTRA COSTA HEALTH SERVICES MR#: OOOOOOMOO4801098 Contra Costa Regional Medical Center NAME: PALMERIN, YOLANDA, D Martinez Health Centers DOB: 05/13/1951 2500 Alhambra Avenue, Martinez, CA 94553 SPECIALTY NOTE DATE OF SERVICE: 01/30/1999 The patient comes in today with her daughter who provides for translation. The patient has a history of having had her right ear irrigated approximately one week ago. At the time she experienced pain in the right ear as well as in the right side of the throat and neck area. The patient became very vertiginous and states that she fainted. At this time she is on Bactrim and Naprosyn 500 mg tablets . Examination of the ears finds a central perforation in the right r tympanic membrane that is approximately 1 . 5 mm in diameter. The edges are clean and slightly elevated, indicating a relatively normal healing process . The left tympanic membrane and canal are within normal limits . IMPRESSION: Traumatic right tympanic membrane perforation. PLAN: I advised the patient to keep the ear dry. Should she have drainage from the ear she is to come in for follow-up. The patient is to return in six weeks for a follow-up visit and an audiogram at that time. Lorre T Henderson, MD CC: Pittsburg Clinic Martinez Clinic Carol J Fishel, FNP I LTH:EDiXll027 D: 01/20/99 14 : 39 T: 01/21/99 07 : 49 DOCUMENT: 990120223745820300 SPECIALTY NOTE GLines 31 Page 1 of 1 Copy CONTRA COSTA HEALTH SERVICES CONTRA COSTA HEALTH CENTERS { �y AMBULATORY CARE i t � ,?.� 3 �` „;> a�� � 4 ' CONSULTATION REQUEST NOTE: This form is to be used for consultation requests (off-site and same-site). TO: ' 1� MTZ ❑ RHC ❑ PHC ❑ Outside Provider Consultation Appointment Date FROM: ❑ MTZ ❑ RHC ❑ PHC ❑ CHC IJ BHC ❑ AHC ❑ BPCWC father CONSULT/REFERRAL TO: IF SURGERY INDICATED: E? Evaluate and advise. I will follow this patient. ❑ Schedule and notify Primary Care Provider CPCP). 1-1 Please assume Care for this problem. , ❑,Consultation only. Discuss with PCP before scheduling. REASON FOR REFERRAL' s RELATED MEDICAL INFORMATION TO BE SENT j❑ None] Should x-ray films be sent? ❑ Yes ❑ No Referring Provider's Name(please print) a CONSULTANT'$REPORT [❑ Dictated—If so,please write diagnosis and plant below.) Ft3 0 c 4 i, t tr _ f } BROKEN APPOINTMENT i PRN Consultant(please print and sign) Date !, . ❑ Send Reappt. Notice ClWoRe"siatingConsu" Consultsits Reviewed by Primary Care Provider/Referring Provider Date OrtainstaeqetinSkeeYtl� que�gkPMR191-8 (3-98) Requesting l Record ow Requesting inktCHP AMBULATORY CARE CONSULTATION REQUEST 3 Ask CONTRA COSTA HEALTH SERVICES MR# : 0000OOM004801098 Centra Costa Regional Medical Center NAME: PALMERIN, YOLANDA, D Martinez Health Centers DOB: 05/13/1951 2500 Alhambra Avenue, Martinez, CA 94553 SPECIAL'T'Y NOTE DATE OF SERVICE: 02/04/1999 Patient comes in today with history of having pain in her right ear, followed by drainage . The drainage has subsided at this time. She is putting no drops in the ear at this time but is on a multitude of medications for the ear infection. The pain is better in the ear, though she does have some tinnitus in the ear . PHYSICAL EXAMINATION: Finds the left tympanic membrane and canal to be normal . Examination of the right ear finds a central perforation that is healing and measures approximately 1 . 5 mm in diameter. The external canal and middle ear space are dry, with no signs of discharge . IMPRESSION: Acute otitis media of the right ear, followed by perforation. PLAN: The eardrum is healing well. I have advised the patient to keep the ear dry and to return in approximately three to four weeks for follow-up visit . Lorre T Henderson, MD CC: Carol J Fishel, FNP Pittsburg Clinic LTH : EDiXll063 D: 02/04/99 17 : 37 T: 02/08/99 09: 30 DOCUMENT: 990205013520820200 SPECIALTY NOTE GLines : 28 Page 1 of 1 Copy _.__.. _........ ......... ......... ......... ......... ......... ......... ......... .. ............... . ......... ......... ......... ......... ........ ......... ......... ......... ......... ......... ......... ......... _ _ ......_.. ......... ............. ..... ......... 99 CONTRA COSTA HEALTt1"SERVICES P7T$BLfW"fALTHCENTER ALMERtN ?OLANDA OUTPATIENT NOTES t : p i :1t9 t giS 411. 9ZS6 Q `$ A'D ?ITT DATEx 9 m _faint. eld PL verl aiizes understandft o An ual PRN: $P. WT � ,- Sm Dkiiig Status. 3^ 4, iv V c _..._. ......... ......... ......... ......... ......... ......... ......... ......... .. . ............... ......... ......... .......... ............ . ..... ........ .. ....... ......... ......... ......... ......... ......... _ ......... ......... ............. ...... ........ 02 _ Y COMM COSM HEALt i'StRNtCES T PITTSBURG HfAL°i�t G`E t R ;. t A . ' TOL XX D A t 0415 42 fs 19171 -11*0 'I�E1f t IYQ 3. W E`er: 4 lri. 7 �.. DATE +a, jI f, .. _. k r PATIENT NAME DATE y 4 49 Al7URES8 I M1 t4.tl. c I NO j� (.INSTRUCTIONS IN SPANISH (4 LU I PAt �^Fi� ( N YOLANDA � � na:F#LL 7 rF_-Flu, r,r Pt .I (�(� SCK Sic': r t r t 1-.1p i *�C) PITT t'u RE>`ti.i.Sf ...�_ t 7 f��.� D15P:/r (,�� �j t'F l, N !'f i 1 T < Z z NO PATIENT I.D.im rent Area must be readable on all copies h in a AMU � }�. � 1 COST QUANTITY � O O n£fiLIL ,d.f J RX 1 0 - I , OKCOST OUAN71TY SIG: RX 2 ' �n $tE! 3S DISP i ibis Name 8 L cense N must be ppresent on all p ascri tions Z MD {D A on Controlled Substances)PR[NT CR STAMP: 4# 14'AtURE r rt}RN#Stt1NC NO. DR.CODE F.N.P. w GENERIC EQUIVALENT PERMITTED CHART i YUN07�3It4'97) P'AT'IENT NAME DATE AADCIRESS NO �, 0INSTnUCTIONS IN SPANISH ' L " , J ri f 3 + Lu 2C d Cr > vU 01.1 .. ✓O w V) OK LU Sic; / 1 T „f � C� > OffILL x J / r 1 .f 1 D1SP: `.. ' C ..�i x 1 , j7 �� PITT T. 0 NO-_ - if ra„ fly K f . PATIENT 10.I rint Area must be readable on aN co ids g ri F1LL COST QUANTITY O REFILL } RX 1 G3 a OX SIC: - COST OUANTITY RX Id”"x w 015P' mo L b+e Name d License must be presom on 04 prwrlptlons 4•A a (ni jon Controlled Sttbstances) P&tNT Oft STAMP: � SiFfAtURE FURNISHING NO. DR.CODE F.N.P. f Y11f>�7r3(10!97) GENERIC EQUIVALENT PERMITTED CHART c , OUWA,nmff Nom ..... ..... ..v.. .. -4r.�. , .i�' _.... ......... ......... ......... ......... ......... ......... ......... ......... .......1.111. _.11.11 _.... ............. ._....... ......... ........... ......... ...... ......... ........ ......... ......... ......... ......... ......... _ _ _ _.. ......... . ........ ......... BBC() ( t N COStA HEALM SERVICES toLlso P Vii.!�'IR 1�y1t 1 QS yyy� 7 PITTSBURG HEALTH CENTER C 1q " OUTPATIENT NOTES T F t ViE l F u p p i `. DATE APR a OW P� Family Practice Mist 0111plai Annual PRN. WT , Sr oking Status: 9 --------------------------- 63i i-1- q00, - a= j t _ 1-2�,r Y W1 r i t MR I a ' s pec (1 o-srj Side OUTPATIENT NOTE'S _111. ......... ......... ......... ......... ......... ......... ......... ......... 11.11. . . _ .. .......... _.......... ......... ......... ........ ........ ......... ......... ......... ......... ......... ......... ......... _ _. _. .. . ......... . ........ ......... X cttWA .rr� aiERVMCES ry T t � Y r� 1 Pwrspum H AI.TH Cd1iTER "A 0 OUTPAt'IENt NQSkft PA-riENT NAME DATE A00RESS d . 1, ry t" AL fi 1. F. - SH 1 i 3J I I025 73�-9256 yp ED INSTRUCTIONS IN SPAN! REFtL4 '/ I y ,! . Y -..i, \ In f3,_.� ry rl .i l,l ... �} A 1.r j ff RFML ! OK SIG ISI'EL . CA FNPfT7LU FSFFI6 L X f;; - ) .. D1sP: r- w .. I I_ i � �. .Y. 1111,... � • 0 .. NO I PATIENT I.D.Imprint Area mast be readable on att copies 2 FiFFn.L COST QUANTITY RX 1 ) O 1 rrd�� REFILL � COST QUANTITY � O / RX 2 ! to SIG �-REMLL i fl--CItsP. MO Legible Name d License X must be presem on alt prescriptions rn 1 {p€Aon CWrotted Substances)PRINT OR STAMP: f �G3{1ATtSA> i FUTiNI TING NO. DR.CODE F.N.P. GENERIC EQUIVALENT PERMITTED CHART a + t ! �{ 1 f f �' � "�f tfi �"ad x,�'� U'"f`M�➢rv`�� hk�Rt'�� '.� _ lbw A- .- ) , cmrft Gist Cc�mpialn kL i �'v � �•�; s;tYw 1��`�i`��t ..a"4 a �a��� h Pt � � �d x xa - � 1� 4 r f- F,�+ s �1 r• � r •r Wu 4r 44 ( G rA uK(�L3 oJ21L04Jr^ ITT �{✓s� � ^ �e �� '� k,, 7 .:�. 1111 � •• f � A OUWATIENT NOTES W t PHC (1("7) ?Ire 2 ... ,... , .......................................................................................................................................................................................... ....................................................................................... CONTRA COSTA HEALTH SERVICES 2 SBURG YOLAKDA Nt ntkT NOTES 4 73-q256 Ouwk 4 n4 P A 0 N F I SHf t PITT DATE PATIENT NAME DATE Alf NO y i:I- OK s 101. nicrit-L x PATIFNT NAME DATE fl! I-S,S 1PAIV04 y OK vtf`�F If f,x F ------------------------- NO U) fin)rwl A,pa must bo road,+Wp on all!op—, f1r.Fft.1, {)S1 Of IANTITY Rx I • (1K CnS 1 OUANTi fY Rx 2 AFF11-1.x L.—---- LIC NO Z.1- lAmo if,L�,�,Asq 9 n,t,f,!h�pwsr,)T �,,af!p,fos--, III.�A V CIN101A 5;10111,1 o51 P N r 0R ti1,V,'F' NO ";trot tasfl) GENERIC EQUIVALENT PERMITTED CHART 42 y MR I PHC (10-97) Side i OUTPATIENT NOM .................................-........ ....... ............................................................................ ..................................................................................................................................................................................................... ................................................................................................. CONTRA COSTA HEALTH SERVICES q CONTRA COSTA HEALTH CENTERS r. AMBULATORY CARE CONSULTA77ON FOLLOW-UP 4 ted NOTE: This form is to be used�r consultation follow-up A r fl P (off-site and same-site) and-tor pq�ient­rnitiat6d Specialty Care. CONSULTANT'S REPOAV- Date of Visit (IJ Self Referral] Clinic Type PR 0 .5 Findings [E] Dictated (if so, please write diagnosis and plan below.)) v­ Chan Check to PCP? Ej Yes f-D No Consultant (please print and sign) Date Original:Consult Site ry MR191A-0 (10-97) Yellow: Requesting Site AMBULATORY CARE CONSULTATION FOLLOW-UP ................I............................. .............................................................................................. ............................ .......................... ------- .............. ................... CONTRA COSTA HEALTH SERVICES MR# : OOOOOOMOO4801098 Contra Costa Regional Medical. Center NAME: PALMERIN YOLANDA, D Martinez Health Centers DOB: 05/13/1951 2540 Alhambra Avenue, Martinez, CA 94553 SPECIALTY NOTE DATE OF SERVICE: 04/05/1999 SUBJECTIVE: The patient is status post a right otitis media which resulted in a spontaneous perforation of the drum. She still has decreased hearing at this time. OBJECTIVE: Physical examination finds the drum to be clear with a crust occupying approximately 3/4 of the central part of the drum and covering where the perforation formerly was . It is unclear at this time whether or not the perforation is still present or not. PLAN: I have advised the patient of the findings via translator, and she is to return in six weeks for follow-up visit . Lorre T Henderson, MD CC: Carol J Fishel, FNP Pittsburg Health Center I,TH:EDiXll25O D: 04/05/99 16: 47 T: 04 /06/99 18 : 16 DOCUMENT: 990405234602820200 SPECIALTY NOTE GLines 23 Page 1 of 1 Copy 1 NIRA COSTA REGIONAL MEDICAL CENTER& c CONTRA COSTA HEALTH CENTERS C5 26 90 } AMBULATORY CARE CONSULTATION FOLLOW-UP P ,a n r / 1 925 473--8256 NOTE: This form is to be used for consultation follow-up } (off-site and same-site) and for patient initiated Specialty Care. n ' � � !'q - 19 � CONSULTANTS REPQRT FRP P i T T Date of Visit [0 Self Referral] Clinic Type E.N T i Findings [O DictatedOf so,please write diagnosis and pian below.)] -- MAY 2 4 1999 , i t , t Y 4 a y i r� t hx!' 4+ � r ! ' � J L ": E: . Chart Check to PCP? i G Yes a No ✓ ;� Consultant(please print and sign) Date ' f Y r MR191A-0 (9/97) Original: Consult site Yellow: Requesting Site i AMBULATORY CARE CONSULTATION FOLLOW-UP CONTRA COSTA. HEALTH SERVICES MR# : OOOOOOM004801098 Centra Costa Regional Medical Center NAME: PALMRIN, YOLANDA, D Martinez Health Centers DOB: 05/13/1951 2500 Alhambra Avenue, Martinez, CA 94553 SPECIALTY NOTE DATE OF SERVICE: 05/24/1999 HISTORY: The patient is seen today with a Spanish translator who provides for translation . The patient states that she has decreased hearing in the right ear which has not changed. PHYSICAL EXAMINATION: Examination finds the perforation .in the central part of the right tympanic membrane to be unchanged. It measures approximately 1 . 5 mm in diameter and has smooth, fresh edges, and the middle ear mucosa is clear. There is a scant amount of material on the lateral aspect of the drum, but there are no signs of infection or problems . PLAN : After a lengthy explanation of the procedure and the risks, the patient has consented to a right tympanoplasty with fascial graft from the right temporal. scalp. A transcanal approach will be used to minimize surgical insult . In addition, the patient is to obtain an audiogram in Pittsburg, preoperatively. Lorre T Henderson, MD CC: Carol 3 Fishel, FNP Pittsburg Clinic LTH: EDiX11035 D: 05/24/99 17 : 43 T: 05/24/99 19 : 35 DOCUMENT : 990525004133820300 t SPECIALTY NOTE Page 1 of I Copy Chit s fu CONTRA COSTA HEALTH SERVICES i CONTRA COSTA HEALTH CENTERS AMBULATORY CARET - CONSULTATION FOLLOW-UP nn4n, 010q - 9 F I S4EL . CA FX? PITT NOTE; This form is to be used for consultation follow-up (tiff-site and same-site) and for patient initiated Specialty Care. :::., CONSULTANT'SRE ORT C)atr3 of Visit � t.�( � [I .1 Self Referral] Clinic Type Faa nd Report to: 0AHC C.:I BHC [..1 BP F I CWC C.:.1 MTZ 1':l NR I .1 PNC I7_1 RHC 0 ElAntioch OAC [J Concord OAC I-]El Cerrito OAC Findings Cn Dictated Of so, please write diagnosis and plan below.)] _. co-iVjoI-t, �'f\_ r Ok,j rno . FAV Ari 1r�g t�j t�j f�,1 - _T MOA a YJ 0v\ -6_kj%VO . - -- Uwe L 4 �.S ,% 7 .i 1. F k . (;hart Check to PCP? _ i...J Yes ❑ No COnSultant (please print and sign) Gate Original:Consult Site Yellow: Requesting Site MR191A-0 (1-99) Plnk: PCP AMBULATORY CARE CONSULTATION FOLLOW--UP ,u,r .._... , a =. CCINTEIA COSTA HEtt T l SERVICES � PAtMEWIN YOLAlitDA �i73.9C56 t P&MRGi HEALTH CENTER OUTPATIENT NOTESFISAfL. CA FKPPITT V", ", .. DATE ,5 JUN-0 7 ig ..,ISIDsfft r Chie Comp1i trlt' ' r* > � A, 8 WT v x'fi �+ fWfelrY�1 >�4a�. h PATIENT NAME DATE „ ADDRESS y v NO [' INSTRi-ICTIONS IN SPANISH ct7 REFILL ?r� REFILL' I r '' }.. '. y .°. REFILL X T- r j DISP' f .4t NO PATIENT i D.im tint Am most ho reartahlnREFILL QtJANTRTY._ _ . REFILL RX 1 G OK COST QUANTITY _ SIC: I s REFILL Rx _ �'.:. ,. ti �. ..� � OISP: iMID4e bIa Nurrtti&t+Cn.<.n. must he rrncn> w r..I r. vk` (D A an Gonfrsxt l,15,rh"dant, si Pnow ooF Sl o,-r, ^' SIGNATUREFU F,N.P?RNISHING NG, DR.CODE r y - — PYUN0I.3{3199} t GENERIC EQUIVALENT PERMITTED _ CHART �r ,( �TM y MR I €HC CIO-97) aide i OUTP O s . ATIENT N CLAS f D . F SLIPS 2 MS OF CQMA COSTA Q►=s I EMMe BOARD AC11tIA U61:117, 1999 Claim Against the County, or District Governed by the Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of thus document mailed to you is your CsliTorria Goverrsnent Codes. } notice of the action taken on your claim by the Board of Supervisors. tParegraph IV beloiM, given pursuant to Government Code Section 913 and 515.4. Please rote all "Warnings". AMOL NT: Nope Specified SEL { # Na CLAIMANT": Arne and Rhonda Romstad ATTORNEY: DATE RECEIVED: July 20, 1999 ADDRESS: 4513 Mlontara Drive BY DELIVERY TO CLERIC ON ___ July _20, 1999 Antioch CA 94509-775.1 BY MAIL POSTMARKED: Hand-delivered L FROM- Clerk of the Board of Supervisors TC> County Counsel Attached is a ropy of the above-noted claim. Dated: July 21, 1999PHIL BA . iELf3R, Jerk By: Deputy ` It FRO. : County Counsel IU Clerk of the Board of Supervisors ( ) 'This claire complies substantially with Sections 910 and 910.2. ( This claire FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( Claim is not timely filed. The Clerk should return claim on gre,*end that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: By: ! puty County Counsel 41r JIL FROAL Clerk of the Board TQ Co Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). BOARD ORDER: By unanimous vote of the Supervisors present: Phis Clain is rejected in full. E tither. I certify that this is a true and correct ropy of the Board's Cyder entered in its minutes for this date. Dated aJ '? PML BATCHELOR, Clerk, By 4 Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the slate this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you waist to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MA L NG I declare under penalty of perjury that I am novo, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:_ `� By: PHIL BATCHELOR By � � Deputy Clerk CC: County Counsel County Administrator Clain.Jo: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the I OO h day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 1136, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud, See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp Against the County of Contra Costa District)) f < � ) AUL 1 � LXK,057TU (Fill in �:Lsyr sj p p, avr . .i &-, B�'fii° 1 n The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sura of$ t,­7W64 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) ; i ' mac 4. .,.at particular act or omission on the part of county or district officers, servants, or employees,caused the injury or damage? z;F;n. v 3� , s �`ey-. -- C d,�'Y 'N cc f?f'`v -� sta e'944A!01 . p�..r >�f 'b�S5 ��E/r 6���W" t�"��t�> 93� ��, �:�` `� "a,�7✓f:3 i d'4.,.�'�+���.%�s.tb' ���k 4-�,�..+'�'"". ,�"�' �°S" ��rlF% k d �✓r� r �r .Y� e.q 5 4 F'e'40— '4y- ,'l .�'f ,i�'� t'14'7'V4; S fir' Ap S i 1 '`$` �j r✓' /,f,' h/ 3 1 e'X 5. What are the names of county or district officers, servants, or employees causing the damage or injury? . r �' `. k lis✓r d , n'- r'`�!:s e'''a :s�`W#1'§'4. a �s�' A a f sf 6. What damage or injuries do you claim resulted?(Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) ;wy& las# ? eCB c 3 2 ate° p�� y - sJS i a'3 ,•srzy'tt�,�`a� .,6�� grfe'r.�u.Sw<�5 of 6.`3 °�fC$ct� s- ' A' R;t d 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 8. Names and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. DATE TEME AMOUNT ) Gov. Code Sec. 910.2 provides "The claim must be ) signed by the claimant or by some person on his behalf" SENA NOTICES TO: Attorney Name and Address of Attorney (Claimant's Signature) (Address) Y Telephone No. )Telephone No. . NOTICE Section 72 of the Penal Code provides: Every perm who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill, account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand(S 1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. To: Contra Costa Country Board of supervisors (a) Rhonda and Arne Rornstad ElIVIE 4513 l ontara lir REC Antioch, CA. 94509-7751 UL 20 ( 451 Iontara DrM CLEW S; STOP ! The remaining pages of this document contain legal proceedings involving a underage child. Do not print or distribute without written consent from County Counsel. REC75i WED ADOPTION GRIEVANCE HEARING U dlo 49 9 BO �K . {. tp� r,�?nnQ`rti U , .rrt Ae and Rhonda Romstad have requested a Adaption Grievance H interrelated events. First, Martin Barbosa,who had been placed with the Romstads for adoption from February 13, 1998,to October 16, 1998, was removed from their home because of the pendency of a §300 proceeding regarding the Romstad's own ini.nor child, Melysa. At the time that Martin was removed from the home, Martin had spent eight months of his 14 month life with Arne and Rhonda R.ornstad. Although the Romstad's understood why the Department was removing Martin, they certainly did not accept that Martin would be removed from their home for any period of time beyond that required to resolve the §300 Proceeding. The 300 Proceeding regarding Melysa was formally dismissed on January 25, 1999,pursuant to a settlement reached on December 21, 1998. Even though all charges have been dropped, Martina has not been returned to the home of the Romstads. Secondly,the Department has advised the Romstads that a"hold"has been placed on their foster care license, including the placement of any foster children for future adoption. The. .Department has identified two erroneous bases for such-hold". First, the Department submitted two incomplete and inaccurate Complaint Investigative Reports on January 7, 1999, to the Romstads . The Department also orally advised the Romstads that a"hold"on a future placements was necessary so long as a Voluntary Plan was continuing with the Department of Social Services concerning their minor child. A true and correct copy of the two Complaint Investigative Reports are attached hereto as Exhibit A. Prior to the meeting of January 7, 1999, the Romstads were told that a meeting was required regarding their faster care license. They were not told that they could have an attorney presents The Romstads were not advised in advance that complaint investigative reports would be submitted to thein. The Romstads were told that they could place their comments on the Complaint investigative Reports on the same date that they were presented with them. T he Romstad's had no opportunity to review the Complaint Investigative Reports with their legal coufi§el prior to adding their cornments. The Romstads have consistently and repeatedly advised the Department that the complaint investigative reports are inaccurate and incomplete. For example,the Complaint Investigative Report contains an inaccurate allegation that, "Child disclosed that adoptive father has been molesting her for the last 2 months." No such allegation was ever:Wade in the §300 proceedings. and as noted above, all allegations were dropped. in addition, one of the Complaint Investigation Reports incorrectly state that corporal punishment was also used on the children located in the foster care premises. Both Rhonda and Arne categorically deny using any corporal punishment on. any Foster care children. Indeed,at no time did CPS ever file any allegation regarding corporal punishment or any other form of Physical abuse in regard to any children in their care or custody. Therefore, CPS rejected any allegations regarding any form of physical abuse before they even filed a §300 Petition. Counsel for the Rornstad's.has written correspondence dated January 11, 1999, January 15, 1999,February 4, 1999, and February 22, 11999,to Los Rutton,which are attached hereto as Exhibit B. Such correspondence complained about inaccuracy in such complaint investigative repasts, as well as requesting an opportunity to be heard regarding the"hold"that has been placed upon their foster care. Such correspondence also confirmed that the Department deliberately refused to return the R.ornstad's legal counsel's telephone calls daring the 000 proceedings. As noted above, a Voluntary Plan is presently in place providing for services in regard to Melyssa, who has significant n.ental health issues. which the Romstads have diligently tried to work through. The Voluntary Plan resulted from the recognition ofthe Department of Social services that the family could benefit from services available roan the county due to unusual circumstances present in the home. Notably, the problems recognized by CPS were not any different than the ongoing family problems that Foster Care Licensing has already been fally apprised. As a result, all of the services proposed under the Voluntary Plan are unrelated to any al'.=egations of the sexual :molestation described in the Complaint Investigative Report. The Romstads have also made complaints regarding the requirement that they use birth control, if they are going to adopt a child. The Romstads have been greatly offended by this requirement. The Department admits that they have discussed using birth control with the Romstads; however,the Department denies ever malting this a requirement for adoption. Attached. +Fc hereto as ExhibitC which are true and correct copies of the Adoption Home Study and correspondence from Lois R.utton regarding the use of Birth Control. However,rather than being simply a request,the Department has put extensive pressure on the R.ornstads to agree to use Birth Control. Please note that the meeting during which the Birth Control was discussed with Lois R.utton occurred after the issue was initially discussed with Heidi WinteAr-nantel. Ms. Wintermantel advised the Romstads that because they would not agree to go on Birth Control,they would need to meet with her Supervisor,Lois Rutton. The.meeting with Lois R.utton lasted in excess of one Dour just to discuss the issue of Birth.Control. The Romstads are not the only persons who have believed that a requirement exists for prospective adopting parents to use birth control. Attached hereto as Exhibit D is a true and correct statement from another prospective adopting parent who believed that the Department was requiring them to also use of Birth Control. The Romstads believe that they can obtain additional statements from additional witnesses supporting the Romstad's view that the.Department is requiring parents requesting adoption services to use Births Control, The Romstads respectively request that all restrictions, including informal restrictions be removed from their foster care license and that Martin Barbosa be returned to their care and custody. ,f Martin Barbosa.has been placed with relatives,the Rornstad's understand that a relative has superior priority over there for purposes of the adoption placement of Martin. Date: LAW OFFICES OF MARTIN F.TRIANO f,. MARK D. BYRNE. � as''.i ,�..•,var„pFq.4a..'.`* .eta. '� '3' :`2q, 'i-� .. ti» �.-.:.:..tLiY:s-s���"&r�Fi'�r'.�st�v,�+'��•-Ss'X��..R�< yL.+'+„`�:3'�-ri t*5.=x'.yF,'.- «�<",s.j40- AM , ',��..'` 'I�.�a'♦.�-rsX'��.`�� :�`$"�ri�Y},by.'�s�r_,te-.'�.>St'-✓a"tF�nIi{ii:M'4<,ii..ka�Y-sL,.4y�xSi,.;.,sa+ . " y x-".r",�: mam Ylt Amsir,.,t'.Cp, ` ` ` .rG)' !W. F,, " p L g�,�� �,r. '�'� �41`W. Yd.tA•T� '��+Nt�� 'F� 3 k xr' '.q': � y � yrs•.. .,� - - .7 "mss* .° z,;,- :. x� p� ,. � r'All ` °a�..L='"` t -,1-c's ''c.F'',..:.��..1' r-d'.r�'�°Y�s" '�.#. �'� ���r'�'`yU`�Sa'� �� :K:•,�"�»'v.+*::�`.�,k'�'�yY '2#'°��+y., 5:�2��'°S;' K5. w.:.p Yom, s*< � x _S. - ,I'a. " � � k-,6, j a.. •a Y ,•_'. �:.w' ,jw'k"�N „-.. e.�' Ya.,..,.•'„v' `y:."•t"�.rr rii,;,.:Y =G P'Y x .. ��., �±' ee, yti� �r^;�����``�4t �, ,..+� 't t'� �i xu "5�.. � X9..^'x ✓r.. .”' oc ,;„, -_w " :+t `,,,,r _.. -r ,`• y, +�o.'�e- Per, •'" y'" t_.e`,-„'; '.vww,„ <`asc-"ar ,fie. i" 't ce. �" - ,q .,,ei:«".�. � "'1: .sk•'tq at ''d' 4',.,' ss'"a .s'T`v x, � a.;�''WM-t y,K..7 .�p .k. aT .. c .,�1 u•s9• - } .h`< ��,..`t � -..+ i.ay s4a� r��F.�s�+.yam. 3h.7 �--.,+�""�"`• t '� q^4e �. � E .+ .x: � 'c"�i+-, � :,�,�......""` 3� K w,,,,�e f"a. � a'rrd '�Z ;,H y✓' y``, '�' �.,. �>� �-x '�..F" r .y '*.. ,F.�s• .^t=�. � 'Y_' i-.'E'tr`�' �?�-r�c�:_ate �,, �-t yt X�t yr s ,� � - „�. T.,w. �. thr�+ - -', .o-..i > � *<.. � 'tt'> •r _, 9e'� � a��' , cw. ,.: 4`i d is r -.k � �s^� x r vi •x arm * i-.c -. � ,`K 3., ,��'#„y��r . .a'-cRKr�-r�•S«--3;r .+ ip..�,i {� � � fa "4 .a "" �'; .,�'` ,:,g,! 7`"-zws- r .S ya.,•-,"s —,rte 3rA-,E. ", ,'•.,. «r ,a .w^�. '.,^ Ls.�, P.3 z. 'r gin.. ��� % � r ,�„ :,.,� x 1� •�, r t �� f� rr„ •tv-` h `'�" p�`- +` ,s-w �*'y % "w^ j �� t `"x � y .•`..1 t�k_a � _ ''e <" �-�,.,.� f��'� "'�+r>�q .���Y.+i r 'Y'�,ys.�v `�a"� s"q s r x"s � t d NZ <rae.• ,�.g - .;: Y w°' ?'`x �.h ,�-,x�s�-�w s '�`:'��a::.�+'.re .,�f`�'„ �_-i�-+� '�- �r 'N is y ti y leyt ✓ .3^ �" L �" sR c "S.�y y'f�-'e i^/VLA Y_'t�: . n.� � k � � _k..• x '� Se-�' .> s� _ k ..^. �x;a'�``�-�r �.r+';�+a* t 'A 1 e � '."'��+' a �•r., w w � - 25.: L =,r k s,<.�"�m'`e< ,�;z� .r s i`.,� y � x.+•-°t„� s �l'`'` '4-r an.. p. 'o,. w•�' -r ..xs d �-i.`�:s. .� ,ry.r- ^-- '- ,: J`� �.+..-+� a.. .� i .�" ��-�+t,�.-''`•�"N+• i S-�.�5—... � � +mss ,��'�,�� �>�:� :.t.•s-,+..� � w'.��' �1y__ �j���, y �,�{. ;, fix,. ♦.A. ":s`did ;,,�. � .r�t10 x „++�. 's�ca 'ka. �,s�` � .7 +�n.',7``,yjy,a w. 3���a+�� �ys �-k a-,r= may„ '�'r _ y" t�*•.v'�# r t - .>��a`"i 'v�'...3` '�'r�,gm,„��+ 'r �.4*. �'� ��r�. X��y ti''•C`�,s�.t.w.�"' ys. C � 'a�f,`i s �` .^h P�?- #•�. ��2 r+ t err � ,t k -���x i �C�,.ice "�` i"'� 5`r �.c r Y.:s:•:'h aro,3;.+.0.. .+9:f ,,..p �s n L'�'% �:,,���,�..�+ :. ;���> �„ "�.�,� y� �' �"``� '""`•may, � `` !n �, �;�`v COMMUNrrY CAR=_UCENSIN4 COMPLAINT INVESTIGATION REPORT COMPLAINT CONTROL}UMBER This s an official report of an unannounced visitfinvestigation of a Complaint received in our of€ice on andcond=acted by Evaluator i3Y NAMF fAdUIY NC. FAC#i."TYPE �I FACWTY REPRESENTATIVF ADDRESS +E'.LPHONE CAPAC'TY !CENSUS -75 V— _ W'N )TIME tN TWE OUT TODArS CRATE PUBLIC t r CONFIDENTIAL ALLEGATION(S): -- INVESTIGATION FINDINGS. Needs Further Investigation°, Substantiated inconclusive unfounded Es,.irnated Days of Completion �7 SPECIFIC DEFICIENCIES i Rr-CO!.NIENr ATIONS!r:C RREC T IONS - J i `f ALN V& �` v e b W { j'' j �j„q ✓'T V { a Failure to correct the deficiency(ies)Cited above by may result in civil penalty assessments of $50 or more per day. UCENStNG ANAt.Y$T s:GhAT',;RE _ tTE� ;Sijn E j ac know ledgereceipt of R + f form. and understand my � � orm. P t - - � l apAea!rights as explained on the back of this form. NAtitE C>F S+J��RVS TELEPNC NEf,SkCaNkTk FkEDAIE Distribution: Original:Agency — Duplicate:Licensee Triplicate:File. nage of + z!c W92 t Fart 1 COMPLAINT INVESTIGATION REPORT COMPLAINT CONTROL NUMBER This is an official report of an unannounced visi`Jinvestigation of a complaint received in our office on - and cordulited by Evaluator rA�UT'f NAME 1EA�sUTY ta0. fACtL7TY TYPE '1=ACY tTY€+EPRESEW,AT7VE - TE'wPligtE ,^APAGTY 7CENSUS AbCS?2'E - - - . ;MET VTTai (711.tE RN-�� 77t6E CbUT 7oDAYS DATe PUBLIC C'ONFIDENTIAL i � �— ? ALLEGATION(S): j — , I*iV�S�'I�ATI'Jf43 F13�f33N�5: , — l (e" Needs Further Investigation � � ✓� 17 Substantiated inconclusive Unfounded Estimated Days of Completion v"Tf SPECIFIC DEFICIENCIES RECOMMENDA`fIONSICORRECTIONS P y- ,s <V t i { Failure to correct the deficiency(ies)cited above by may result in civil penalty assessments of $50 or more per de UCIENS!NG ANALYST S7GNAIUFAE } E�tPr oroE I acknowledge receipt of this form and understand r t'7. Q/ — �appeal rights as explained on the back of thisULZ fore, NA�NWUPERVisLEPHONE /-,'�7 ,}i�SIGNAJTUURE 'JR7€ Distribution: Crigiraal:Agency Duplicate:Licensee Triplicate:File, page ��of . UC 0099(SM) _ CONTRA COSTA COUNTY Social Service Department W. John Cullen, Director January 11 1999 Arne and Rhonda Romstad 4315 Montara Antioch, CA 94509 Dear Mr. and Mrs. Romstad: This correspondence is a follow up to our office meeting of Thursday, January 7, 1999. Present at that meeting were myself, both of you, your licensing worker, Heidi Wintermantel, and your adoption homestudy worker, Kathleen Marsh. The purpose of that meeting was to review the current situation in your family and to clarify the Department's position regarding future placements of foster or adoptive children in your home. As we discussed, the Department is very concerned about the emotional health of your daughter, Melysa. We feel strongly that you need to focus your attention on her needs at this paint in time, stabilizing her and normalizing your family relationships. The events of recent months have been traumatic to each member of your family. Therefore, as we informed you, it is our decision to keep your home on "hold" for a minimum of six months. To assist your family, a Voluntary Family Maintenance Flan has been developed by you and the child welfare staff in the Antioch office. When we met, we reviewed this document together. Upon your successful completion of this plan, the Social Service Department will evaluate the submitted written reports. If you are still interested in foster care or adoption at that time, we will arrange a meeting with you to discuss your family situation and make decisions regarding the status of your license and home study based upon that new information. For the next six months, however, we need to be clear that your home will not be considered for concurrent, fostiadopt placements or foster placements. Should you be contacted by a social worker for placement, please direct him/her to contact your Licensing worker, Heidi Wintermantel, or myself. This holds true for staff from our department or any other adoption or, placement agency. Should another agency conjact us regarding your homy:, it will be necessary to inform them of your"hold„ status. During the next six months, we will continue to do what is necessary to keep your foster home license in effect. To that end, Ms. Wintermantel will be contacting you in the near J 30 Muir Road; - Martinez - CA $ 94553-4642 - Voice (925) 313-7387 - FAX:(925) 646-2759 _i 40 Muir Roa(? - Martinez - CA 94553-4692 - Voice /925) 313-1827 - FAX (925) 313-1875 i_.! 2500 Alhambra Ave - Martinez < CA - 94553-4692 - Voice 5925) 646--2941 a FAX (925) 370-5889 future; to arrange the home visit necessary to renew your foster home '=license. As we agreed when we met; she will be accompanied by another worker. At your request, we ars forwarding a copy of this letter to your attorney, Mark Byrne. It is our understanding that, if your attorney contacts us, you have consented to our discussing your case with him. We ars hopeful that you will make use of the next six month to aggressively deal with the issues that led to your daughter's allegations, to use therapy to its best benefit, and to heal as a family. We will look forward to hearing of a successful outcome for all of you. Sincerely, jA Lots Rutten, M.S.W. Social Work Superviisor 11 Homefinding Unit- Al JO LR: cc: Linda C.anan Danna Fabella Mark Byrnem, Attorney �'� Y� ��. :� S ✓ Crr.-� S ax s .-�'..+t. Y'.;�."s . t-< p., �:"�'v'. "-d*r '"y.�P 2 4 1r,� ,�C �.- �` �' 'E'. - v y ✓ ''s ,u Zr�;y. r ays 4-f'�`v �t�t�-`�a.-t -.. ,c` d 5�• '"A �� Y'�,.�,s!�'1�.�" �"�'S. #n r r" •h., Y«-� ; s: ��r` � r j' f ik '��K�E, � z�'a"�'�w.���.�y 3,�,j� ,*t x �,•at+��..5 v+ K�rs,� � � �� m s'C �,-�,,� x S.�� �" .dn,y `tri a:.. of a,- .� y�,:r..� Fs �"t"'s�t'y�t�"c,,i�°.a'�''%-'.� +#'>sF-x a�.,r�.v ,�x �y,-�',''r `R "7•.s �'' �`,a.��.+�r..,•:t,,A ' sd c a� •�' .•. .: j.5,� t•y t -x, ,rs^�,-r.'+. � s �y,�c � �,"rx yy Vii"},,�t+..p Yr ,� 1. 4.r y�'� }b c v�h a'�*�"'�r.�' ��,V•.�+tw �,�,.-z- 1 i h� F... 'r �j�" "c �?;~ f -.:4-- �... a-�.� � -t ��.z � t.� �. $�: �.- � � ^��'"?e w ,�'��',�e<�u„�,�- --a„':z'� y a -[� v.��-•..:i� r <#s sd.�.b.� i` r r L - r c y :.� •F�`.-,. ,Y, �.a� 'ar-r *y',. j - ..rt�-�ie '�'�-Ci"• { ..,rte,,,, -> w-• s�^;'r„e x > ��r �r 33kC ti ;Y:s�: Y w,nL-. e � w r' k*ka-t.�4r .z.. f-S-Y`�-�.y.. .iw`� ���` y,.e�``e.,5 '^""C'� if s> �' t ! 3r:-.%•.. k'otr:� d'+. ',¢-+,a ' y�y � .. .y- ,,L xs:i•'�. <”" .s^� y 'b-` ra '.S.�ii''�. a`,i' , `s�+'•°p�{% �V'p'T sYrZw '✓a' r v yY r�av< 4°r, w y+t'""�' „8'�".h�� ,oy.k '•4'T+ey_ :+�'."` r 'a x .q [!bY !'.�.e , p.+.s"� d .LP' 7. J +'�w .� i-a ,- '✓� '6 J'✓r 'i x%.�-r-+i'M .4y .5` p C�+s�,, '�k�r� x t �:^. ...�"r,_ "�.b � < <`� Y �""?ss R ..a.s'''a,,�..y,r..� ems,.tA "3 i � v ,y' a` 4" ."'.?.iF'i.' +,, a.-4, � �Ny;v-+•6 C ,4 d t{ q. �t -'=i •y 5, +t'- yT"` �; a'h' (y''.y".«r''S,✓F`'.t Yas.."s''`,�'. rt.'iit rteA",}r !-`T r+'m.,'y3*tw `+c..'"�+, 3fs' ��"� £' .r�r . �� ,.'fir�.+.d.,iw-9U `- ir .fir r�.e,i•, ,�-,3^ *i.,.#,;,,,r xi>, `gt-a," +z�,t,. trv'tcd. '} Z'^" 1 t ,..-•r*'t�c��-ee Y " /� .�` �_` y`Z'v }: .ice' ��'�„•+s': '^''6 'w,r.t”.t �f .,p � � a '.� � . '�&. ,� x� ,P,r3.v' w xi ��•_3 •,�, ¢ .� .•r LY ,✓ •-- h 2v,. ` RM b P.v. x' r '•'s * s t" mac.- c '6: _r .v -� q' ..3 ! ry a^ t'..err s ti ,1.. ¢�5• yX'!3 �' � p 7� _ a.. .c ' f :.-.`t R•T a �_ "e'�•�'""` 1 f'u"i•`• w{�"*�`P"i i q `^•d 2 Y',s< :� '�''a s _c -r t �:-�'f ,,-rt�y„r r -,• � '''7.� ,.,+ a�.new b !,� �Y. d'� ;-� r � ,.'�w.,�'� y�,<d•,, a .., j .�u,• t �.� � •.�' �y' rs r5,,„, <.. -re.- '� L_j � ry x. � A 1 f-,t. i.:: :'r ,y,. �,.� �" '^w -r .t` se -h •'t ^m� �"'K-�'�` x..�.2' i tad.... �� -., r :�+� Wy s ..may,s-Kt'^�'�, i �vr '3'-•""^�-f�;t`•3•'. s: �.r x � i �"_n.""}. S x � ^.,-ea,.r�• �,,.v ti., s sC a �& -� 3. �y ..r �� c •3`_ { `r. "'.s:T_..ct-moi. p rz+ :'`ems s 't' s .-�• `"L d"- 3r r - c. 'Y y '�.,o= y�q�✓ . ,» :r 9> r. a r "''•t"�4 5= �'"' .t..^-5..�'.� -T1�`e.'!�.n'.t°,+i�•k,,.!"'X d, ..F,��.- $'`5 „d�` ,n'7 '� jr. tC ^E, s r w„ +' - "' '`.-s ,t k k;t, 7s" y„�s R h•-.v tic ,a. .. r a ..i} yb r 7 ✓a. + ""'.r N ...k.,r L ....,, d ;.f '-� �",ti:- � *„•` ." 3'.'ter �, +" -y .-' � :'� .;y-.` r -ay '','..�R�� �.C.'�j•�`s':1'��'��:,.r `t,,�'' ""•y .'�°.�F� "' j �., at •a-'• � orb a^- .y ,w-"`M- •id#y� .- y 6 `�t`yr`s y P+,,,ic,1• q,r Y'd ^e.:- � "q�.,..��SgA �.�^-� .p r * r" ,Fs -."`�'�s g �! �tl� ��y �.ar �_•y.�,� - �s ft�rr•7'.- ,t, �� •a^ ✓' gin. "��:p sk "�'X3',1 ?` r.�,�-• � `g•" ,i. r ,e "- ;_,� ��r_st�,�� *ja-o-�X,{y. rr..a•K, � ,$': 'a�. a �`-' a-.. r d .s w -Y 'x{ J',,,C.r° Z,,.t •w::Y s.. 5 y .-, x3'ng*.'"i"�"�y" i� --+ ". Y�:f"w T� � 4 .+_. sa+-.• �, x..:4k � .t s• .t: -"� r. 4T s ,t'-_'4 �,�.,Y..:i � d_ - - r"r l z j. .4 ��¢ .4 _t x r�f` x�✓* �'•'7 � ✓ A t1y�� fi� �=`C� ��V���'��(Y .�ws°`yt�,c�tr,�,.a, r r. ^ re •e. `,e'+.ar ^.}. ',z t�• y -z`.a'`,-t su "+'"` ie 1", r .� -K +r+"'S� -� ':,,`Y�--.. n"r"� �sW "'rt�'w' -�..c;p.'� r o• d�t+F '"-u. Yyg+fp Sf `�Y�9 «��t���*�'�"`', J �• 1 v. :! Mt"��Sc'•M'S 3°. LAW OFFICES MARTIN F. TRI NO MARTIN F.TRIANO 25TH FLOOR,SHELL BUILDING Of Counsel ;SARK D.BYRNE ALAN H.DAVIDSON FARIBA FAIZ 100 BUSH STREET KRISTINE FOWLER CIRBY Attorneys skt Law SAN FRANCISCO,CALIFORNIA 94104-3927 TELEPHONE(415)(415)391-2300 1505 Our File No. FACSIMILE{415}391-1922 January 11, 1999 Lois R.uvon Contra Costa County Department of Socia` Services 30 Muir Road Martinez, CA 94553 RE: Rornstad 300 Proceedins Dear Ms. Rutton; As you my know, I represent Arne and Rhonda R.ornstad in regard to the Welfare and Institutions Code Section 300 proceeding. My clients have provided me a copy of two different Complaint Ir,vestigation Re art dated Javaary7, 1999. Upon review of the Complaint Investigation Reports, i was alarmed to discover{flat the Reports have been. labeled"Public" and contain information which purportedly arose in the above Juvenile Count proceedings Because such proceedings are con. idential in nature,.I would appreciate receiving%,our legal authority to use information allegedly resulting from. a conildential proceeding in a public report. Upon review of h report, lam also alarmed that the information continued in.the Complaint Investigation Reports is either inaccurate, Incomplete, or has clever been raised in the above Juvenile Court proceeding. Indeed, It is important to note that the County has dropped all §300 allegations. Therefore,we request that this letter be included as a response to the January 7, 1999, Complaint investigative Reports Because of the conf`ldemial nature of the proceeding, itis diffiC 11t to respond to the allegations made in the Complaint investigation.Reports. Hcwever, I can confirm that no allegation.was ever made in the Juvenile Court Proceeding that, "Child disclosed that adoptive father has been molesting her for the last 2 montl�zs. ` i.addition, ail §300 allegations `��ere dropped when tree county proposed the voluntary plan desc 'bed in your Complaint Investigation.Report -The VoluntaryPlandescribed in your report resulted L-om the recognition of the Department of Social Services that the family could benefit from services available from the county due to ;unusual circumstances present In the glome. 'Notably,the problems recognized by CPS were not any different than the ongoing family problems that Foster Care �icerlsing has already been fully appr�sed. As a result, all of the services proposed under the �lolurltary Plan are unrelated to any allegations of The sexual molestation described in the Complaint Investigative Deport. I also note that one of,.he Complaint investigation Reports incorrectly state that corporal punishment was also used on the children located in the foster care premises. As both Rhonda and Are advised you,idle categorically deny using any corporal p=shrnent on any foster care children. Indeed, YY, Letter to Lois Runon at no time did CPS file any allegation regarding corporal purnshrnent or any other form of Physical abuse in regard to any children in their care or custody. Therefore, CPS rejected any allegations regarding any form of physical abuse before they even filed a §300 Petition. If CPS declined to ever raise this issue in Juvenile Court,atter a thorough investigation, why is foster care licensing interested in pursuing another investigation regarding this matter? :Notably,each of the errors described in the Complaint Investigative Reports were preventable, by merely returning my persistent telephone messages. Regrettably,this letter will also confirm your Janizary 7, 1999, representation to my client that you had specifically instructed Ms. Winterrnantel not to retu=rn my telephone calls during the pendency of the above §300 proceeding. In view of the valuable property rights associated with a foster care license, I hope that pry clients are somehow mistaken regarding t1 is impression. However, in the event that any administrative proceedings are commenced against An, and Rhonda Romstad's foster care license,we will strenuously object to your faire to communicate as an interference w th my clients due process rights. Importantly, if you had comm,umcated with me,the inaccuracies in the Complaint Investigative Reports could have been avoided, In the future, I Dope that you ,A l be returning my telephone calls as the counsel for Mr. and Ms. Romstad. "'s letter will also conf=, that the above incidents are not the first time that the Department has acted inappropriately toward Arae and Rhonda Romstad. Specifically,prior to the commencement of the §300 proceedings,the Depar hent of Social Services "advised"Ms. Romstad that she would be unable to adopt any finer foster children unless she used birth control. When my client refused, she was compelled to undergo a psychological assessment. Such treatment by theDepattmvnt is a violation of the Constitutional rights of privacy owed to Arne and Rhonda Romstad. Please be advised that we Have located two other couples who have been simularly treated by the Department. Mr. and Mrs. :Rormstad are presently reviewing*,Meir legal remedies in regard to the above. I hope that the Department'�r ll reconsider its present course of action in continuing to hold their faster care license. All of us are aware of the severe shortage of qualified foster parents. Arne and Rhonda Romstad are eager to continue their role as foster parents. Your courtesy and cooperation are greatly appreciated, if you have any questions, please do not Hesitate to call. Very truly yours, LAW O S OF MARTIN F. TR1A_N10 yl'3.1"l.Zli`1.D. .3 M SB:cmw cc: Ann and Rhonda Romstad 2 LAW OFFICES IMAR�g F. TRIANO £?AKLAAI3 OFrjcE 414-IP 5t.,Stc.450 25TH F°LOOP,SHELL BUILJL'G Oaklsnd,CA 94612 MARTIN F.TRL&LNO TEL:(510)451-6782 hLARK D.BIMNE 100 BUSH STREET Attorneys at Law SAN MCNCLSCO,CALIFORNIA 94104-3927 Please reply to the - San Francisco orrme TELEPHONE(4M391-2300 Of Counsel ALAN H.DAVIDSON' FACSMLE(415)351-1922 Our File No. '1606 KRISTIN'E FOWLER CIRBY January 15, 1999 Lois R.utton Contra Costa. County Department of Social Services 30 Muir Road. Ml artine2, CA 94553 IE; Itomstad 300 Proceeding Dear Ms. Rutton; hhis le ter� gill cor�f n receipt of}'our Janua� 11, 1998, correspondence, which l received Born my clients. I ha%,e not}ret received a carbon cop), of this letter firom.yolz office. However, upon review of}tour Jantraary 11, 1999. correspondence, I am confused. As reflected in my van��lay 11, 1999, correspondence, my clients had ea:lien provided me v ith a copy of mo diflerem Complaint Investigation Reports dated Jauuazry t, 1 999, which they had received from you. "dour January 11, 1999, correspondence, which purportedly follows up ,he January 7, 1999, meeting, fails to mention the existence ofthe Complaint Investigation Reports, nor any of the allegations contained wthin t1he Complaint investigative Repos. Therefore, please explain the Department of Social Services' posit= regarding the siatus of the..-ne and Rhonda Rolr.•stad's foster care licerse, as well as the basis of any restrlctlons or suspensions, ?nterim or other'N45e. Indeed. al°bough the licenses ofmn, client is on "hold." I am not sure what-.hat means within California Statutes. In v,ew of the fact tl;at any clients may still be contacted by social v,torkers or other agealcies for placement, it appears that no legally mcograzable restrictions nave been placed on my client's 'kerse. "urtherrnore, ifvol r action: represents a interim suspension.,the Department has not complied v,�th lite provisions of Healfh and Safety Code Section 1550.5. In view of confusion%n the record, as as the inaccurate and incomplete Complaint Investigative R.-ports. as more particularly discussed in rely January 11, 1999, correspondence, it is very difficult for rely clients to determine whe liar to request a hearin g �rnder Health and Safety Code Section 1550, et seq.. Irl an exercise of caution,please regard this letter and any January 11, 1999, correspondence a Notice of Defense and please set a hearing pursuant to Health and Safety Code Section. 1550, et sec.. If the Depaanent requires any further isSormanon or doc*.mentation in,regard to the setting of the hearLng, please let me know immediately. Your January 11, 1999, correspondence is also confusing in that your letter focuses upon the >:• a Letter to Lysis Rutton 7 ua iS. 1999,Page 2 months:, Your co,—,espondence implies that such mental health issues resulted fromw-natio events over the hast few months, "requiring stabilizing her." The only trauma which.occurred to this family was tl e-ae:noval of Melyssa from the home after the Department overreacted regarding Melyssa's cornments. As stated in my January 11, 1999,correspondence,all of the WeLare and Institution §300 allegations have been dropped. In fact, as you also know,Melyssa has been having such:rental health issues since Arne and Rhonda R.omst„ad were fir=st plaoed with.her over eight years ago. Over the past fo-Lz to five years, Melyssa has been-under the care of Dr. John Whalen, who is the Director of Wahtaut Creep Hospital. Indeed,,the psychological assessment discussed hi the voluntary plan was already sched5.de-d to begin with Dr. Whalen. While the Road family recognizes the benefits of the proposed Voluntary plan to assist them regarding their daughter's and their own needs,the R.orn.stad's have done nothing wrong or inappropriate to merit any foam of restriction upon their license. Rather than instituting farther harm upon this family by`holding"their faster care license,it would be more beneficial for this family to return to normalcy. Over the past eight plus years,Arne and Rhonda Rornstad have been involved in foster care in two different states and three difb`erent co mties. Melyssa en, oys the interaction with the babies that have placed in their home over the wears. Indeed, ift6he events-of the past three months ltad not occurred,Melyssa would have had a new adopted baby brother who she had know for rnost the baby's short life. Please reconsider your position. Yol..ar co=esy and cooperation are grea*�y appreciated. If you have any questions,please do not. hesitate to call. Very truly yours, LAW OFF OF MARTIN F. TR.�.I` O 1N :ao cc; Arne and Rhonda i.orastad 'z. 2 j L-ANN,OFFICES ° ARTF. TRIAN � OAKI.A?�D OFFICE 414-13TH St.,Ste.453 25TH FLOOR,SHELL BUILDING i)akland,CA 94612 hSARTDti F.TRLO TEL:(51 0)457-6782 N ARX D.B'�'R.NE i0�B7 S}3 STREET ,JOEL DONAHOE SANFRANCISCO,CALIFOR-MA 94104-3927 Must reply to the Attorneys at Law San Francisco Off ct TELEPI:C'�E{415}391-2300 i6c6 • f3iCounsti i ACSnIrLE(435)391-1922 Our Filt No. � ALAN H.DAVIDSON KRIS T E FOWLER CIP,BY February 5, 1999 Lois Ru-non Contra Costa County Department of Social Sen-ices 3O IL`ui-. Road Martinez, CA 94553 RE; Ro nstad 300 Preceeding Dear Ms. Ruston. 1 t};5 1—Tier wili foljow p my y % iL 1° 11. 1 GGO and TL11L n '5. 1999, corresp0ndence to you , as well as cur 3a.n nary 29, 1999. telephone conversation. During our January 29, 1999; telephone conversation. you promised t0 speak to vcuz supen`isor in regard to my proposal and get back to me b% Febniary 2. 1999. AS cf'�%a tint tl,s lever, I '^:ave not received any response, As we discussed during Ct r telephone 1-onversation and in nay past cc espondence, the Depanrnem has placed a de facto suspension upcn clien—CS license wi.hdut any due process proteGtlors. .t;ere }'ore, n, Glie^t5 ue;•`,ia�!" ..:at :: :�` reGel�`�. . e hey e,l. 0. -.,hepre eGtiC�17 provided under Califorr: a Law, includinc ...e heart:: and Safety Code. as Nvell•as the California Code of Re2ulation<_. Furthermore, I understand :hat the Dep='`mew-uses a grievance procedure regarding adoption placement. Because the Depanzynent has a so placed a "hold" on any fl ether adoption, placements. I %Fish to snake Glean that we ate also regues.ing an opportunity to be heard reaardina this f-inher resUnctisdn on nny clients ria .5. AS we discussed on Tanuan-- 29. 1999, my clients still are deeply interested in the welfare acrid ,,yell being ofMannt °n. indeed; as you know. my clients were prepared to adopt " ra. •n a -Ler he had Spent 9 months of his 13 month life wit' \e Ir, and Mrs. Romstad. As I certain `lou car, irna2ine. tl-, s urulateral decsion by the department to "hold"further adoption placement (including presumable° 'afar `nj has a large en•ictional impact upon my clients. As you also knoNv, my clients are convinced that-heir res 1sal to use birth control has effected the I:3ei;artrrent'S decision. While I appreciate %-our denial that the Department has never made such a demand on any adoptive parent, my clients have located Two other N%itnesses gyro%vill Support their position,that the Department rewires potential adopting parents to use birth comrol "herefore, we to be heard in your grievance procedures. Please provide a respecti�=ely request an cppor~�irin copy of the riles regarding grievance procedure as `�°ell as anN other pen-tinent it orration to conduct such grievance procedures. Letter to Lois Ramon Febmary 5. '19,9. e 2 As we discussed, my clients have little desire for litigation; however, because the depaxt nent has taken these unilateral actions based upon inaccurate information and without due process in violation of state law and possibly federal law,we are being left with little choice. i hope that we can still resolve this matter. Please contact me as soon as possible. Yo?rr courtesy and cooperation are greatly appreciated. ?f%ou have arty questions, Dlease do not hesitate to call. Very truly yours, TIDE LAW J/C/�l OFFICES OF MARTIN., F. TRIANO MARK D. BY TE, DB Hr cc: Arne and Rhonda R omstad Appeals C-oodinator . 2 LAW OFFICES MARTIN F.TRIANO NI ARTIN F. TRUNO OAKLAND OFFICE MARK D.B MNE 414.13T"St.,Ste.450 JOEL DONAHOE 25TH FLOOR,SHELL BUILDING Oakland,CA 94512 Artorne s at Law TEL:(510)451-5782 �' 100 BUSH STREET SA;!FRANCISCO,CALIFORNIA 94104-3927 Please reply to the Of Counsel San Francisco Office ALAN H.DAVIDSON TELEPHONE(415)391-2300 KRISM;E FOWLER CIRBY FACSIMILE(415)391-1922 Our Fl#t No. February 22, 1999 Lois Rutton Contra Costa County Department of Social Services 30 Muir Road Martinez, CA 94553 --RE: Romstad 300 Proceedin Deo-Ms. Rutton: This letter will follow up my January 11, 1999, January 15, 1999, and February 4, 1999, correspondence to you , as well ar our January 29, 1999, and February 9, 1999,telephone conversations. During our January 29, 1999, and February 9, 1999,telephone conversations, you promised to speak to your supervisor in regard to my client's request for a hearing and an opporturty to be heard regarding the Department's unilateral decisions concerning the "hold" status of their foster care license and the failure of the Department to provide a proper weighting in favor of the R.ornstad's for the adoption of Maartyn. During our February 9, 1999, telephone conversation., you stated that the Department believes that no hearing is required because the license has not been suspended, it has been placed on "hold." As we discussed on February 9, 1999, a "hold" on my client's license has the exact same effect as a sus;ensiori, wi.thous any of the procedural protections afforded to suspensions. You agreed to main discuss with your supervisor my request for a hea. ng. As of writLng this letter, have heard nothing other than your February 19, 1999, message left with my client*hat yet: are confer ing with County Counsel. Regrettably, the Depar=ent's continued delay in even confirm.' whether we car.obtain a hearing has become intolerable. As noted above,the Department has placed a de facto suspension upon my client's license without any due process protections. Moreover, the department:las made adoption placement decisions for Martyn without providing any consideration for the Romstads despite the fact that they have care for Martin most of his life. Therefore, my clients demand that they receive the benefit of the protections provided under California Law, including the Health and Safety Cade and the California Code of Regulations, as we'll as the Department's grievance procedures. Essentially, as we discussed on February 9, 1999,my clients demand a:searing. Because of the Department's continuing failure to even respond to my correspondence, F have been leftwith the distinct impression that the Department will not provide my client the due ti Letter to Iasis Rutton i February 22, 1999,r Me 2 process ruts for which they are entitled.Notably, even under the department's own grievance procedures,we should have received a hearing by January 21, 1999. Over one month has now elapsed since my client's first demand for a hearing. If the Department dues not respond to my requests for a hearing by February 26, 1999,my clients will consider that the Departrnent's position that they are not entitled to a hearing has remained unchanged, Therefore,my client's-%�i11 have exhausted their administrative remedies and will pursue all available remedies Very truly yours, THE LAS QMQES OF MARTIN F. TRIANO MARK D.B S 11vMB.ao cc: Arne and Rhonda Rornstad Appeals Coordinator John Callen a. 2 't S'• hrl.s- s"�<'4:W`€4 S'waK+4..tu a��i.�x�`t-- ",y PIX wmi zW,�t- �.r< ;� �a.•};s u.,'=c"P" •• `+zi �i- .;,,fs ''ea°u. �7»z..`a v .�„•, +• '$ �"''s�r � �"i�'"' a t,}� ��,wy,'�i.`���� _�xi..?"'�� d� •r. ��•:'�'�`»t�?--,s�ye+�Y `9�' y ts, <S++,=,$ .,..JS'�=��,y E 's`��Y` � -..';'�, .� n= �' x W ? � �-,�'<.&�* .«r �7.Sr"� . � �'tx'�'"^}�+•c ;rf•�� _;� s �'?':>_,�"3' Q"�``.$,_,,,y aa.7 r�•� ��w'a .',,c. v�Frz4n 'i+ea - rs c tc.�„i ',y � '1' •.,. ' ",.;�f .�' '.-psi • `_!''�' ' `�.d! ecN „`.3 '�.yw, Y ' .y,t„ Jy+'yr� lt, � r� �. yc. .. •,• � .,rT � "'i�r`� ,k,=• e„x,.}w^ ,y°'��s.r xr-' : +s- �'d AN- iF.,e°' �` u ..x"L r_�l''ys �, r�'�sa�r. w�/,,,,.a�'.r r .Yr,,• ..•,xe,'"n'ti•' '"�#„', flYsafi+"'Y ?°x+ ;y ar..;:r..- }.t _x t,,�.F.. ii'r^ai w- � e`-r "?y c' Y k , .r - "`'L`?.o.,,Y � .v.3 'tx_,�`"e;"r ".x :�"�•.`” t t., 'k�v bg" Yy roa xk. h� C r�.¢ �c sliaiSe ^..1 ' PEI rL �-q-Y+*;�s``,J` t•y � }.$�,'�� � -., "z "W�`•�#+7�.�`"'S � .�.E'4L'?.:'id`V!r a:� ,y .4,�,.3?���•• ^'�" _ '' +?' :t `" " t .L h �.'• '`2Y^�' z -.T'. `: va--+:'e. s -a'G" 'r*., .p�,�s.� ,.�.t'' Y .�g�{,s�§�,�„.;.-r s ar.-�.d� „fie�..���rc,•w`,,r'" �t� �'' _�1�',�r+�, K�' •a�' ..[-#- "'!S �� h,�+q.#v< x"+�{r. ..7'" 'x y ..."° i€. :J y,, 4 "�y,*'-�3.t vy>,•9'flr ro,¢ a 1,jPS l {... -,�5 ,.,z Ti .,�5`:;'S },•` � .w- o d 4. v .F f s .sr z, �.v- rt }; , 1' k Yy '« 3,.f .,,x/..`YN+ y.,, � d ° � ; �rs'"4-".F'�m-w ,n r 7 fsx y' 3,•-ms's `� K_'.y„"`, ..s,..�y= .... , ,a,n'vr� ,�r^- .,,.: r ,�.....,.rr-ct �•z7 s,s�',.;:',� ��. Y `�,z.3�:�a§v'� ; '�`c` � � l Y ,�.. *.+'- ,"Tr f ✓ <v S x r .,� ,,,xt .� ,xy yH f t,z �',t sa". r �> .� a s�•_. ``" 'v` ,��r5 �-.Fsz�„tf'.�A � L.f ,+r? 3 � r fir.% s+ r.� t .,q+ �. - fiat, '° g. +-` r,.� '.'e+ y '•>,"•"x: R r y"�"-u.°sa 2- �',` r.a 'o- �"r -i ,.t Y x -' ✓'-fz,.u•:;"'P'M+,�� 1� E�G`_ �". �- � .e, � ,.,': r t :�� $,a � t° a -��.�' � r t t-a. 't n. �,�• r�„ �:�' �q�,,,, x _ €''ry �.3.J Q-=z ,r../ t a. ,+. a a - y 3-.J +s."..` s r 'r � x t-�L..'�,f '«.-�x N""r�` T u{ 4.r�. .'cv§z,.ft' w +w' a •�`+s."''ia-,...`�' ,� •. ,t re r » �t j2R3'i r 1 z r -.; .-+ r�-.k 3,�k}' -u•,�'"�, e� t.�`a� y-c'�',a t ra,-n- --, n , - � w s :�� a � �'. +..a'-�y � :.��•'z` ?�.s"�x+�� °' ..sn,yi. s' yam.§�'a� �t`z�'"Pe'.� -. X x zr •Frt tfc -t q ° s t i "`� A-- �..,,,,,,. .ar•'� r �• r •yv+:° w yam` "' �? "TMJ• s r .r- �1, { .J F+�T f..,,,� � � .�°z�. a�7."°""`y fy r r 's x .{• r LA- *^ .r, z Y,. t' ,� 'J:: t 4.: f r w' v , �. � '>: � .'�.� ?f � x` t z � V -� ,�._ Y y ',: })..1^"'� t +w 3. ��'x �.J �--•r ZW x .� ta,�„3,fr, x ..�� - ��` '�`,„,, '�,,,•-�s�r 9,�.;, .r�y.{ "s `�x..n ....• o- �. ,�•``s��.xX-`Y". �^'„.,�� x�.�.,,�'� •'���'' z..¢sY *� ..>te z S..u• sem-w a +1• 7�',Y i �„ .'c fis'.,<. a r s ^. w-'a`� -..sec•nab" L. 1 ,sL`r .». ,yij meg+' p .-_ "Y•+J" r 3� L �... .3' tr " 3.."-q 4. ,t '1 �: ..` ..y �' ,y at..�"4 .+� .v�.r<.-�k5K7��•t�« �.. e, 5•-, b t =�•sy, 3 v�+.*r �+ ..a '�.,� �'�t� ,,m """a -'• .x y,•' ."'..Y'�'a`y�": } .� =i' � �`�'!�Y_t''M y�r -: L..` �,."� '�'�s^i `�&.� '� "�` 'f �+ �'^� �' Vtr✓ 'yd-Y_ �"`m«� '.R#��"a�+;`;� ww is'4 ,�.:sir `xY' "y�7'.$ �„�`.�" F � •� <r���t. +��,.+'s'�"`v � � � �Y '�S' "r°s r � �-"•<#- � �e>s-:�tx�,* ..��.- ,� ..� '� '�YTS�`��^ W T ONISTAD, Arne and Rhonda All 8379 ` (NI ARST i:1(V2 1197) IiON1E ST€11)Y CHILD(REN) DESIRED: 1 I B -anis- flip ' o " C)137 ie3 f13V'ti i0 11 ,iii Clllit3'�li. ?liet' ;rl' t' t? ;3C�C7✓1 ]1 ?E.'?y bi)� T!ieVprofer n n—vvhorIl hov z7ElI \, illal I W111l#1 t ) 13Cf tt)i a bov I?j? 10 i1 ]lltl i1 <3 bov and `._'}Il sibil-112 '.`.31" I\\`tt bi)v`• 5t ll; € }il'` r Ln ar-� U' lory child. I hey iare iCsilit t toEIcccj-'I't;;7I1 ? !CIS i ?0\ } tiJiiClti Child who has C\"4 r a::i!11'? ou?. C:v r: or airy ,icod:i th;;3 '• 'l.}illi l 1111 It?(3]`L`1],;7Is.' .2111C�:i2"t{ t7f•;";;� 1i) C)il;' 11111 i�11�22� ;€I1 EIti.I1C;?1 t}il ;�Ct�t'J?i t: " ;f Li1:E:1 \\ +I9, :lI',1 3 }co of I'll c ° con g,'.'t€Jit; ti„:tii1l,`21 �\q.. ` :�.. I�+ 1.\rSt'i;.Il l€\l'. C< p \IIIl."t�.`•. lilw':vc l will) :1 111ontl ll• her silila,'on. 7 he ti<)lnl ii :,js al, '•Ii3ii?._ ICS C011sidef i3 dill �tTL t1j t??1 it C ri d desired zira1 i llli ' 1 L%`` C:i;�t_ �?:6`"ils c 2.Ci ?it�t; i),.7C11 Ti`3 t;\�?,".I?t�tt'sr.? t#lc'1?` �?. ,<,�:??t_:it'.I`:+_ ?�li: 1 € <11C: C:iC;.t l?`\' dio dl-slre it mall cl;ll;i. ril% >�,itli icCl� 1 :\ the �Jili i ;t1 i3t '�j7i lt)iit illi)2'c Children Info thcnr alt?liil' .inn \\i7ulul be \S ; Yti't`? it> ill] ihosc spot ; wifll :-1J- M1\t: 1;-;l ldrc l': 21I\ f1 Ilv i �7,;C?2�iiiltl\ . ?tlit!'i's�t �.li1lC °\lili ilii jIi`tiI1 lili`.21 111<fl ti€i \t3ltIti '? 1 ik C_' l.o 1 t avc C?�?,tf ClilitiI X31. i' ROMSTAD. Arne and Rhonda Ali 8379 {MARS1 .i1X71/97) ?�ty ' 1 , 1997 Screen-In intervieNv aviih Ame and Rhonda in their Antioch }d orn e, ;ulet .) , 19 7 1tldiridu �I InaG'Idil'\ ' \111;1 1:�}?`I - R�} .stall i}: mllc A} tiocl� '..ome. Oclober ? , 1997 Itld r,I I 3t}tC'I if'r1 r>ei Anic Ronistad iI; elle Social Services �I`Iice. C3ct `c3cr 20, i;9 �33G�iv}dl}ail Illtet\'}ce\. \\ltl Rhonda R of nslad "n t11c Social Stiri•'ces o I lcc October 20, 1997 IndividuLil inns view r\ itis Gr-,Ice IZomst;ld }}, 1i1t oci.il SC?-vices 1C'. N o v L}1)1,e C,., 1 Cit)j €t1C.., vid11ti1 11",,er •t0\\ w.11) `.11-11vsa Ronlsl id }}? t 10 Soc"If Nt3von l-.)c, 6, 1997 Amin il)I�_?\'' \\ \t'It ; T,I .iii Z ;oI)CJ,3 ;Ind `IIpt'i-\ ?tic)r }� 11t f-,il I;I €he Si cMd �7C1'\}C�c �)i31Cc til disc <'s ICP"?Iiil\'.`1i; �i?ilc'C C lS Arne, I.Jtivid I\o'11:,,mal waw 'bon", iti C1!1`re1t1l\ �4 011d. it ;erne Is 5"1" Mll and \tie)' 1., 20,"1 l,owi i. 11-11c 11115 brown 1li?ir ;inn'; lmro\:'i1 C\C-�. !�3``: \_\,,.Is sev' Ciiiholic but t and I vcar 1 1C' }•C:Ct'.ivt!d 11111C: 1 o 111s oduc<iil0l1 1}} teit:-Co ni'}1i1Inc—I'LlOil 11'13m tI1'c Air Forcc In r\vl)1c',11 hC 50I-VOC1 1}'0111 \=12Y 1 . 19 .i ltIII?31 A ug i i st, 218, 1?). H 1 0;1l-I-CIME: \' mplS:ved ns ti I el.-,Coll 1!11X4 1111 ,;110)!1 sci-\ 'M ')C1; "i31locr for Sprint. ---,:,-.-:�..-�-�• =;-;may-;� .x -- - ----_-•--� :� - �---•_ -�•---�,, ,r--;..-,• -. RUNISTA D, Arne and Rhonda AH 8379 (I sAI.SH;10/21/97) R11orda Lois Rornstad was bcm July 27, 1953, she is currently 44 years of age. She is a Caucasian female of Gerr;an, Dutch, I=rcnch and Native American descent. She believes she may have Cherokee and Choctaw blood. but there is no official it nda was raised and currently is a practicing Seventh Day Adventist. She has brown fair and brown eyes and is 5'5" tall and eveYr3hs about 174 poimdc s. �11oI1da has a high school diploma and has reccivcd additional cducanor; rr car restoration and vehicle :s),olsterlrlo. Ri"Onda IS lit 5TW-3t-honlc parent and en'oys this rolC VII-r, lilllCh. Individunt IT1tervicw i-°ith Arne Romstad: A—Isle RClms-NId Was 1"Or i an"i rals LCT In F i'=CC7m"', \N ;islll))1;1'on. He is 1.11C Tlllyd child an'd st Conj s`on !Ii 41 fanill\' ()I Il\'0 bo\-, ilCl t\l o 'rls. J-11C Stt3 es that Tke family \vas Cioce a-1,11)1\'1115` 11 ty" 111t)tll r T? ?;:?�l r lli +1C .fly 1"ENCS iT"s tilt f1�1T1e. l�Ii; ±y� /r•��ry�p j). i jCS / 111`C/i}S p</'� C .�/'`+ T . �� then / T } back, { lslf�till :" \\;al i iilJlli lite ke ��t}i1c the l.l!k:dren were. `'1.•unz-:U but Lt�en 1�tW�li ac I to school and 1?ctWamc ,:m X-rel\ .eclmni,cl'an \\llibh is ,N-h It she did R)r 70 years. l�t"11 S r Ci711�1:-)"Cts 5 ;I T1'-t iC '\'1111 iLcr "i a dic"j)r`!I'imci':i Smrt -and eventually ec-a e the 1111in1)T:0 . Bt'c.—u-;e ills I M'ihe wol- ej to tilt' I?i)Ire, she %vas t11e One \v110 would "et llC`3Ti e rst so shle \a,o.ulld p1'Cj);liC the irealsS s 71. IZ RONISTAD, Arne anti Rhonda AI-I 8379 (IMAR H,1o121l97) Discipline in Arne's hone -vvas dispensed by both parents equally. it was pretty much who was ever in the room was the one who disciplined the children. Discipline consisted of being sent to their rooms, being &oundedErest�Hcted,`clores or an occasional spariOng, by both parents. Spans ing usually was with an open hand over clothing on the but-tocks, Arne feels that the spalkings he did receive were ustif ed ahbough he carp", remember exactly what he had done, lie remetnbers them being big incidents. lie does remember being grounded for one Rall week when a Pre accidentally ilgnited a neighbors yard when Arne, and hi's friends were playing with nn;tches. .erne down t remenibe his parents 4?i7tJn�a.. 113i uguli lie is Greet ill "hey must have had some disagrCell enm lie says hoo ver his parents h=added Ihintas inu-st have worlked as tdhey f':a\e Leen married for over fit€y \tars. Arne does recall af`Iectioin expressed Ji-Qely in his hol-n, lie reml:i!Si.vvs htl's. kisses, pats on thy: head 'auld verbal aiTnumions. lie Minks Tal hitt ?"ltPer ms more afl ctit)n;:tm, ihoE:j his imher \vas as \\ell. Arne fe'�1s ;i ,ii Ile. �,xcw up in a zgood and stablc environi;;cir lie remains close .o all OF NS despite the physical dimanc he.t\\'e.en tlzenl. Pe Sag's illat .his family is n1l ib' s'llp oro. of Ih m ndop.in fir ili(`mf Childs-c1?. lndi-v-ic ual Interview rvith Rhonda Rornstnd: ��XpAt�C�T f� +�:� ST .erne and Rhonda AH 8379 (MARSHA;S s; 0J2}1/9- 71 - - -- l Rbonda Romstad was barn in Lincoln, Nebraska and raised there for eleven dears before MoViriq +0 California. �11onda was the ounger sibling of an older brother and sister until a paternal half brother was born 16 years later. Over a11, PUnoInda remembers her childhood as being a happy one as her family \,v ?s very close. Th-ouch when Rhonda was tele years cold, her parents divorced, This vvas a difficuit time for Ri)onda as she had always been espec.ially close to her {ai.her,, Rhonda and her s1blings were lefi to be raised by -Uhonda's Mother; whom Rhonda bele\les slid a good job ofraising the three of them. Wincl; S I-ondti-s `7e?renis m'et'e sell married, Phondc's #? oilit, was the priI'll ai'V, d,SCPinarian 3i1 the !1omth. L)ISC, phn- iftil?liil4 CC?i3 1;1CCi i)t i�1�113d'. i`i ;i�i!il"n ane spanks C7ii it-1;' Do,,iom Lmi31 )h—.. chilcl %�otild sci-cavi',. Mic)ncl,,-, s-,iys ii wi*lti 11i�Cr C1Lli C",�� :land or e-lbusive to them. She says that her f-mber 1 o. uld I)r iilC IMIC I^ Sl7cii3k \�`Ith a lealedi t strap or beit. hc,nda i'cc,2,1s iff*ecimn alsO b-Z11)2 C!.'XpI'essed LI` cliv 1;3 the 1}C mc3 Aft.-cil'011 cnn:^;l�Tcd t1i 1111�m >, l;iSS4 iliitl vLt`lJii 3fil;tY3tyilC.,13 a3 Tit'tiI3lIC i3i)i 11 c1vll?u a 101 of MUMC ." P'llonda `av tilc41��cJ�l\ ki,£-;.v i,i ai Lhe `,C--C 110\C ! aj)d feli �( ct.,rc al7om idle S.€3tef: d.a F-11 'IIs .lose Nv,lh hei }i i:JChc }.h lives tli C)I t15wn ,i-ci I-,, 61i"''n i4'd fii resides in Texas. Rhonda is c]oSe to Ilei• threw siblings a=l 1!'l3om I:,s*d- Nv-iiihin t-in 13th"s drive, fi-ola) thc. Ron1s1ad home_ 10 ROINISTAD, Arne and Rhonda AH 8379 (MARSH;10/21/97) t On August 12, 1997 a latter Nvas sent to the Romstads of dining the necessary documents that deeded to be writ to t1le Depa--mein i-In order to proceed %v'th the homes ud.y. As of October 4, 199-1, 1 still had Trot heard or reccivcd tl e listed documents fro�� them. I called the Roiristads on October 11, 1997 to Mrd out the status of their paperwork and to lnqui�e if they would be interested in possible placement of a baby. I ha spoken to Arne who said they could quickly gather up the doc'urnents. ; lead askcd l in`i to speak -with RlIonda about. plac.ernent of the baby and to ',`t back to me. Two dans later I received a tele-phoiic call from Rhonda IMP- they � oiild be the balby and*`v�`ifl have ffic par civork read"". ENJP LOV NM ENT: Arne Z3,, J)Ce'„ -Ms�lcy a., Sprint s' n �11 as aelaco ` i � G- ce .Miairaler. HIS Ctir reili sail lig' is S69..=�6 per t c,Rr. He rectives full health c-overacre and benefits. Arnie i` able ?o \\or'; o7'11 of the 1"OlnC t loin j .days a wee i. Oil the otl?�r tt;`o t1�i�'S lic (;Ui'li`illit�'� i{) Ci:,f4.1 ill ,,c.Fl �' r,.Lt, i)ftiC�` C)i' tl:e �xi''�;iliii ICCf`; office. His tir4ne is flemtble vOiliCl3 15 ,I real b-enefi; iii tl;e Ro ns-mCI ho-,ine. Arne has leen in iii? tit!d Since ie`oviima il':C Air Forrce in 19-19. Rhonda t� ) nen it �} s .ry �y i S is nr� h e he p dF S Ttc s aS t fps �� ��1 VSe�a eJ L'Cirl ls�f lii}' Ci. �t ia�� sat�f F�,titl�..� it Oat i'r s..r. She i.+i•�i.i 4.I��� .�.`c<is�� C1�61' 't3� i�3 :J y choic-C. In the past Rho"lda 'has `7Cdn eni—p14oved as a day cEird provider. I I-iond- also ?a35 occil a foster parent for mimcrotis ve3r4. At tl't presem Lime, SM-, has no `plaits to work out of the ho-Ine or to go back. f,n to day care stinvic,cs. t a is y w.sra.4 R.OMSTAl ,Arne and Rhonda H 8379 ,MARSH;)0121%97) - FINANCES: T he Rornstads appear to be Financially Stable with the One paycheck into the 11C lne. Tl1e list l,avi= SclVIII(>?S accoll is and 401 K plans in additio). 10 insuran-Ce polices. In the event that they heeded to brins? i;1 additional income, Rhonda has experience operatingday care and slle )s also skilled in restoring ;als and Ieupholsterni-ig INIARITAL HISTORY: This )S '111C In-St 111a?'I`)of ff0I' tmil1 .�:`i1; al)(e '�holida. the1 Inct I)3 (20t 2`adc) SI)I- .n OS vviiere Aii e Nvas Steanor,led. Rhoiida l l-:d been vii Stint. hicr fne"nd.. vvh'le Ame I'ved next doer. 3 i1ev have bc'e'll to uc',h r -lincc il;ts 11aeenno. Th v t'vert emiaocd dile.:` datlll'; foo 10 i,):)))thi aI1d ultiti)jiel .iiarriedl oa? jVIal`ch ; 5, 1. i) 111 pol- 0'a vaIIe y. Califtal;;la. l hcv hoil1 Cl,Crdhe ii1L:i` I'.1i;rzl't3`'e as ioo . wchd and vcry equal. DISa(:�reClniell1S ?i1d tl�gbit; l;mve ei) Arl c a,d .R'11cnda a?e i?Stan" handled by arourrients and oc:casio ml velli;luuy ti,'l)e?1 one 1�,`�^alcut ut of the I'o, nia,. usually' r�.nie, � i-1-cy Iccl 111at Ohev are <ablc to rW-Solve 11'eir diffc,"ences afier .Solne c:ooll)1�14 off tiTrIe. They \vill Fk2ht iIi frolit oCille chlildrcnl, but also let tele cll;l(lrc)1 n;;")\v 1hat i1 is okay to fi-Ig1t and that t 1ev Sill! love 4.ach s) filer. i 11ev boils ;,av hitt the`' dont fight oft aind Leel 0,M1 they ,ct alo.ii`.7 veeH miost ),'the ii111c. Y ^� Sr ROI ISTAD, erne and Rhonda All 8379 O MAS SH,10/2 i i97) PARENTING EXPERIENCE: The Rornstads have had lots of parenting ex'De.rietTce as they have soccessfuily raised their 24 year gild biological daughter, Clarity. They are currently raisin -, their 10 year old aelopted daughter, Melysa, %Nho is hyperacti,,-e. bi-polar and suffers ftonl n.ild Turrets Syndrome, and their 4 1T'% year old bio'log?wal daughter, Grace. The 1`'omstads have been foster parents for ni.merous sears, three ��ears in Contra Costa Court-, a few ,ears ii1 San Mateo Counts and a Vicars In flee state of Ali aS ililgtoil. They ei` llli4'C' s1aa M1111Croilw chill ren placl-CI with them, ilius o' � experiel`1C'III c1 1i 1C1w �?i1 t C)' ClillCdi Tl. he. Romstads have also pro,,.-'dcd C-day 5 r Ces r�1- id C . U C.�'; have recelvoel pa 'en'lim., tra ln'nu ftor acdoptiol. }1 i}? >4att#C'1 5 and d<)stcr !'fir i 3, tl; , C; t' I='i4 of \Vaslh sinCi `sci?i l`,Iltc'C7 % otii?r1'. I-I A LTH Bo ll and Rholili j C t ITC.sli tll'4GEC71 CNam 1-cpal `;:s `ela tC tial 111c4' arc 's;1 sC)o-1 � llea:llh w-Im Ito colliCe n's tll4li wC>ii3l'"i '-,Mect pI3I'iw'?' ill flan ilon 0 life C'XpCclanCy. Accorcd ni-, to flit: pi`lor "st i`s'C iif ti from Picv-.0 t noses tli:li AmL ''•i,35 C:1rd"a" ablI ?d"ImIlity ilich I`' tally in an 4 Irittlt,liltlC'Ilt i-hw1hint t)rot)lem ' A letter fi-oml r�?`ne's docici- David Pomeroy, IMD datcd Au,--ust l ! ���. notes tllljt A,1n1C's condilioll is mol llffc, threnlCilillu ar d �zho,11Cd h a4't Ilt) Impact on llf� ex, cclancv or cullitV oi'1ldt. AI` c1 s CC?rl_dltion can be controlled, by q;;ed'c Itlu'n J", a lerter dated A€1pist lot, 1988 li-om E d%�-ardl J. Przasn1 sl~i, NA,D, it holes tl?mt Rhonda has a Iniad forum of adremil ilist,fhy.iency (AddlSon' DI'sease) and t1i,,it liz- fiitill`c p -m-plosis ;S ``exc"Ilent' t'�llll 11;:3 expe-cie.04i complications In Illi✓ "s lorl Cat` loil�7 tti'Ill RUINISTAD, Arne and Rhonda AH 8379 2 FERTILITY: Rhonda and Ame first learned of Rhonda's health problems when their first bjoloalc,al dau Inter, Charity,, had been born 6 weeks prennature In :973. In 19,74 Rhonda gage mirth to a baby boy 7 weeks early who only lived 8 days. With tine assistance of fertility hormonal treatments, Rlnornda conceived a child. 4 more tirnnes, in 1978, 1986, 1994 and 1996, and lost all of these babies in the first or second trimesters. Daughter, Grace, Nvas born %N'th the assistance ofhormonal theral)N In 1993, but ,vas barn 6 w.eks premature. Ame stated haat the most recent loss in 1996 teas tine l$ardest one of all, partly because of .? onda`s a.)e arnd the realizatiOli l;n c rf n ` '` i ) l to tri o Stat ' t 71 nlda \1 en 't t °irrt�ntener' � ,�lrn =�c•.r l�at��� r nb`yl�� not b� ��,s:� �,'e. � :: >r �.�i �ln�: ��.,r: t to \ isit '�Ie1�=s�r`�; sasvclnit=.tri;t ar:cl -ece:r„ed medicat;onto lie],3 cope w th the loss of this last bab`,. .;Zhonda stated that slue st{\\t 'N'ICIN�sa's ps��chiat;ast; Dr. .]cn,1 t� Faie.rn ti' w a ! l A 4+ d r � 1 6, t 2 for a couple ofweeks and that lie had put her on anti-de-pressanis hull t1?at slue disconrtirnued them after 2 \\eeks because she did r.ot feel iliey \sere help'A'H . Rhonda Ro innsluad lntis b.-eji in lno rrno-nal tther�-.uv to rrncreast: Incr cliarnceti of ornCti tICnn. T, cmost re-Cm fer,Iiiv specia ist overseei,niz this rs Dr. ���ill.nnarn o grind ; California. rrne \as t;itc c ern and caltnn \\-lnern discussing ilne irnfcrtilih! and %,\�as open to sir. Willman beir12 corntacted for additional information. When quesi.lonnrrna, JZhonda. dur Frig tile. Individual anter”,-im ahen:Rs " rtility Issues, Sl:e rnunediately ;recatme dclCiISIN:e and almost am rV. Sihe simcel drat slue d-d )rot sce \,°?hjv ;13e Depamnnem needed it) pursue rt itrnher .,Mcc she was 4 %'ears of �m_?te and 14 lulu... ............... lulu.. . . _. ..... ...._,«... -.., .. --•.. .�.._ ,.. _ ..�- �.. .Y ..w..i_>,4,s. ,.Y, .-r. . ..-s..��. �i�e ROINISTAD. Arne and Rhonda All 8379 OMAR 1;10/2111,17) not likely to conceive again. Even after, it v,,as explained to her wily further inf'onmiption was needed, Rlionda was still defcltsive about contact being made. A letter was received from Dr. S=usan Willinan noting tbat Rhonda had a history of rectum pregnancy loss and pregnancy Complications. She „7ites that Rhonda has been pregnant 7 tines, delivenne, 3 babies and miscarrying 4. .All of her deliveries „'ere tinder 34 „seeks coinplicated by pr`tenn labor and the last one by gestational diiabeies. Rhonda's last conception was in Ociober 10,96 in, ,thiel she iniscam'ed despite treatment r,°tlh aspirin, hepnrin and progene-rove sti�,plcrncntat'on. She has also received clomiphene and hiu nan nienopn,sal tyonadolropins witli HCG and progesterone. for luteal phase sup port fru-ni Dr. ��'ill;:�t.is. l�l�o.1da"s cl;f�tic�s for COrice)N'3>'O 0111 C�r'�.l'- inn a prenanc�' to teen �:rt �'L;ti11C �7'i`iT!) , aCCOrdin- �� ' r. Willr nn, She doc�,,„lln1ents ;ltat t;tc �c� �,�tf3cis 2r,- n(:) 1�:��.-er :ictivel,j t� � ,�<� to d'+'1✓d1�,�.°Y1.'€.' f. Childand lf�tat She is 1e) „roupporl o then) .21cl ..SS✓ting ti S.i`ild, 1701110\v up tele-Phone C �.1rLi`,�.Tnnon wi fl1 :6h4'}lld t.1 to ,iie 1 cli v'idui7ln,\-flxle%x She Soiled tl SCt Nvith a Couple Of iSSIICS. The first „'Cts t m tint' did not \vish to p,y flie X2(,0 p:s,,c.hiamnst bill foi• Dr. \ hal n to write tip n rcpoij silicc tiler- wary 130 gi3ar,-iI`tCt". 'of 3n adoption occurtin". Rxhor iii ivi3s :3d"'lsed flim rtinnbi.,,':ement would be possibl : upun a ffill4lizatlon. Cif an adopl on. ! advls't d 3ii'I that I could 1101 mlararlce her an ;adoption „vould. occl.r. RUMSTAD, Arne and Rhonda AH 8379 (MARSH,1012 t l0`?`s The second issue that Rhonda wanted to address was, the Department's practice of askino couples to use birth control or refrain from, Fictively trying to conceive a. child once placement is imininent or a child is placed with them. Reasons \,�=ere explained in the Seen-lti i?iter-,view as well as durin tl3is telephone call why} this practice is in place. She felt that she should not be ,asked to do this and fblt it \,..-as uncorlstitinional. She repeatedly stated thatshe ,vo old never treat an adopted child differently froin her biological child.. She was ad%ised to speak -%)�rith my Supervisor, ^f urt., , over this issue .since she was -not a'?le to tii3derstand Xhe Department's ra ibna le. Mlondla had ad\'iscd Ine fliat site 111ad ptit her Conder? 313 wi iting and as,kcd that tlic\ 1. C '.?3vcn ti'. 11he S11I)Crvi'sor ali \"e . The J 1,1121 Page letter was 1' ce) V v and Indicated tlitai ;leer %\aS o n)ci;Z`• ilia"s LiL'r`ti�i1(iiilt? on the P\oinsia3d s i;)ti?"t. The follc,,v;n`.t week a lc.ter dated October 24, 1997 .-orii Rhonda and Arne was e/'�ii-I en to ion-rier Asscnmbk roan. ��ober-t J. Ca-,�npbcll, w-hick \vas':'Ien fionvarded to 1..,ount� St3per .vilis i3. R:(.�C f,...ta-Cirami :ja. ��S`l`ho 1 en li-IxL dic leil r to i}:i,3 i Oster Recruiter, �.sn-ie!cida �}l\;rmdo, %�1i .i �iib;w�tSii�3iil�s� gave a copy • e .� � oa{ th� lettot4r to 3ii1�,�.li1 Supt-rvisOf r`lld the ttl t4i' Iiicn`zii'y_ 11`i rk- r. TI--'s 10-itc1 io the Asci bl tear sta.+,ed the Roiiist«d s c:oiice1-11 €3.at co1,11d 1}�: "i lacltiLt:lied" by he Departmeni for their disc-p-e' "inei t the birth Control isw�iic and asking that the D partinent v cl.a.3�_,e 111eir stance In birth control procticw. O:3 Igo%-ember 0. lc:97. Clic Roinstads c Sin ei to the �,�ciaI icr` ces o,sC� to meet with t133S \voi-ker iii(i Stl oerl issoi- R."111c") to di,�cii` s t,eIlilliv and kiss concL''ms that the Depr?ri3 eni iii d. 1�honl.da !Nei,ain a9€ €I3-, firs" 33'•a:`t'ition 01 111fertility. 8 4� I2OMSTAD, Arne and Rhonda AH 8379 i l)ey Nvere L'ive,) the names of few thcrapists specializi,19 In lass a.i.d inferti ity NV io could help their,. They agreed that Arnie would check v6th his insurance co,-npa.?y to see if�3iN of the therapists might be covered by his insurer. He SSSILred tis that he would get-back to the Departiiiei?t.the next day to inform us of leis Indinu. leo word N�,ras heard *ram the Rornstads until November 20, 1997 when Arne left a lengthy message to Supervisor Rutier ad%isii? l?is insurer did ?' t confer the list of thcrapist liven to them and they did not i nd-erstand why they needed to see a a.,id could not under siajid what the problems or concems Nvere. lie srii? -11ed it tip 1.N sTaiing if they x.\?e;e,hist given sOn e cl?ildren,, there wouldn't be a prc)lJlern witi? -Mei`l. On December 7, 1997, S,ipen,lsor I uite=? spoke ,Oih Rhoi?da oi? tl?e i le,;hoi?e about hoe'` to pl-oc:eed will? 1t';?int tie Dpaniricl?i l?eCded- Supe,vis-or tiller' a-,-,reed to ailow'Dr_ \Vhalen make the necessary assess;? enl ai?d to provide Nvrittei< dot:tl','" en ia,kioii on the Roi,,,stad�s behalf. 3 l?onda age-ed khat this would be si.iiablc lot` tl?eni. 1,10 evci i?ii L Ccc,,nber 22, 199 t, ii?s' 1"oi??S3�C�rs �i"i`C)tt' a biter to Ili: Appear Gi"ii v rMCC 011 111C l sue Ot"oirill control practice by 1his Il? the lelTe ` Ii7circ wetre i??isperGept]ioi:s slated al"'Ol!t ivi?43i h d bee li iIl +t iii ill with flnei?i b0 bodi this work' i' ajid Stud-%!1sor Ruud, about this Departinem*s hot? estudy process. the leiter to the Appeals Coordinator \,.a.s for-warded io Division Mai.agcr, I_iiida &:i,-i? 'o handle. hi January 1998.a Rhonda called Divisio, 'Manager ram—n to discii s ihv birth enrol issue and on 17 RUMSTAD. :erne and Rhonda All 8379 (MARSHJU21l97) s ja.0 f 27, 1998 a letter was written to the R.omstads from Divisioil Manager (2allan updating them on the states of Meir case. On .lai uarg 13, 1998, Svper icor Ru:ten met Nvith Ur. Whalen in person and discussed the case. Dr. W lialen \vas able to give a clearer picti.tre of his work with the Romstad's. On fiailuary 22, 1998, a letter dated December 17, 1997, was received Iftorn Lir. Vlhalen addressing questions from rrly initial letier to him dated October 22, 1997 inquidng about ser rices provided €o the Ro s+ad fan-,ily. Unfortumatel4= the is`iNal letter did not request in-depth inkmiation pertaining i}cy irfertili y i°W�.uey Chi alc3il',aq, 0, 1998 €"te�l,C:rvisvr Riiiteii Beni Dr. 4�{E�t?'Ien. a lener con irnni g their discussion e31 ouT €he Roinstad fwn ly, ��ii ii�tl�r3t"l�' r?"s'47t1:7U i"( Stilt}i i)13 \Viih their fcndi€y issues. 011 Mowry 998, Supervisor -Runt:ii Sent th Rt3mstads a letter slab 4'in; Ale De annie'n'S stance on, birflh control pic^.�,�.ii s. a we'l, as coi°ri1-03111wiih Dr, 4`l'•��i.l1.''i�. ."At copy o .Ji.ipervisor Rubens leiter 10 Dr. Whalen Nv,s inc lAd with this letier. The icrillity issue frond the CH1I...1)RE,N IN I1IL FA�I1I.,Y: Indk idual IntervieNN, with Gr-ice. Gract Roillstad. [rage 4 1:2 teal:, old was intet,lieweo in Ole offilcc. She is a. very energetic and laltCaitive t'L`tlil+? sujrl. Shc was vee, clear K 1varitl;;g io adopt a nodier chiU She Spore Aller exci€ellient aind desire Iii share wiih a l?t:'w laird} member, It all odd Nvay she spo kc aln{iost illall adUll l_ntl1l1le1ill hCr dCSil-e to l8 �"'4ea.r.v_..»'i.c.>+-+h�.aw.�ws�,e.A� 4r:• __ _'x.. i ._. ..... ... .,, ',':... .` `V�.. RONIST D, ,erne and Rhonda All 8379 (MARSH;10121/97) - r have another child in the borne. She describes home life as very food. The only problem. in Qhe I cine was xith her sister, Melysa, and when she acts out and sometimes becomes mean. It did not appear to be anything traumatic to Grace but more of a nuisance. Overall it was obvious that Grace had been talked to about adopting another child mtd she seems to be fine vvith the idea. Individual Intemie", tiVA MASS: N elysa ;fates that she has a small Tinily and would like to have snore babies. Idearly she N ould also like tc have P. girl her age so site cot.ld have :someoric to play with too. She believes her maher and ether are good parents and do take good core of her and the other chAdrai. She s^a> thq do ;..'.et any): "A her 5ometin ess -when .she has acted otnl or did sGs3 nihinlgwrong. Disciplinc usu;fll�: no beii,, ? put in the corner or `ing sen'l -to "her n't'3o(hnn. "t,�: ' � i� i she alw '.s ]]SS, qq tt 11 s L ,w a.. 3 V �.i��.�St d y {'}d 31i�1/1��.. '!%shy she :s being chi scip'.1i ed and believes it is fair. The iardem thing Wr Wysa'i is "Un die Sister cl ildrei: t?t? onnc. She son-aetitnes her pnrems ,FJk ko her cI' o,,,i t hien sail ;1iio :OnlW'.tin',Cs lhe�; do I101i Mevsa is able to E::l`pazlhize 1i'dsth 'he fa alike s as she slaat��''.:s flhm the families Insist have Ich hist as bad l't`lhen the lAd s 1�' r:' 'io d "i s s C � f`::IS i ti's t he does \vlt>oI' lhear go ick to therm. Mc, -,sa docs ',cc] smire in her honI e and believes thcre is enough love to go firo."In'nd. She sa�-s fl-ml she wants a3 b3ggcr ht'u sc and that I ' l /Sof S '}r'{°'"t she '} ))c�`.c will 9y r� ��rr {'�o �+} y d, 1 be x�4.a S,i i1i8 c>I�y €5 f Y3!�� Gracc ~<��311 share Yi room �Z.�y.12 ��i t�t;`l beds 19 RCla� S`1: ;3. Arne and Rhonda AH 8379 (MARSK 10/?1197) LIVING SITUATION: The Romst.ads reside in a tract horde in Antioch. They bought the "hoillie brand :less- in August 1992. The horlie is a 2 sto.,— wall-to wall blue carpeted home. There is a rned;d m sized kitchen. both is,-I"brinal and formal dMidig morn, living room, family room, 1 fill, bathroom, indoor laundry room and playl."oom/sewring room located on the bottom floor. Upstairs are three bedrooms, one full bathroom and a master bedroom and bathroom writh lame full bat]-,room racili:ies. The home's clecor is Country scaiterled with antique anif=.cts. The home is veil, fi ll ofdecorat.iv.—I knick kn;ac.'-,- It'-nis, but the hol-ile is f;.rlctiona 1. i dere Is a locks?l1.4 sloraae shed, In the Iiced-M b2C101121'tl, W11,11 F ccii) n't °diccl, ;3'sld 4ui-een L asi for chit lr--n to play;' on. T l;e Rornstads 1:7:'o\']tied the ilamds o3 thiree rCl,rences of wh cl, all three resp ndled in suppon of elle l onistr ds, Pdt:piiii'° a cl,.ld. ,U)OPTION FEE: lie Rolnsiads are aware i) 9!i i<`'Ci;t\ iii cfS5GO, 'i lid ts, 1-)rCl,arCd1 til i'°`av d ON-REC"1 RRI-NG ADOPTION ICS\° FFF: lhe anplicancts hCv- i err iiid lse iklM theV i1 aV be 7(' 1nb:it ed lir 11 1,-rCL'kti'i31 adop+.ion cxpt.nses of'S400 o A.A.P 20 12OMSTAI , Arne anti Rhonda AH----, (MARSH;10;21197) Pie provisions, of the Adoption Assistance Frog-ram Nvere dis Ussed Nviih the applic.ant.s and writ!en :naic:rial N,,,-as given to thee; desc€ibing .tax'R at is unknt xvn if P will be nccdcd as a child has not yet been identified for placeane-nt in tl,c bone. CRIMINAL CLEAk-kNCES. 1cre have been no crilrli ial or child found for either Arne car Rhonda. GRIEVANCE REVIDN': i"h Tievnmce re`'-im prcccss was explained to the Rolnst.ads and a copy of the pie0jancc provided. 3 ^! '�'may. n, n f de f Odd i i•'+ '.� i 7•` 1.. 7 # ��{:.. ��:;��€titci� aren, �#€"C3�tt.., .;�e;re C}s :3 C,l;l:: ic'1 �df�I. l�h,.�' llit���. �,.iSt€t...<9 1€t-C.irl?t 11 fel ilhy m,ork to try to conceive a child. There have been some obstacles dtitim, tht course of this 113 mestudy "A much of11te focus being around fertility €ssiics ane, 1..t ocu1I1e€lt dd'.1 VE1. it is evident Lhui the Roi.lsit;{lw. have the rhVui~4.i..^ 1i,J udvot,.ail,. 3& them selves my,Icn 111CY J)�:r`ci%C -t hal t iS ui1i us., bi'.l'n a mi,liN'-€' s>f n-ostnid£ :rsimidwigs Lai €4, Ronislad s ?:')a it will1 I,?inin- a3 cch"a3;Ces 0 the ilC:pill'#€iiclit to res?pa `d to bt'.R7l's: the next cG'i.[se ofaction is taken. Despiie the delays that this holiles'nudy has had. there docs not appear to be any barriers #;lilt tvo ld preclude then- Bonn adopting a child or sibling, group. I therefore recce€nie€ld that this ho-mesa€dy bWc approved. 21 i"tOINISTAD. Arne and Rhonda AH 8379 (NI RSH;10121/97) (Rom.stnd.H S) Y nGC� F1',7l�I C�e� b3 .. s Social Worker 4 f e Approves i�``r;.�.� �, .` „�� ,. 1 `; Date CONTRA COSTA COUNTY • -'' Social Service Department John Cullen, Director February4. 1998 Rhonda and :erne Romstad 45 13 Mamara Drive Antioch, Ca. 94509 Dear ?OM1-. &y N-Irs. R,onlstad. As nWed in The letter you received from Linda Ci3nan, C"1ild \?Welfare 1.))v)slon Mana2.-r, dared}Ja�;�any ?{{ !, 199-8, ; ;gave be}e:� s� �i:eP� t��tr�:��,c�ntcptt�t� the {.i?not-:n1 �•'ou i}1t dined ill %'-1131' !°L'TTCr 10 Tile t"111peals tr .c�oi-dinator. dated Decc.i,flbci- 22. 19 9;. The adoprion unit clues not have a policy 0.1 niaandann birth control for PI-OSI) CT'Nre -10 o l,tl 'e i1 liCa31Fs, I7g' d`a "'}a i i1 , birth control in Il1e context of a homesrudy would have a staled purpose. be discussed openl.. �d..ith Fila' Couple and would be n resented to each faa1nii,]N Laking into a,.-cClint t 1Clb` r%11. 3011 + �.:le S ind -°ali.i-s. At no -,.j me is an aat.rori'on 1 onnest'. dv deSlit:t sii`?Ctl ° i l tl:e i 3 is C? ei" Lsil e�T7re5�e ie cs. bel:ef-, 4o3" .-fused r� utilize bir d1 control. As FC) your st,31ement that we h31 e refius'd to s Ccepi the word o F DI.. \V'ha'je11 regarding his assessment of your :"aamAily. had not lead any coilespondence or contact with lel Nk'halen at The tiMe YOU rN"rote volar --oncerns to the Appteals Unit. On January 22 1998, vve received a leaer in our office from lir. Whalen. reea•ding leis i)nt;ractioils \vitl1 you. '1*'his Correspondence prima lily focuseJ ai.ound 3CwLleS and ti'Latr" ent needs Nlelysa.. alt?t 1,3+ <I elldntion1 tbi- Ri;ondo. T h's letter did not address the spec3'ic i.uestions 013t were asked o h1)11 r(,r?arding his wiilinaness to proVide OPI-Oc,i118 st.ppot-t TO %i011 , should a co11C11r1'e31t plaectnent occur that could be a -potentially high t-isli.. situation. SO i uis ne81d :aar;s'nez a CA 94553.4592 . Voice (513) 313.7897 FAX (510) 646-2769 «3 vluir ir;aC Martinez CA 9,tv a"-4i 9.e • erica ;B10-- a'::s 1827" FAX (510) 313.1$75 2500 Athambra Ave . + lallinez CA 94553_4572 • ,;;'C.i9C1 • FFAX 1510) -470.5539 . ._...__..........--..-.. ...-•,-....�., ,._.`...,.-„.,.,�.., - .--rte..,-�.;.::�-.-,.�;<:,”- - - ��...... I had the oppo-,tunity io meet Lir. WTalen and we discussed Olis specific q',2eStion. TI)e content of my discu.ssioii u.i,]i Dr. %N,,}ialeri is outlined in a etter to hire ofNNhich you have been provided a copy ( attached �. In conclusion, with Dr. W-halen's input and recommendation, we will Proceed forward with your hor:estudy7. Kathy Marsh indicates to rpe that he required intervievrs have been. completed and are in the process of beim taped for mV reVieWI TiII review the ale to ensure that all necessary documents have been sub;nitted. Please- feel free to contact me xvith any questions or concerm. inCerel . t� 1-611 a ten, �,/Is ' Social Wort; S;ape. =icor Jl, Adoptions cc. Linda Canan. Child Vel#arc Division -%Manager ce. Kathv Nla;-Sh, I- OJ!ICSUJ l-V 1Vorker ,o.., �♦ �� n�.�, ay�.�.,,x.4rY,�,,;'F.� �, ,`� .�'•t�y.. � hA�� 4� „f4 i � � � }.- � f .� 'j >" _ »tt<�.z� '1 tw.�._`1.'F ; s'°'.rr .,+x <vr ••z-.. Y+a. Lr"g �'l rF� t �'•5..+ y y1,r,�.., F,t �{:. �+:t .L ->> ���•�v,�y,4�'- +��p'��� v, `"�.'�,'�r;,a�'y�t.�u b �y.�sr.' '�""`n, � .•�js j�`�'•'i 1;a L� .y�r�, rw.;.�»rity a�«• � �r a:�.. � B"a. . e4`�"``.r s y 'g' t .r���'t i :tk,„ _ ,�., � f r - i c� Y '4 x+�.� ` ..,.-Y•`' a fir•. , s y .i x+•s..�'a sr". .re � ? .w. :..d Yn f< ��,i-;v�rs�P+s-y,41 �"a„ *L. -,�S Y ,� .�- j �3•- ..�.�+. §„�T �a' ,,... 2®4,y^`� �y%„ i r-.ice"u`., y'L..., ;..•s t, ,r -i'' `. - is�1�x .:..r x y Y w,. -rY-•a.�ss `A,•r.r�n �` e"'a`ic*-"�'i.`"' s�-.✓ u j,sl- �>4,�"�!�"r`-y`�x'�„ a'a`-s"�.,.�..�L.�,.rr„.�`3�w•� .��"� ..'fin J'd ;,,` "� �.."e` $�{��.�.� �•w...+�dgwYtnr.�-awl`�r+r�M.:=�'�'�-rrr: '� �. � d �.``o-^v.['�'.w..'vi•�r+� -`= i Sy r=rt+",�'d't"t•� -u'3 e, y,+{..i:,. ���,. �_-. a4y.�i, ��`'tr,,,� ��,,,,��y."� r �`Y. ����.`�}�,.FX k' x d"�witu=. aara ..+ .-�..� ,s,, .m: "'.;•P. K- x,,, ,�-.•-" .tet: ,Wt._ '"3 s�,o,..'� r „ ; G's'zr-' Wj i'�..tee`? ''�0..• ti w' ' . IS ,d• � � � �-g rY '+'r v'�-••`���."� ..��'-`sem- .3� � .' +'�. �i-y } st R:r ��-X c..,,s�'t*''�ar+-�.. y-...� �' ''~ -�'� r �» t ��,.,a.Y§v�..,' r �� � ••'•.:y t - .` � s .i++-. `s- }� - ,� �'... ..Y �ti�'tg.���'•F .z}. k6 r :�• ,,,:'a -. '�' ,"`..r-.f t7 _,': r -.t� 1 �r -v -fi +:g4'd `Y Gt ,a,. r jx .✓ t `y• -r"`s-. ��""'�3r,.. �,-h" s,.t- ,; � --.:•s- � „r } -< r`> -_,� t `` '. x-- r Y. `'�'�'+c.s+.t."'K`s�; : ,•- ?'-r i m -� ,{' `+.:.rZen > r '�..'� �: r ti tt'"f ;p "'` _ i ,Y f•Yr .`s"= y sT�+:,v'dar{s `• .�� ...x.. s. rzx•^�z �v,N•,,. 5 _- ��,,, � s-, A,:=+.�,<a �✓pt'r'`�. �`'s..'k•'7'-. '{ - r _ ,_x`.wj s""�- �� ?.�L� »M� t'� �M.�+�t�+ -'7.'�' ; ? C`•"Y�m. fes{ S:•- Y Y.Fa of 1 1 }• L-Y 7 ti ' d �,�.'c `'s yt �'"�_ �•o}���?'i��7g'�`�trz"tr"y,.':"'�"5 r '-����'M1��'�s:.sygi r�,,5v�� _ - "'y%`"� � ...f•'�- �� 'hh�g`�'�"s '�``� i.LL;,%1--4 a>,_ra..,e- '"""�ht 'y'� "'`'� a +tae-z..r. �-y,�,,�'",. d ...a =r x :" it �t'"-erg€. ,g"'is..,rt.� -o-. ,�v�ew'.*'e'2�.Y,� ,..n.�� cr-;:5"�•-. �� . � _ #�.w x � �-s5'}s� w•�.e,� ...9�:.-,."�'$e�Yt'.`:s" � , s`zs��='"? d. � �'.��`��� r � 4��+ yw.k t"°r �<�Sy�"n'.si4�'" "'iC -Yw act`ia� �- �`'�'L.1' ��, -"'„ ,y�,,•�`k-� ��„�:.7' °` t, ��*.� �� •�- t 3+t ���er ;9 P*-, •� - �•'���"" � 5` `�� � .a:' �� •" �..,e" s�"..k.�r°�erg+ R f 4-c) moiI'D\cc.n s <" tai4- f on -- n ukn C, \0, P C C C C� f� C�- '' e C a I-)-1\7 C�e c '\ A,- a Y"') jy1 60: 6 _ ♦{}fit r A ? � '� CLAIM BQAED QE SIME, ISS 0- CQN,"MA COSIA GQI.fi's AT:fEQH?� tt► BOARD Air`11August 17, 1999 n � a "4 'a Claim Against ft County, or District Governed by } yNOT1Cl 71 CLAIMANT Board of Supervisors, Rotting Endorsements, and Bord Action. All Section references are to IU copy of this dD=mnt mailed to you is your. California Goverwent Codes. } .� 'w `#:notice of the action taken on your claire by the Board of Supervisors. (Paragraph IV below!, Oven pursuant to Government Code Section 513 and 915.4. Please note adl *Warrings". AMOUNT: None Specified CLAIMANT: Jeffrey Lee Snow ATtOR1,MY. DATE RECEIVED: July 30, 1999 ADDRESS. 3777 Willow Pass Rd. , #75 BY DELIVERY To CLERK ON: July 30, 1999 Bay point, OA 9455 BY MAIL POSTMARKED: Hand-delivered L DRONE Clerk of the Board of Supervisors 70t County Counsel Attached is a copy of the above-noted claim. PHIL BAT R, Cie Dated: By: Deputy IL FRONT L° County Counsel `DJ: Clerk of the Board of Supervisdfs } This claim complies substantially with Sections 910 and 910.2. } This claire PAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). } Other. Dated: By ' p uty County Counsel t M. PROnA Clerk of the Board Tai-ld/ounty Counsel (1) County Administrator (2) ( } Claim was returned as untimely with notice to claimant (Section 321.3). 1V''. BOARD ORDEFL By unanimous vote of the Supervisors present: ( } This Claim is rejected in full ( } Other: I certify that this is a true and conv4t copy of the Board's Order entered in its minutes for this date. Dated: Q PHIL BATCHELOR. Clerk, By. Q- 0 Deputy Clerk W ( - code section 913)WARNINGCrov. Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section. 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING - I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By: PHIL BATCHELOR By f'uty Clerk rr: r4unty Corel County Administrator Claim to: SOMW 07 BVPZR XBORS OF CONTRA COSTA COVNTY Ar Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the -100th dray after the accrual of the cause of action. Claims :relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any rather cause of action must be presented not later than one year after the accrual of the cause of action. (Gov*t Code 911.3.) R. Claims must be filed with the Clerk of the board of Supervisors at its office in Room 106, County Administration building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the board of Supervisors, gather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. R. 2!raud, See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp 7? RECEIVED Against the County of Contra Costa) g or yra�a .a } 6JUL 1999 t LDistrict) (Fill in name) } CL OARD,OF'-UF :vas RS D } WNTIRA COSTA,Cu. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sura of $ ,Kt- 0i and in support of this claim represents as follows: &%�,; ; I. When did the damage or injury occur? (Give exact date and hour 2. inhere did the damage..,or injury occur? (Include city and count 3E. Now did the damage or injury occur? (Give lull detailsi use extra paper if required) : fjea !AUS . k� ." t 8 r ,,vAp3y� �y- ..� 7�s ���?I�d` �Y>S S�'4.?•^� �-f:'� � ��$f"r S' �4'�+P' � "b a+v2e �}'-0 :� P�s7�'�� STs"adsd X46.,r 4. What particular act or emission on the part of county or district officers, servants or employees caused the injury or damage? (over) s. What are the names of county or district officers, servants or employees causing the damage or injury? Dlep ze '17 t S. What damage or injuries do you claim resulted? {Give full extent of injuries or damages. claimed. Attach two estimates for auto e'y�S £1 r .tea ;a k 2rYd J4-hsj 7. now was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) - = H+s A f j o ey of v ewe t €Ysa S. List the expenditures you made on account of this accident or injury.� } Gov. Code Sec. 910.2 provides } *The claim must be signed by the } claimant or by some person on his .Name and Address of Attorney } } _ ( aimant•s Signature) j '7 7` IJ O 53, Y?x } (Address) } � a} Telephone No. } Telephone N : XCTICE Section 72 of the penal Cod* provides: Lvery person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any country, city or district board or officer, authorised to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more, than one year, by a fine of not exceeding orae thousand ($1,000) , or by both such imprisonment and fin*, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. CLAIM $_. 3 RD OF SUI'EI2VUt".►M CII` QQMA LOSTA +CQI?N` . ['ATT 30AED ACTlf llk AUGUST 17, 1999 Claire Against the County, or District Governed by } the Board of Supervisors, Routing Endorsements, NONCE TO CLAIMANT and Board Action. All Section references we to The copy of this docurnent mailed to you is your California Goverment Codes. } notice of the action taken on your claim by the _ Board of Supervisors. (Paragraph IV belovo, liven pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: Approximately $400.00 �,­ -NMu CLAIMANT': Damien Stark ATTORNEY: 'Maurice Moyal DATE RECEIVED: July 20, 1999 Attorney at Law ADDRESS: 1899 Clayton Rd. , Suite 100 BY DFJJWRY TU CLERK ON: July 20, 1999 Concord, CA 94520 BY MAIL POSTMARKED: Hared-delivered L FRONE Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted Maim. PHIL BA�k,�I.,OR, Cl Dated: July 21, 1999 By: Deputy :�_ 1_ ' <, IL FROM- County Counsel TO- Clerk of the Board of Superviso s ( Ibis claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). { ) Other: Dated: i i By.— Deputy County Counsel x M FRO? Clerk of the Board 7 unty Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I`,. BOARD ORDEYL By unanimous vote of the Supervisors present: This Claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated ,` PML BATCHELOR, Clerk, By -Deputy Clerk WARNING (Gov. code section 3) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek thr, -Ivice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. A,FFIDAM OF MAIMG I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By. PHIL BATCHELOR By Ate. ,, putt' Clerk wt CC. County Counsel County Administrator ......... ......... ......... ......._.__... _. . ........... __ _ ....... ............ ...._..... ........ ........... . ...._......_......_.. ......... ......... ................... ........ ........... Cairn tc: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100x'day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553, C. If claim is against a district governed by the Board of Supervisors, rather than the County, the nameof the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp `` Ig 1, P '1 rrl (Z RECEIVED EID 2 3`i c­t Por r?T G Against the County of Contra Costa or ) U ) CLERK ONR 1' 1SOFSrd ri 4 Co S 'rs - rn to(,)--V I Ne Z District) CA COSTA SUPERVISORS (Fill in name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$1Z.5",a00'"and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) -7 . 1--) , 9c1 , 1 0 : S`0A (" 2. Where did the damage or injury occur?(Include city and county) Co57c- \Re,�iovwkL Yhe_oi(cL- C1'sy(_teL4rk_ ELALVa4)on t,0r4) 3. How did the damage or injury occur?(Give full details;use extra paper if required) Prt' e.,f -- 10 ' SX,Aen -7-Ii-cil 1M-� �clr}rn�� CcxGL SatntipSdn e,_vld _r Weu'C Ucf-'r* 1rc\ -T"G Lrc.1ce c> ocvr, PSIQ&Vric FDOAL-vcL�to" S-cr\pce, A ► 0_0 Wc'� S Sttnp;n Ee1„ US S-fc.irtn� �-1 CrS, 'tt3 CHr9i2ft-6 rvS�= YoH� ►?1�nt��r 5 L-AL.Kfo 'PAST Pt%+1enl- Cc., HO L--,0o& Aa-r oo(t P ,_ArenT , a-YNd C,_rak (5,IN ra 'C'e 0 e_0 10 f N �,eC r--f o 'D oo fa_ 16 9 S 0,t,,t ro 0 o k 7'.1 e GQ1 le 1� L c'.r u i— ``.:,fo iq c t .j -cl /n - "?"_ ten ? � 3c s _ C ��E2 L tSC' a 1 se ���w mu Lx..' %'i.d`,t` � r• �7 � r Gam" ..,�'4'i+2 �9�l.� �.3 ::�` �ii�r 4,"..)f; iii � s..2 ;.0C..eR.C � d.�<E c,�'� �0,� S:>' "I,.:£.. r.. ��,, Gr.. £` .tw o. C✓ dt..< hn iia st kt £ C tZ Z"` r. t y S Via_ �� � CL .' -T 41°4 1 �.+.._ ;�Yi q�✓� �� ".,f S'�a�9.�'`"f i i�"�``�`k,b b�C.'i �'GF t'i °jW.a.� '£{�?c�,f� iii'C�d^'� �3,i'-�'' Oil Pc, `e Yl Pv€55rb1g3g L 4.✓ � �C.°y :G`C+P C'� �• '�-C.�.� $f'� ;�t''.i �4 r{1^a-f"7�5i.� .a t1✓a �" t v d: 'Ct i ria Circ i en i fra EM 'E'Cas s av 1�s`''- 'esr3�J'#'ieer4f,� �k6:.s"eS � .-fp,.`� ;!S,I�O;�rv�,'f b!`� :^+'Ytc's ,;._ 5..:./.:,. 4� .,�''-3t{nc'a? o��� -� t_C�-"'y.� ;��.C.J•:,:tea�. �Ci�'o-`-y+'�'-f frdy'Ctisty s >rNE I d ?c E c s�L e.a i �aTc)r r L F 4 13 �Q.. i �6's nc, >•4 :' 1 �r.dvty 'S 5 �v� 5s'v t. g� �fE _ . F w is tfic arc i2i ££ . 3 h t; ;�;�tV* t' �iw6vtt� s#�fzgv �a" cu�lCs e r ,�1 �� �•� i�. ;-i+_"y 5's`i c i r, t'..a o ovt�' :S 6'@^J'°S �. v�e-2% e+.. 1�` a t i.� `.�at e mac'�"a,o , '�`a s�: , .!. c,_ sem; L�I -g /E1 y i i } 3 $ °✓ b r c,'c, trsc��� �.Z �2tPT, �ls� cLCJ3 �€ ,� c'.a,, '' 4 c; `l S`L.L..d" {fce'-Q r w, �" '`d. :l .. �'' >:.b al iF�.r:; .,. :r�,r,fj vu ir,,,x rvl vs-,,ea his LS^ �a S ��a a"a ca,4e• C'�..Yi� �=9t���f:'=�.L- ;��-c. r �F �r`F 3 a� �, 'lam t S �ca_�5 i 2:2 � ex:i."`�:�a � ��ea-�i�� ��:�"' `�'Ee:'te��� �`5Ls �a���• ��i'rea�.6�'.� � s,�r�-�. �avM"s'� �4ru �.;3t��.P r r-��-e r-S�c.E�'v�9 � �w�l� c°'c;s'Z� �•,� S�`"�� � � s..�<;,��t�a 'a�ts�:;� •,:�c:.$ a et ;�f�,c t r $°'''- �'cL L:.:,^ �s't•�hl:?C,n$�,�,j .+'a` ar'a.s�.,� •� °�„��Eay d.;�r;` k- r- * S'A. 'G.Z.. c«-F. OC,vS::t c..-t. .2' 4'p^ C. 4 .. :'t..3 F:.`3 r az�9+. °fig p, �` .e .�f 'L'a^e k.,.ra s R _._.......... i 'r. ghat particular act or omission on the part of county or district officers, servants, or employees caused the injuryor damage? >, i t u c . a = .c. y r c>° v .T i;, ti., ..-» I- Ss. VC eFICfC F_ • :.,. ,T, t w 9✓ai �' e- ,t` if'fir..,."f`�a Q';' L"'e�,':f tip. ," g �. ,� iC'o� � :th.�' ;t5 ey `s C'_ 0A 5. What are the names of county or district officers, servants, or employees causing the damage or injury? L I 6. What damage or injuries do you claim resulted? (Clive full extent 'of injuries or damages claimed. Attach two estimates for auto damage.) c k)t L j Cts e d L @ ' ` 4`'` s rytcs\},atLL C� ✓Z �, GJ u— �'-� J t L 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or i damage.) c o n r c C c-� S . C r.� `S F�eg z s aG�� y-�1ti' 'r e,^� r L- �a t 5` Lr =<. .. '"�"y,>., "�:.0 ;�a.t`� i `JC i e �., o--��.,i�' e t,-' ends'e: `",'3 e. ,.C i- C� 4 PYi 6e o +r7 e1teZ- rn, v 8. Names and addresses of witnesses, doctors, and hospitals. '' tech 5 ra"ea _ iz ��t v ? 2 rn 0-n v% V(11:,L C' ry ga% HCS r ,Y , 9. List the expenditures you made on account of this accident or inluty. LATE TDI E AMOUNT "_.f v°7---..._..�-----�,- "?, as ...,.-�� p r � 2 9 S✓c'. >- .,. .s f k= a Cl�sros S C, 6,2415,�".,.�, rc3y'v v L.} S.N,,-- S't y Fl F ) Gov. Code Sec: 910.2 provides"The claim must be ) signed by the claimant or by some person on his behalf." SENA}-NOTICES TO: (Attorneyy Name and Address of Attorney ) C t ) (Claimant's Signature) L; ) (Address) _ T i_:a C7 5P Telephone No. p )Telephone No. -2S i -3 77") 6-N--Sv = 5 c NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,'bill,account, voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not exceeding one thousand($1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars($10,000),or by both such imprisonment and fine. JUL-z1b-•1999 07-17 3'EF-1C?-:s S!--� SE" P I CASE NO CONTRA COSTA COUNTY PUBLIC SERVICE REPORT FORM 2,CODE SECTI GI31ME 4,CLASSIFICATION 5 REPORT AfK$A , '�' t� "+�?�• �.,5'�s'/Jt�'�' ,art t�,v�.r F�' �-"r"T�2 6 DATE AND TIME 4CCURREO DAY 7 0A'tE a TIME REPORTED 8 LOCATION OF OCCURRENCE .-I—'.1"- lit .trr" 'tet.. '`3 / y-rrtz- "ratrc> t G , f ��, 9.VICTIM'S NAME—LAST,FIRST,MIDDLE IFIRld IF$ SINES$) 13 RES(OENCE ADDRESS �� } .1 RE PRONE 12.OCCUPATION t3 PkACE-sex 14 ACE 15 DOB '16 SU INM A67{713ESS ISCHOOL IF Jt1VE-NILE) ,17 Bus PHONE 6P —-5- rg ,� ,4rYr. crr� t•7 _ t ? `1.;r.2 V VIC71M tN:t ITNESS P•PARENT RO=POL.ECE OFFICER s 3 18 v?^Ieck A more Conunuatton cj 11 NAME—LAST,FIRST,?'dI90LE 20.CODE 21,RESIDENCE ADDRESS 22 RES,PHONE 23 OCCUPATION 24,RACE-SEX 125.AGE 126,008 27.BUSINESS ADDRESS(SCHOOL SF JUVENILE) 28 SUS PRONE .tJ.41VIE--LAST.FIF4ST.iut►I Ui.E317.CODE 31.RESIDENCE h REBS 32 RES.PHONE :33 OCCIA'AT1ON 34-RACE- 35.AGE 36 005 37,13USINM ADORM(S4;KQOL IF 1t3VENIL F) Is WS PHONE METHOD OF OPIERATION Downba aharirctellsuo of pram ats and arta where Wtones occurrad Delitfst*botfly how~.—St was cowifflMd r +" __. c!-`•t' t"7it yam;. •�e .r� i ✓ 7*/ t car �I� ...`��✓ YJG+►Y"'1 I i t�' �, '^"' ♦ i 7/' GµY�� ,.i...� _....�✓ Y V'a iM.a w- 2=,Y �'S f/'Pj� ci 46.SvIllood No I(tett.Ft st axlds m 41, $+pP so.Age Tit."t W.Wt LS3.FSaIr S;.E1+Ds 35.It7 Nrs.yr CXM3 56. er utd'r +'a� •,ttr',✓r � � 1--'?7 L 57.Adm,0011 ing 41`4 0111mw ldvnWtV Iftft at *tm Sd$VV00d Ne 2 4Aat Fltat MWW tom.Ey" S&0 Na.m Dos_ ,, 63.Af '?� 67 Address.Cton"j;and Idtndtytrsg Marks or Gharacterllsrial el Cntct<if more /d+ ./ CUrt6nval,st5 REF Cifl IIMC3 t3€1It } 3i6t�ENE[3 BY C)ATF ANDTIME FURTMER COPIES AC1'1{7FI: M YES TO., 0 0 0 0 RE1I1lEWED ay VA,TE AND TIME FU8UC SERVICE 2 (9151) J$jL"Utx"1JlD �>f LJ 1(F1t.."w S:3 i J t ';'•..�L L ✓%� .,#t`�F x..1 5`t•:� f �1:. 97t41�0. COMA CVS *iCOUNTY PUBLIC SERVICE REPORT FORM f 3 -TG.CODE ft rt.Cf#ME 72,Ci.ASWCAT)ON ?I.vicTivs WAMS—LOST.FIM,MOtsLE"M w susoJE 3 74,A E Ats�d�ettg _�t3 as �` 75 p►+UNt -41 act -4 r . _rte --J�04C-- ,r 44 4 A d� ".n( A)r .r l G:�fe t r+�7 derAc= !�'" ,r..-� . r�}r` ..t''1° t.�" i�:�' . ,tom, ��"r- •-�c "°.�' d .t'°''c`, rr,?" r' .r ACT}tf: OYES ta: LINO cl _. . RrF+f3#Rt' a C s 0 err CAT#AND TIME TOTAL P.02 MARTINEZ POLICE !. ! wx . Raw ##4118 ._ wwrwwien...w, -� ,.. - >.«..ye.T�#,lw4"S.}fiP"�' �IIS��►+1� im I HEREBY ARREST THE AES, ABOVEs SUSPECT(S)ON THE CHARGES INDICATED ABOVE. a f.-:� :siEi�S. -_ _. _�« _ �.. i+ .. __ :i71ER4}:*:S..#�1�1.=ilS _ r,t?M • _���rff� s ti. • IW t�-� y f r• f i .K! •7i TTx'i{t ,,r, iT� rt zrT•r�s�rst Tirt'°:T7 � { r 243(c)(1) PC BATTERY WITH LNJUR.Y i EMT 99-2494 PAGE 2 On 7/04/99 at approximately 1044 hours, I was dispatched to the emergency room of the county hospital located at 2500 Alhambra Avenue for an investigation of a battery. Upon arrival, I spoke with Victim STARK who told me that he is an EMT with American Medical Response. He stated that he and his partner, CAROL SAMPSON, had just dropped a patient off at the emergency psychiatric unit of the hospital. He stated they were exiting the unit with their gurney. Prior to leaving, they advised one of the staff members that they were leaving and the staff member hit the button to unlock the exit door. STARK stated as they were walking through the interior exit door with the gurney,a patient,later identified as Suspect forced past thern. He recognized the subject as a patient and attempted to pin him to the door jam with the gurney. He stated the suspect then struck him in the area of the right cheek bone with, what he believed was the suspect's right fist. STARK stated that he attempted to detain the suspect and, in the process of trying to restrain him,the suspect hit him again. STARK stated that he fell to the ground and rolled part way down the driveway of the emergency unit. STARK.stated that he began to get up and"blacked out"for a couple seconds. He stated that he then got up and started running after the suspect. He stated the suspect took off his shirt. STARK stated the last time he saw the suspect,he was running down a hill which was described as the area of Duncan and Ameba Streets. He said the suspect was wearing only greenish blue pants which are similar to hospital scrubs. I asked STARK if he desired prosecution and he stated that he did. I then spoke with Victim#2 SAMPSON who told me that they were leaving the emergency psychiatric unit after the employee pushed the button to release the exit door. She said the suspect came from her right side and punched her in the arm. She stated that her upper right arm is sore,but she is not seeping medical treatment. She said that after the suspect knocked STARK down,he ran away. I then spoke with Witness NEUFLAUSER who told me that he is a Public Safety Officer for Contra Costa County assigned to the county hospital. He told me that he received the information that a patient had escaped from the emergency psychiatric unit. He stated that he assigned Paramedic STARK in attempting to catch the suspect. NELIHAUSER stated that the last time he saw the suspect,he was running in a northbound direction, down a hill toward the area of Arreba and Duncan Streets. S .. 99-2494 PAGE 3 During my investigation,I spoke with JOS WHITNEY who is also a PSO for Contra Costa County assigned to the county hospital. He stated that they had received a request to stand by as the staff explained to Suspect the rules and guidelines of the facility. He stated at that time,now stated that he was going to leave. Also,WHITNEY noticed that while was being spoken to by the staff, he was continuing to clench his fists, in which WHITNEY recognized as possible violent behavior. He stated it is the policy of the county hospital mental health staff not to lock down violent patients until after they have committed a battery. WHITNEY also advised that the hospital had changed the door procedure,entering and leaving the unit. There is an exterior door which leads into a small area and then an interior door. The exterior door used to be locked until the interior door is closed. The way the door is set up now,the interior door is locked and must be released from an electrolock inside the facility, but the exterior door is not locked and can be opened just by pushing on the bar of the door. At approximately 1228 hours, Martinez Dispatch received a phone call from an employee of the county hospital stating she had observed the suspect in the area of"C"Street and Marion Terrace. I responded to that area., along with other Martinez Police units. A perimeter was set up and we started performing an area check for the suspect. At 1245 hours,Police Dispatch received a phone call from a doctor at"E"Ward advising that the suspect had made a phone call from the Wendy's restaurant to a family member requesting to be picked up. Martinez units responded to the Wendy's restaurant on Alhambra Avenue. Just prior to arrival,PSC)WHITNEY stated that he had one in custody at Wendy's. I responded to Wendy's and accompanied PSO WHITNEY back to the county hospital with Suspect At the emergency psychiatric unit,I spoke with the charge nurse who stated that the suspect was going to be put on a hold and would be placed in a lock down room. I advised them that the Martinez Police Department would be sending the case to the District Attorney's office for review and complaint. At the time of the battery, both paramedics were distinctly dressed in dark blue coveralls with the letters"EMT"on a large patch on the rear of the coveralls. J, STRETCH,#77 lam 7/05/99 Ceq CLAS STA C'.Q=s CAi WDEMA }ARD A00 August 17, 1999 Claim Against the County, or District Governed by l the Beard of Supervisors, Routing Endorsements, NOTICE TO CLAIMANT and Board Action. All Section references are to 1 The copy of this docurnent Trailed to you is your California Goverrimrit Codes. l notice of the action taken on your claim by the F 7 Board of Supervisors. (Paragraph IV below}, given 3. w<:4 pursuant to Goverryne Code Sec#ion 913 and 915.4. Please note all "Warnings". AMOUNT: Approximately $1,500.00 Z�f d •o CLAIMANT: Unreadable ATTORNEY: 451 S. 21st Stree� DATE RECEIVED: July 9, 1999 San Jose, CA 95216 ADDRESS: BY DELIVERY TO CLERK ON: . 3 31 y 19, 1222 BY MAIL POSTMARKED: PEr Dzan2m ttal L FRONT E Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Clerk, Dated: July 13, 1999 By: Deputy IL FRONT: County Counsel M. Clerk of the Beard of Supervisors s This claim complies substantially with Sections 910 and 910.2. ( ) This claim PAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). { ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). Other: Dated: F F By: �° �K � ��C�,unty Counsel s III. FR0?1I: Clerk oe Board T0. :Coun y Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with not)cc o claimant (Section 911.0. #Vr BOARD ORDEFL° By unanimous vote of the Supervisors present: This Claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this slate. Dated: �'— PHIL BATCHELOR, Clerk, By. Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claire. See Government Cade Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. 'Tor Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF IVLUIJ VG I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service to Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. erg Dated r � �By: PHIL BATCHELOR By - `' Deputy Clerk CC; County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 198' day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988,must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the came of action.'(Govt. Code§911.2.} B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,651 Pine Street,Martinez,CA 94553. C. If Claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity,separate claims mast be filed against each public entity. E.- r..awd. See penalty for frauduient ciaims, F'enai`Code Sec.'72 at the end of this form. RE: Claim by ) Reserved for Clerk's Filing Stamp } Against the County of Contra Costa SHARON HYMES-OFFORD or JUL, 0 7 1999 District) (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above named District in the sunt of S and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact Date and Hour) s 2. Where did the damage or injury occur? (include City and County) �_ ------------------------------------------------ 3. - -- -------------- ----------------- 3. How did the damage or injury occur? (Give full details;use extra paper if required) y'9-4., _ i _`L- ,,i.__ 3 # ._ t — 4._ #-k-�' __Y*`t�e `�`r"'G+tif0li 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? (Over) S. What are the names of county or district officers,servants,or employees causing the damage or injury" ------- __ lr}. _ �____! C K ------------------------------- 6. ------------ -----------------6. What damages or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for sato dsmage.) 7' How was the above claimed amount computed? (include the estimated amount of any prospective injur}or damage.) _._--- C(-k-V'0 --�-- - - -------------------------------------------------------------- g. Names and addresses of witch✓ . ,d tom,"d hospitnl& --------------------------- List the expe.liditures you made on account of this accident or injury: DATE ITEM t tAMOI?W. Gov. Cods:Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf`." Name and Address of Attorney f, 1-2.1 r (Claimant's Signature) (Address) Telephone No. Telephone No.( t J - _ NOTI COSIN TRA 0 A COY Section 72 of the Penal Code provides: "Every person who,with intent to defraud,presents for allowance or for payment to'any state board or officer,or to any county,city or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim, bill,account,voucher,or writing,is punishable either by &i-a my jail for a period of not more than one year, by a fine of not exceeding one thousand dollars(SI,000 ),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not exceeding ten thousand dollars ($10,000), or by both spch imprisonment and fine.