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HomeMy WebLinkAboutMINUTES - 09252001 - C.10 This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific . statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive' rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. - 3 I RODERICK P. BUSHNELL(46583) BUSHNELL, CAPLAN &FIELDING, LLP 2 221 Pine Street, Suite 600 San Francisco, CA 94104 3 Telephone: (415) 217-3800 Fax: (41.5) 217-3820 4 JUDITH R. COHEN (100533) 5 LAW OFFICES OF JUDITH R. COHEN RECEIVED 495 Gate Five Rd., Suite E 6 Sausalito, CA 94965 SEP 10 2001 Telephone: (415) 332-6226 7 CLERK BOARD OF SUPERVISORS Attorneys for Claimants/Plaintiffs CONTRA COTACO. 8 MATTHEW SUMMERS, a minor, by and through his Guardian 9 Ad Litem/Parent LORRAINE SUMMERS; and LORRAINE SUMMERS; MATTHEW SUMMERS 10 I 1 BEFORE THE CONTRA COSTA COUNTY 12 STATE OF CALIFORNIA 13 14 MATTHEW SUMMERS, a minor, by and ) Case No. through his Guardian Ad Litem/Parent ) 15 LORRAINE SUMMERS, and LORRAINE ) SUMMERS, MATTHEW SUMMERS, ) CLAIM FOR DAMAGES AND 16 ) NOTICE OF INTENT TO FILE A Claimants/Plaintiffs, ) LAWSUIT 17 ) V. ) [Cal. Gov. Code ti 910, et seq.] 18 ) CONTRA COSTA COUNTY, ) 19 ) Respondent/Defendant. } 20 ) 21 22 Name of Claimants: MATTHEW SUMMERS, a minor, by and through Ills Guardian Ad 23 Litem/Parent LORRAINE SUMMERS and his parents; LORRAINE SUMMERS and MATTHEW 24 SUMMERS. 25 Address of Claimants: 4529 Pronghorn Way, Antioch, CA 94509 26 Address Where Notices Are to Be Sent: Roderick P. Bushnell, Esq., Bushnell, Caplan & 27 Fielding, LLP, 221 Pine Street, Suite 600, San Francisco, CA 94104, (415) 217-3800, attorneys for 28 claimants MATTHEW SUMMERS, a minor, by and through his Guardian Ad Litem/Parent, CLAIM FOR DAMAGES AND NO'T'ICE OF INTENT"r0 FILE A LAWSUIT summers\Not_damages r ' I LORRAINE SUMMERS, and his parents, claimants LORRAINE and MATTHEW SUMMERS. 2 When Did Damage or.In'u Occur: Claimants incurred damages and sustained injuries on 3 March 12, 2 001. Their damages and injuries continue to mount. 4 Where Did Damage or IniurX Occur: Claimant Summers sustained injuries on a school 5 supervised field trip, in the City of Oakland, County of Alameda. His parents, claimants Lorraine 6 and Matthew Summers, sustained injuries upon Iearning of incident with son. These injuries 7 continued thereafter. 8 Nature of Claim: Claimant MATTHEW SUMMERS, a minor(hereinafter referred to as 9 "Sunimers"), and a student at Via Center School was assaulted, battered and harassed by 10 MATTHEW WILSON(hereinafter referred to as "Wilson"), a much higher functioning and older 11 Via Center student. 12 The sexual battery and sexual harassment occurred during a school field trip oil March 12, 13 2001. Summers' teacher and supervisor, Jennifer Dorn, left him alone in a men's bathroom with 14 Wilson, a much higher functioning and older Via Center student with a history of inappropriate 15 sexual conduct. As Ms. Dont waited outside the bathroom for the two students, Wilson battered, 16 sexually battered and otherwise sexually molested Summers inside the bathroom. 17 This incident was allowed to occur as a result of the School's and Contra Costa County's 18 deliberate indifference to Summers' safety notwithstanding its actual and constructive knowledge of 19 the risk. Specifically, the School and Contra Costa County failed to provide Summers with one-to- 20 one, uninterrupted adult supervision as promised and obviously needed; the School left Summers 21 alone with Wilson knowing lie was defenseless against the foreseeable risk of harm the situation 22 posed; the School and Contra Costa County failed to provide Summers and Wilson with adequate 23 training and education regarding appropriate sexual conduct; and, they failed to adequately 24 supervise its staff, including Ms. Dorn, regarding sexual misconduct and reasonable protective 25 measures to prevent it from occurring. The School's and Contra Costa County's acts and omissions 26 to act in these respects breached its duty to protect Summers as promised and as legally required; 27 they exhibited a conscious disregard of the foreseeable risk of harm involved; and, they caused the 28 claimants great disruption and distress for which the School and Contra Costa County is legally 2 CLAiM FOR DAMAGES AND NOTICE OF INTENT TO FILE A LAWSUIT Summers\Not_danlages I responsible. 2 The Contra Costa County breached its State and Common Lav duties to provide to Matthew 3 Summers and to his parents Lorraine and Matthew Summers, for himself and for them, a safe 4 school environment and the appropriate special education and related services. 5 The Contra Costa County breached its duty to adequately supervise Summers's special 6 education and related services by failing to insure adequate sexual harassment policies were in 7 existence and followed; by failing to insure that the employees and students of the private school in 8 which Summers was placed received adequate training regarding inappropriate sexual conduct and 9 protective measures to prevent it from occurring; and by failing to provide Summers with a safe 10 school environment. 11 As a result of these breaches, the claimants have suffered extreme emotional distress. 12 Nature of Damages Claimed as a Result of the Inju as Alleged Above: Claimants claim all 13 damages associated with the harassment, assault and battery that they have suffered since March of 14 2001 through the present date, and continuing into the future. Claimants claim general damages 15 related to medical treatment and care, and other injuries, all in an amount in excess of$1,000,000. 16 In addition, claimants claim emotional distress, pain and suffering damages and compensatory 17 damages in an amount in excess of$1,000,000. 18 Names of Potential Witnesses: Matthew Summers (son), Lorraine and Matthew Summers 19 (parents), c/o Bushnell, Caplan &Fielding, LLP, 221 Pine St., Suite 600, San Francisco, CA 94104; 20 Wilson, student, Via Center 2126 6"' Street, Berkeley, CA 94710; Ms. Jennifer Dorn, teacher at Via 21 Center 2126 G"' Street, Berkeley, CA 94710; and other individuals unknown to claimant at this time. 22 Names and Addresses of.Medical Treatment Practitioners: Jean C. Hayward, M.D. at The 23 Permancnete Medical Group, Inc. 280 West MacArthur Blvd., Oakland, CA 94611-5693; 24 25 26 27 28 3 CLAIM FOR DAMAGES AND NOTICE OF IN'T'ENT TO FILE A LAWSUIT Summers\Not damages I Children's Hospital 747 Fifty Second Street, Oakland, CA 94609. 2 DATED: September 7, 2001 3 BUSHNELL, CAPLAN & FIELDING, LLP 4 5 Byy��7 RODERICK P. BUSH-NELL 6 Attorneys for Claimants/Plaintiffs MATTHEW SUMMERS, a Minor, by and 7 through his Guardian Ad Litem/Parent, LORRAINE SUMMERS; LORRAINE 8 SUMMERS AND MATTHEW SUMMERS 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 4 CLAIM FOIL DAMAGES AND NOTICE OF INTENT TO FILE A LAWSUIT Summers\Not damages CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Sept 25, 2001 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 document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". FD) ce,- II�ED AMOUNT: $30,000 SH 1. 3 2001 CLAIMANT: Maxine Ballard COUNTY COUNSEL MARTINEZ CALIF, ATTORNEY: R. Nicholas Haney DATE RECEIVED: September 11, 2001 ADDRESS: 227 Broadway St BY DELIVERY TO CLERK ON: September 11, 2001 _ Richmond, CA 94805 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEET , Dated: September 12, 2001 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his 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: / By: Deputy- 'vim Deputy County Counsel III. FROM: Clerk of the Board TO: County 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: d() 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 minute for this date. Dated: JJOHN SWEETEN, 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. 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 ddressed to the cialynant as shown above. Dated: JOHN SWEETEN, CLERK By Deputy Clerk This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. �r-961141/01 : 12:49 H.A.C.C.C. 1,,5102377267 NO.032 902 Claim tot BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INS UCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or m personal property or growing crops and which accrue on or before December 31. 1987,must be presented not later than the 100th 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. fid. See penalty for fraudulent claims,Penai Code See. 72 at the end of this form. #�kr,r���,arrafa�r�t.,apt*r�Mt��aoM��r�rr*«errt*r�*a�,�►,r,��r��*raa��,r��r►�*r..**,�r RE., Claim By ) Reserved for Clerk's filing stamp Maxine Ballard _ � RECEIVED Against t County of Contra Costa RECEI or SEP 112001 The Housing Authority of Contra Costa (District) CLERK BOARD OFSUPERVISORS (Fill in name) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the Cowry of Contra Costa or the above-named District in the sum of 5-io . p Cn_ —and-in support of this claim represents as follows: 1. When did the damage or injury occur? Give exact date and hour) March 12 , 2001 at 11 :30 a .m. 2* Were did the darnage or injury occur. (Inc ude city and county) 82 Medanos Ave . , Bay Point , Contra Costa County , California . 3, How did the damage or injury occur? (Give fulldetails;use extra paper if required) Claimant tripped and fell on broken or uneven sidewalk causing injuries . 4. t particular act or omission on the part of county or district o ieers, servants or employees caused the injury or damage? Allowed a dangerous condition to exist which force.ably Omform could cause someone to trip and fall . ebf7.3�01 12:49 H.A.C.C.C. -+ 151023?7267 •:0.032 Dl�s 5. What are the names of county or district officers, servants or employees causing the damage or Wtry? Unknown . 6. What damage Zr injuries do you claim resulted? (Give full extent of!;juries or damages claimed. Attached two estimates for auto damage.) Claimant lost two teeth , required stitches to wound in mouth , sustained left foot injury, right arm and shoulder injury. 7. How was the amount claimed a ove computed.? (include the estimated amount of any prospective injury or damage.) $10, 000 medical bills , $20, 000 pain and suffering . 8. Names and addresses of witnesses, octors and hospitals. 1 . I z e t t a Parks , 81 M e d a n o s Avenue, Bay Point , CA 94565 ; (925 ) 709-1672 - 2 . Diona Stewart 76 Pan-clio Vista Drive, Oroville , CA. ; ( 530) 533-1125 . 9. List the expenditures you made on account of this accident or injury; DAM M &MO 3/12/01. to CCC Dental present and 2147 Loveridge ongoing . Road , Pittsburg , CA *r*��rm**#*w#*w##•r#��******►#*t#�wrt********•#�****b********at*rt*w�**art#� Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICE TO: (AnoMe ) or by some person on his behalf." Name and Address of Attorney R. Nicholas Haney (Claimant'sigtnature Attorney at Law 227 Broad ay Street 82 Medanos Avenue Richmond , CA 94805 (Address) I � 11A Bay Point , ra g_aC;C, 6 Telephone No.23 7-1624(510 ) Telephone No` ( 9 2 5 ) 458-1332 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 Ar same if genuine,any false or fraudulent claim, bili,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." elmform R. NICHOLAS HANEY Attorney at Law 227 Broadway Y Richmond,California 94804 � � 7 2��� (510) 237-1624 Fax (510) 237-7267 ORS September 11, 2001 Clerk of the Board of Supervisors County Administration Building 651 Pine Street, Room 106 Martinez,CA 94553 Re: My Client: Maxine Ballard DOL: March 12,2001 Location: 82 Medonas Avenue, Bay Point, Ca Dear Sir/Madam: Please be advised that this office has been retained to represent Ms. Maxine Ballard in regards to a slip and fall she sustained on March 12,2001. We have previously filed a claim with your office and hereby enclose the medical records, reports and billings in the amount of$747.92. Please also be advised that Ms. Ballard will have ongoing medical expenses due to said slip and fall and as soon as we have accumulated all the medical expenses and records, we will forward them to your attention for review. Also enclosed please find photos of Ms.Ballard on the day of the slip and fall as well as photos showing the uneven condition of the sidewalk outside Ms. Ballard's residence,causing dangerous conditions. I look forward to hearing from your office in the very near future. Sincerely, R. NICHOLAS HANEY (Clara ta: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY �---- INSTRUCTIONS T()CLAIMANT S EP � 7 10U 1A_ Claims relating to causes of action for death or for injury to person or to personal CLERK OARD OF SUPERVISORS property or growing crops and which accrue on or before December 31, 1997,m CONTRA COSTA CO. be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death'or for injury to person or io personal property or growing crops and which accrue on oii after January 1, 1998,must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action trust 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 naive 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. Eaud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. t�iktir,Lek#IrIrf1Y#tlrAtltk*#*1r�t�rtMikJ:ItMitt#tk*t*#11#ik##*�##t,Yk#*,kttttA#tf## t*# Claim By ) Reserved for Clerk's filing stamp Maxine Ballard RECEIVED Against the County of Contra Costa or SEP 1.12001 The Housing Authority of Contra Costa (District) CLERK BOARD OF SUPERVISORS (Fill in name) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of S 3 n 0 nand in support of this claim represents as follows: 1. Ni'hen did the damage or injury occur? (Give exact date and hour) March 12 , 2001 at 11 : 30 a .m. 2. Where did the damage or injury occur. (Inc hide city and county) 82 Medanos Ave . , Bay, Point , Contra Costa County , 'California _ 3. How did the damage or injury occur? (Give full details;use extra paper if required) Claimant tripped and fell on broken or uneven sidewalk causing . injuries . 4. What particular.act or omission on tha pert of county or district officers,servants or employees caused the injury or damage? Allowed a dangerous. condition to exist which forceably clmform could cause someone to trip and fall . 08 13.x@1 12:49 H.A.G.C.C. j 25102377267 S. What am the names of county or district officers, servants or employees causing the damage or irtjury7 Unknown . 6. What damage or injuries do you claim resulted? (Give fill extent of injuries or , damages claimed.' Attached two estimates for auto damage.) Claimant lost two teeth , required stitches to wound in mouth, sustained left foot . in"jury, right arm and shoulder injury. 7. Now.was the atnuunt claimed above computed? (Include theestimated amount of any, prospective injury or damage.) $10,000 Riedical bills ,' $20,000 pain and .suffering , 8. Names and addresses of witnesses,doctors and hospitals. 1 . I z e t t a .Parks 81 . M e d a n o s Avenue, Bay. :Po,int ,.. CA 94565 ; ( 925) .709-1672 _ 2 . Diona Stewart 76 Yancho Vista Drive , Oroville , CA. ; ( 530 )_ 533-1125 9. List the expenditures you wade on account of this accident or injury: 3/12/01, to . CCC Dental present and .2147 Loveridge ongoing . Road , Pittsburg , CA Gov. Code Sec.910.2 provides; "The claim must.be signed by the claimant SEND NOTICE TO (Attorne ) or by some person on his behalf. Name and Address of Attorney R. Nicholas HaneyClaimant's Signature Attorney at Law 227, Broadv4ay Street 82 Medanos" Avenue Richmond, CA " 94805 (Address) . UAI 3 B Telephone No.2' 7 16 2 4 t 510) .Telephone Nd,, (9 2 5 ). 458-1332 ' 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 sante if genuine,any false or fraudulent chlim, bili,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 ofnot exceeding one ahousa,-td($1,000),or by both such unprisonment find fine,or by,imprisonment in the state prison,by a fide of not exceeding ten thousand dollars($14,000)or by both such imprisonment aind fine." &moan REQ IVED CostaCon SEP 17 2001 tra AEessionai C0rp0fad0n CLERK BOARD OF SUPERMSOR CONTRA CU fA CO. DATA' TO: rt . 'S! FARC FR i kmi°lam tin d S 1�C_ ca%l : ti Y PAS $` {SNCL�SS COVSRSNEh"�) OF raw tax(9�)jj52,400$ foftsta 432r2444 .._--- e Road fittsbufg.Ca b sow t-a-as 147 {pveffd9 y w b i ar�a'dnz'aZ!_ A Hemid Rezapaur, D.D.,S.: . ,(925) 432=2444 Account history as of.Sep 10,2401 Maxine Ballard 82 Medan6s Avenue, Bay Point, CA 94565. Date Description ..For Debits .Credits Balance'.. Mar , 2, 2021 Bitewings-Two Films .: Maxine 10.00 10 .00 Mar 2;2c0z Intraoral-Addt"-]. Filth Maxine 3.00 13 :00 Mar`. . 2;200.1 Intraoxal -.Addt' l Film Maxine 3 :0Q Mar .2, 2041 Intraoral-Addt' l Film Maxine 3 .00 19.00 Mar 2',20.01 Recement Crown Maxine 30 -'00 49 .00'. Mar 612001+ Predetermination Sent. Maxine 49.00 " Mar- :- 6, 2001 Insurance Billed Maxine : 49 .00 Mar 6, 2001 Insurance Billed Maxine 49.00% Mar. 12, 2001 intraoral-First. Film Maxine , 10 .00 s9.00 Mal.- 12; 2001. Offi .insurance �.. PATIET INS CODE:;. 800 900 400.. 300. 200 i00.. PHONE DATE OF BIRTH. IJ LSA E TOOTH . EATMFsNT ; RECALL I . —CARD- c., � _I . (61 � . . A. 10 rn I , 04 i i ,1��L�=G.f�►/. 4" sr s✓moi 4- Q0 'd v w 1 6 ano.dIDza8 PIwnH .ZT : b.T NOW T0-0T—d3S Insurance: . PA TIENT 3iE11✓E - INS CO s 2800 00 - A00 300 20G i GG U PHONE DATE ci BIRTH. ATE � LTOOTH TREATMENT RECALL I.. .: CARD 49, �y` J -` • fen Q - DT (bw pl-I i vA 44 , ol �cl ,. . . {rbc•}C ';!g' ic: llc _1'r1� /�!� xJ�1 o TIr j i 1 X. o p K i . � I b tI Anodnzoa pIWnH . 1.7 t , NQW i0-0T-d3S pATIE V., �TAP1E PdS GODS: 1800 900 400 300 2,0-3 .100 PHONE DATE nF BIRn . I 33 LATEI ^coax TPEArrPECALL dE � FIT dw i I+ j { '1'irlNA l Ug�, �(1) Tt� ry�-f�'.�rA� 5711�"Are IT . j r ,. iI .�4'' •`� f;i.�;,11t`h: �. "•{� L� 'I.f7'r 4/`�j �'��'n r'� ,��• •• ��: "�i " i { i I I l 40 ,.d - jnodvzaN. plu"oH 9T : bT NOW . T@-GT-das Patient's Name: Date;IIJ117 r Chief Complaint{a); Patlent's medical history and chart reviewed: 0 Healthy Flew x-rays taken: a Panorex: '0 Perlapicals upper 0 Periapicals lower Diagnosis: C Carious of Abscessed toottyteeth# 0 Impacted#f .0 Fracturesi toothAteeth# 0 Perlcoronitis it . 0 Periodontally involved toothfteeth Other; EzustosesiToti; .: d sipper _ 0 Lower Treatment Options Explained: 0 Partial Dentures 0 Crown/Bridgetlmplant,; Other: 0 Periodontal Therapy 0 Endodontle Therapy -0 No treatment Risk s"of Surgery Explatned: 0 Temporary.or Permanent lingual Nerve or Inferior Alveolar Nerve injury 0 Infection,Bleeding.or Injury to adjacent teeth or structures .0 Sinus:Opening' Anaesthesia 411'IV sedation C'see anesthesia record); 1.1docaine . 03%c arbocaln.e Nitrous-Oxide tl Valium i0m S . Mth 4:100K kpl: / VAthout Epi. Treatments CSI; P131 STs ;Surt{lcai . Routin4 0.Tooth/teeth fractured•,flap required 0 Required flap and bogie removal . 0 Required flap and sectioning 0 Hernostasts verifieit;written post-op instructions reviewed. Prescriptions: 0 Ren.VK 660 mg x26, :- O Darvocat N100 x30. C Clindamycin I50mg x28 . :13 Vicodin x34 ,'0 Tylenol 03 x30 Q Erythrotnycln 500mg:X28 : . . 0 Motrin 600tmg x30 Other Follow-up rail:. late: :. . (raj .Sweifin9 not goings dowrn M [ I`t�tite+r prolaiern:: :. Narng: mIN] Prolonged nurttGnestt UQ Pain not resotvltfg If a yet,them a follow up appL was made for(Date and.Time): any of!fw resgons�as era . Z£ "0TC. anadDZO6 p 1 W-0H ST : b.T , NOW T O-O T-d3S MARC DOYLE,D.U.S.,M.D:. CONSENT FOR ORAL SURGERY patient PLEASE INITIAL EACH.PARAGRAPH AFTER READING. IF-YOU HAVE ANY QUESTIONS, ?LEASE ASK YOUR DOCTOR 9 _VQJ3F.INITIALING..., You have the right to be informed about your condition and the recommended treatment plali to.be used so that.you may,make an informed decision as to whether.or not to undergo the procedure after knowing the risks and hazards involved...This disclosure is not meant to alarm you, but is rather an effort to property inform you so that you,may glve:or w1hhold your consent. �41 My condition.has.been explained to me as: 2..� The procedure(s) necessary to treat m ve been explained to me and.l understand:the nature of the treatment to be_ 3. ! v een ormed .of. ssib of a ve methods of treatment . if any, including .... . e nd that these other.forms of treatment, or no treatment at all, re choices that I and the risks f those choices have been presented to'me. 4. ..1 understand that there are certain in Brent and potential risks and side effects associated with imp Proposed treatment and.in this specific instance they include, but are not limited to: A. Poato erative discomfort and swelling that may re uire.several days of at-home recu eration. p 9 Y q Y p V B. 'Prolonged or heavy bleeding that may require additional treatment. �:�C: Injury to adjacent teeth and fillings. �✓ D. Postoperative infection that may.require additional treatment. . WFStretching of the comers of the mouth that may cause cracking and bruising and may heal slowly. . Restricted mouth opening during healing; sometimes related to swelling and muscle soreness. and sometimes related to.stress ort the jaw joints(TMJ),especially wften.TMJ problems already exist. 9..O. A.docision to icaYc.o 3ma.1 picot of toot in the jgnr when its removal would re> uiru dAteiisiue su:ylriy 4� or risk other complications. lrv► i-i.. Fracture of the jaw(usually only in mate complicated.extractions or surgery). Injury toJhe nerve underlying lower teeth, resulting in:pain, numbness, tingling or.other sensory disturbances in the chin,.lip, &.eek, gums or.tongue and. which may persist for severs! weeks. months,or in rare instances;permanent{y. h_-1 J. Opening of,the sinus-.(a normal chamber situated above the upper teeth) requiring additional surgery . or treatment.: Dry socket(loss of-blood dot from extraction she)... Aft ergic reacWns.(pteviously unknown)to any medications used in treatment.. ..J..understand,that during the'course..of treatment unforeseen conditions may be.revealed that may ' require changes in the procedure or surgery performed, t authorize my doctor and staff to use . professional judgement to perform such additional procedures that are necessary and desirable to c mple�te my-surgery: ' `T anesthalt�I have chosen for my surgery is: �l iota: IV sedatbNgeneral `nitrous oxide(gas) ,,,:Va!iumMa:cion -- 8402 Z£b 4TH , ano�ozaa P1W-0H 6T = *,T NOW T0-OT-J3S ( 7) ANE3THE11C RISKSinclude..discomfort, sAe1nq, bruising, Infection,.prolonged rfvmbness and allergic reactions.There may be inflammation at the site of IV in)ection.wP?ich may cause prolonged discomfort and or disabilityr and may require -special care. .Nausea and vomlting, although uncommon, may be.unfortunate. side effects of IV anesthesia. Anesthesia is a serious medical procedure arid, aithdugh considered safe,.does carry with it the rare risks of.heart irregularities, heart stlacic stroke,brain.damage or even death. i fuliy understand that a perfect result isnot or cannot be guaranteed. ► certify ihat t speak, read, and write English Arid have read anti Cutty understand this consent.for surgery, have had my questions answered, and that all blanks were filled in prior to my initials and signature. ASK:1'GtUR DOCTOR IF YOU HAVE ANY Ot3ESTiONS CONCERNING THIS CONSENT'FORM. Patient's or"at guardian's:signature Date 1`;ftness'signature Date Marc DoySe, D.D.S.;M.D.:Date S@ `d � .' anadozetl PIwn.H 6T1: *.T NOW . 10-02-43S. HAWD REZAPOU X DrL .7.,NL�rL• CONTRA COSTA DENTALJFRURVA►LE DENTAL p �1 PAUI7<:NT NAME CHART r O. .j Z`` t. a. AItB.tiT.RATloti1 - Arb'itration is the ftsiat prpcess for the resolutiori.of any dispute or controversy between a patient,or a personal represcantative of tk�e.+agent,as the case may be;and Contra.Costa De:ltaITruitvale Dental concerning the quality of patient services provided to the patient under iitis agreement for any_dispute or controversy concerning the construction,interprttatian,gerformtutce or broach of this agreement..By entering into this agreement;the.patient agrees that such disputes shall be submitted to binding nrbivat.ion under:the :"appropriate"rules of the American Arbitration Association(AAA)• 1. Patient'understands and agrees that any and.all disputes batwecn patitnt and Contra Costa Dentalll'ruimle Dental or its Pro shall be resolved by submission to binding arbitration conducted by the American Arbitration Association"(AAA). S:cfi disputes or controversies include,but are not.liraitsd to,complaints concerning"the.quality;necessityor outcome of services provided pursuant to this Informed Can;cnt Form,as well as_ihe construction,interpretation,performance or breach of the terns of this info ued. Conseut.i arm.Patient further recognizes that by consenting to binding arbitration,patient is giving up the right to have sueb disputes decided n a court of law and/or before:a jury." It. .A declaration of a court or other tribunal"of contpetent,jurixdiction that any portionof this agreement to arbitrate is void or. tinerforccable.shall not reader any other provision hereof Yoid or unenforceable_ b.XPUTIATION OF ARBITRATION ArbiEra rion can be initiated by filing a dtmand for arbitration with the,AAA,located at 225 Bush Street,18th Floor,Saa Francisco, CA 941t!4-4207,telephone number{413)98I-3901.A demand form bray tie obtained from the AAA.: In all arbitration matters submitted to the AAA,the party initiating demand for the arbitration shail advance alt administrative fens . connected the If the,pitient prevails in arbitration,the patient may,bs entitled to reimbursement of costs including reasonable attorney's fees incurred in cnnnectior w[th the arbitration proceedings.Any such 4ward of costs shall be made at.the discretion of the . arbitrator. .. d:.LOCATION" arbitxaticut proceedings s.hall occur in the county where the patient's treatment was performed.unless all parties to the arbitration otherwise mutually agree in.writing. e FORM OF DECISTW The parties aime that thc.atbitraiors shall.issue a written opinion. The,a*ard,of the arbitrators shall be binding.and tray be . enforced 4:►.any court having jurisdiction.thereof by filing a petition.of.enforcement of said award. The arbitrators award shall be accompanied by a afiitten decision explaining the facts and.reasons upon which the award is based,including the findings of fact and conclusions of lave trade and reachr:d by the arbitratai. . 2. WORK TO BE DONE. I understandthat the following treatments may be performed on nit as part of my dental treatments: Fillings,Bridges,Crowns; Fxtractions,,Impacted Teeth RemovriL Roca"Canals, Dentures,Partial Dente.res,Periodontai.Treatments'and possible other dental treatments, 3,. JFIIXINGS Flllingt are proced+res in which the dentist removes decayed tooth structule'o r a,faulty restoration and replaces it with Composite a[Siler Amalgam fitlings..l understand that these proeedurea could cause the teeth to bc'stnsitive to hot and Gold as well as chewing. The majority of the time,these sensitivities are temporary and they will ga away within one(1)or.two(2)'weeks.However,there area. tunes that due to the depth afth,e fitting in the tooth,the pulp or the nerve of the tooth becomes irreversibly sensitive.In these cases,tate tooth will need to be treated for root canal therapy and might possibly require a post and a crown to be fully restored,l understand that-, the dentist cannot guarantee that the teeth receiving fillings will not need to receive the above mentioned additional procedures acid that . l"will"be'responsible for pay mtnts.for.any additional treatments needed to restore the.teeth,_if the initial filling procedure does not correct the problem: 4.. I.?RVGS AND MIEDICATIONS t understandtnatantibiottes;analgesics and other medie•atioits,can causealtergic reactions causing redness and swellingof tissues, p=,vo )ting an_d'or sn'aphalactic shock(sever allergic reaction). . S CHAINGES 114 TREATMENT PLAN' I understand that during treatment it maybe ntceasary to change procedures because of conditions found whiie working on the . teeth that were not discovered during examination.I give my permission to the Dentist to make those changes as necessary, 5. REMOVAL OF TEETH:". . Alternatives,to removal have been explained to me#oot canal therapy,crowns and poriodontal surgery;etc,)and I authorize the. Dentist to rern6ve the teeth outlined.in the treatment plan and any others necessary under paragraph#5.I understand removing teeth anodo�aJ ri f WoH. 0Z: bt NOW Te-GT-d3S .b - does not always remove All the;infecdon,if present,and it may be necessary to have Further amtment.I ttnderstarzd the risk Involved in - having teeth removed,some of which are pain,swelling;-spread of infectio%dry socket,loss of fisting In my teeth,lips,tongue and stJrrourding tissue(Parasthesia)that esti last fbr an Indefinite period oftlmo(days or months)or fractured jaw.l understand I may need further treatment by ttapccialist or even hospitalization if complications arise during or following treatment. . 7. ANESTI•IESIA JFgaUe thCrisks iuNglved.inteceiving a local anesthetic;some.of which nre:partial facial.ptuelysis,inflamed tissue, aJvtas. reactions.todnigs causing cardiac arrest,miscarrie�c;hemorrhage;nerve damage aad%or numbness. 8. ICROWNS,BRIDORSA"4'APS.. .;:ir tj understand that sometimes.it is not possible to match ttie color of natural teeth exactly with artificial teeth_1.further understand . that I may be wearing temporary crowns,which may come off easily and that I tnust7se careful to ensure that'thcyitrre kept on until the Permanent.crowns are delivered,and that if i don't have the pemianent.etown(s)placed permanent serious.damage,or lnss of the tooth/ teeth.involved may ensue,and that if f delay placetn�nt I may -the teeth Involved to move so that the'peratanertt crown no longer - W}It��itpropeCly,T�, ;:' 1 :. :.:: :.rxttCzYy'rj J�"•itFl? •3rr;111�{��f1.Mj�ij.la t�{�rtllS 3L'1��' . k:•:'i .i , �:-r 1�. i�. . .. 9�sc:�RFi3VTAJRFS-C,QMI'>i l Q.ItPA14i,TIAL�r:%1�i1;.o;Y' ;xis n; �s !.Err realize that full or partial denttues are;ertiflcK-.ebnstr Oed of plastid metal and/or porcelain.Tate pro[?1Cn19 of v1'earitag.these. applisnca bmve been explained to mo i6cludh*looseness;sorelicss;and poAlble breakage;and relining due to:tlasue and bone change. lt). rENWDOKIXTRF.ATM N"—T,(RflQT.CANAL),;'04q.,jt;!P t{Lrrr41V: .,,.::. .r: t,...na ,l�sealAtheie is no guarantee that root anal tretitmeat will save my toodt,and that egroplieations can occur from thc.treatmen and,thet occasionally metal objects are cemented In the tooth or.exteW through the root which does not necessarilyeffect the success of the+treatment,and.that tI11S tdt;nC[1t,Qe4uiro111141W�. le Xis�ti,$�d that I c ►cause seriau4 de n;ge:4r loss.of the;�ooW/teeth. involved Z do not capopleto the,prc�Cli�d.tC D ' {i.+'�` ori a :bw r: r:, !f .�izq s , r L .k 41. T4} .wi.sS(TISSUE AND : I understand that 1 have a seriouq f9aditi0%f 14ju m and bone�rtftatntnation orlosa and that it trait Iced to the loss of my teeth.. TIJe,elicrpstive treatment plass irnve bi n exp arQd.to inet Jdchidarg 9WA#urgocy,replaremeats and/or exaractiflps, .:; �',;� „•, .; . `�{) >i 1"ni r1v+ �Z:- A J.,,,.; +� , t, I, . I• 0 �°' L�� V � '�� t�: I he by,rcqucst trod authotiu the.Dentists,slid cu tdfli tu.perfacm dental work upon eat forAt:01irpo3e,of.atteinpting•10 Mprovtr mY.Sppear-ar?ce,flwWba send the health of my mouth,teeth,bone and tissues,na explained above. Thi eff"t and nawe.of the proceeding to be performed,and the risks involved,as well as the possible alternative nledwtls of treatment have been fully Gxplairted to are: i also authorize the operating Dentist and Assisiants to perform any other procedure which they may dam neocssary.or desirable in attempting to improve tit condition stated on the diagnostic treatment form or treat unhealthy or unforeseen conditions that may be encountc"d during the operation I lmow that the practice o£Dentistryturd surgeryjs not tin exact science and that therefore reputable practitioners cannot properly guaraaceo.results.I admowledge.that no guamnteo or assurance hes boon made by anyone regarding the treatment which I have herein requested and authorized. Altcrnativcs and possible bad reactions have been explained to me io detail.Complications,such as infection,hem6rrhage and/or . bleeding,scarring,contraction,possible deformities,prolonged healing time over the estimate,reaction to any drugs before,during and after stet cry,numbness or iiching of the.tongue, lip,teeth,tissues(Parastho3ia), fractured jaw, Temporo Mandibular Joint(TMD Complications,which could cause Iocalized and systemic pain requiring f iture.treatments including joint surgery, etc., have been cl%arly explained to me. I CERTIFY TTiAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT.TO DENTAL TREATMENT AND THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE,ANY'T'HING I.DID NOT UNDERSTAND HAS BEEN EXPLAINED TO ME, ss NOTICE:BY SIGNING THIS.CONTRACT YOU.ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL OR DENTAL MALPRACTICE DECIIlVD BY NEUTRAL BINDING ARBITRATION AND YOU ARE GIVING OF YOUR RIGHT TO A JURY OR COURT-TRIAL SEE ARTICLE.]OF TIM CONTRACT. 4. Sigrsetirrc ., - ., ,;�r �r <<� - ., c: :,�.:!,._ Date••.�ft,!!! ;U,r,r; r.r, r - - r �• 'd t ti i t.Y. '!.i �. :Patient Or Tragal Itopresentative, . WrtrlG�f :i•ar+-r �•,:•!•' -�-.`r-';•-:'i•• .. ,.,_j. ._-. _..._..__ .'. '-I)ate7 •.u, _.__. W .._ - Doctor: . ,�. ' T Date:• 8807_ Z£t- 07Q . .InoaiaZab P,I W H IZ: itI NOW TO-OT-d3S . R- ar CONTRA-COSTA DENTAL/FRUITVALE.DENTAL y� r A.PROFESSIONAL CORPORATION . YOUR NAME {'�;•:�-'cb DATE - • r---.7.r._.��.T_ HOW GID YOU FIND OUT.ABOUT OUR OFFICE?PLEASE CHECK ONE: 1 FRIEND OR FAMILY 4.0.. BILLBOARDS OR BUS BENCHES. 7.❑ TV COMMERCIALS 2.O"YELLOW PAGES6.0 BUILDING SIGN.. 8. OTHER 3..O RECEIVED AN ADVERTISING 6.0 : ME01-CAL REFERRAL. P.Q . REFERRED BY - POST CARD/FLYER PATIENT'S NAMEr !V G 6��R t`cA f`d FIRST INITIAL.. LA8T PATIENTS ADDRESS -ex 4 � m 6-9 d At 2 4Ad t PA-4-m� 0 c CITY . SOC.SEC. NC '�lz`!advV 3 HOME PHONE NO. „S/c G_ STATE z,F . (�). BUSINESS PHONE N ❑M.ALETE AGE -�_q MINOR. IF PATIENT ISA MINOR: GIVE FEM�L VIAMIED�- Cl YES' NO. BIRTHDAPARENT'S OR GUARDIAN'S NAME. _ __ '� RELATIONSHIP DRIVER'S LICENSE t�0:�-�;�7LQ r EMPLOYED 9Y OCCUPATION EMPLOYER'S ADDRESS STR ET' CITY STATE ZIP. SPOUSE'S NAME: _ DRIVER'S LIC.NO: SOC.SEC.NO. SPOUSE'S EMPLOYER.:: 'Y - OCCUPATION BUSINESS PHONE NO.(_ SPOUSE'S EMPLOYER'S ADDRESS ST ET CITY STATE 14NME.OF NEAREST RELATIVE NOT LIVING WITH YOU BL4T10NSHt � � � j_ ? RFLATIVE'S ADDRESS HOME PHONE NO, g'R _CffY 87ATE Zip PAI IENTI PHYSICIAN ' �i- f�Y�t n�.� �, BUSINESS PHONE NO.e; J PHYSICIAN'S'ADDRESS&L 14 ciri"7. STATE . ZIP PATIENT'S FORMER DENTIST kz. BUSINESS PHONE N0.( ; FORMER DENTIST'$ADDRESS STREET CITY STA?E Zip DENTAL HISTORY 1. HAVE YOU EVER HAD A LOCAL ANESTHETIC(NOVOCAIN,ETC.)? ...... . .. .. YES Q NO 2. HAVEYOU R ANY UNFAVORABLE ? U EVE .HAD REACTION.FROM.A LOCAL ANESTHETIC?: .::.. . 0 YE�O . .:.3: HAVF YOU HAD ANY SERIOUS TROUBLE ASSOCIATED WITH PREVIOUS DENTAL TREATMENT?.. .... . . .......... ❑YE�plO IF.SO,PLEASE EXPLAIN 4. HOW L04G SINCE YOUR LAST FULL MOUTH X-RAYS? 5. HOW LONG SINCE YOUR LAST DENTAL TREATMENT? 6.:DOFS DENTAL TREATMENT MAKE YOU NERVOUS?... Q SLIGHTLY p MODERATELY EXTREMELY ❑NO CONSENT FOR TREATMENT. THE HEALTH HISTORY I HAVE WRITTEN ON THE FRONT AND BACK OF THIS FORM IS COWLIETE AND CORRECT TO THE BEST OF NY KNOWL- EDOE.I AUTHORIZE AND GIVE CONSENT TO PERFORM DENTAL SERVICES AGREED BETWEEN DOCTOR AND PATIENT ANDM GUARDIAN TO' BE NECESSARY OR ADVISABLE, INCLUDING THE USE OF LOCAL ANESTHESIA AND OTHER MEDICATIONS AS INDICATED. I AGREE THAT, REGARDLESS OF INSURANCE COVERAGS,I AIM RE3PONSIBLS FOR PAYMENT FOR BERVICES RENDERED AND THAT A FINANCE.CHARGE OF Z%{ONE AND ONE RAL;;PERCENT).WILL.K APPLIED TO ACCOUNTS OVER SIXTY DAYS PART DVI. 41GNATUAf OF pAT1ENT,.P ENT QR OLIRROWV. . . Z£b.OTQ ano-drZON PIWOH ZZ: bI NOW TO-OT-d3S .. , MEDICAL HISTORY THESE QUESTIONS ARE FOR YOUR BENEFIT AND ASSURE THAT TREATMENT WILL TAKE INTO C0143I0ERATION YOUR PAST AND PRESEUT HEALTH sTATUS.SOME QUESTIONS MAY SEEN UNRELATED-TO YOUR DENTAL CONDITION,BUT THEY ARE ALL ASSOCIATED WITH PROPER 'ORAL HEALTH CARE.PLEASE ANSWER EACH QUESTION. 1. ARE YOU IN GOOD HEALTH?.. 0 YES G NO 2, DATE OF LAST PHYSICAL EXAMINATION 3. ARE YOU UNDER THE CARE OF A PHYSICIAN? IF SO,WHAT is THE CONCNTION SEING.TRFATED?' T`+ 4. HAVE YOU EVER HAD ANY SERIOUS.ILLNESS OR OPERATION?. O YES IF SO,WHAT ILLNESS OR OPERATION? 5. HAVE YOU£VEP BEEF HOSPITALIZED?. ..:. 0 YES IF$0.WHAT WAS THE PROBLEM? �.. ARS YOU TAKWO ANY DRUGS OR MEDICINE?,, .. R YB�0. IF$0,WHAT?. WHAT DOSAGE? 7. ARE YOU SENSITIVE OR ALLERG TO ANY DRUGS?...:. YES 0 NO WYE$,WHICH DRUGS? 9 PENICILLIN. 0 7ETRAPYCLINE Q SULFA DRUGS D ASPIRIN CODEINE p OTHER.I ER.WHAT 0RUG 3? . 8: DO YCiU OR HAVE YO NAD,ANY-OF THE FOLLOWINM(PI EASE CHECK KNOWN CONO,'TIONS): O ANEMIA O BRUISE EASILY. Q CEREBRAL PALSY: 0 EPILEPSY OR SEIZURES , 0 HERPES a HERO INJURIES ©BLOOD TRANSFUSION :.. Q ARTIFICIAL PROSTHEMS D 6 TROKE O HEART FAILURE 0 JOINT REPLACEMENT`_ 0 PSYCHIATRIC TREATMENT ` i7 ULCERS D WAR DISEASE. . . : 0 NERVOUS DISORDERS:' 11 CONGENITAL HEART LESIONS . • DIABETES R SCARLET FEVER .' : 0 TUMORS OR GROWTHS Q DIFFICULTY IN SWALLOWIN4 1l! D GLAUCOMA 13 CHICKEN PDX Q ALLERGIES OR HNES 0 HEART AILMENTS OR ATTACK O ARTHRITIS O SINUS TROUBLE. O EXCESSIVE BLEEDING. . : EI X-RAY OR COBALT TREATMENT O EMPHYSEMA Q BLOOD DISEASE 0 ASTHMA 93 FAINTING SPELL$OR SEIZURES 13 HAY FEVER J DRUG ADDICTION. Q HIGH BLOOD PRESSURE O CHEMOTHERAPY(CANER,LEUKEMIA) 0 TONSILLITIS 0 KIDNEY DISEASE ' . O AIDS RELATED COMPLEX Q RADIATION TREATMENT OF ANY KiN0 Q COLA SORES. ..:. G ANGINA PECTORIS 0 PAIN IN,SAW JOINTS O HEPATITIS OR JAUNDICE. 0 HEMIOPHILI Q MENTAL DISORDER ID RESPIRATORY DISEASE [3 VENEREAL DISEASE.(SYPHIUS;GONORRHEA) a RHEUMATISM .. 0 RIiEUMaTIC FEVER 0 SICKLE CELL DISFAft CI ACQUIRED IMMUNE DEFICIENCY SYNDROME(AIDS) O HEART MURMUR Q THYROID DISEASE .. D TUBERCULOSIS(TO) []OTHER 9. DO YOU WEAR A CARDIAC PACEMAKER,OR HAVE YOU HAD HEART SURGERY?... .....:;..........:........❑YES NO 1C. Do YOU a JIVE ANY OIWFASE;CONDITION OR PROBLEM T USTED rMT YOU• INK I SHOULD KN ?, DYE ' NO IF SO.V%fHAT? t 1; (iM1rCAt�MARE YOU PREGNANT?....iO YES. NO..IF SO, MONTHS?. 12. {1VOi1tAN)DO YOU NAVE ANY PROCLEMS ASSOCIATED WITH YOUR MENSTRUAL PERIOD?.................... Q YENO 13. ,Wo"00 YOU TAKE BIRTH CONTROL P11167. .. ..... . ....... ,., 0 Y NO TO THE I? 3T Of MY KNOWLEDGE,ALL OF THE PRECE094C ANSWERS ARS TRUE ANIS CORRECT,IF.I EVER HAVE ANY CHANGE IN MY H LTH OR IF MY MEDICATIONS CHANGE,I WILL,WITHOUT FAIL.INFORM THE DOCTOR AT MYNEXT APPOINT.KNT,; LATE: ^" SIG1!!1NltE THIS SPACE FOR ORfiCH USE ONLY •, YEAR 1 YEAR 2 YEAR S YEAR 2: OATS v up IN TN. DATEi + 81: 6IGtlA7tfAE' ,,.�:. YEAR 3: PUL airwraleiiw I+�ALrN; ER AMP GATE:_.,_.,.-..--•.. .a+GNATima; FItACTht CWSTIONNAIRE MUST BE UPDATED EACH YFM V. Y FINANCIAL INFORMATION. i. DO YOU HAVE DENTAL lNSUItANL'E? :. ..... ....•...... .•.0 YE$O tit} NAME'QF INSURANCE COMPANY 'r ' ADORE$$OF INSURANCE COMPANY POLICY NO LOCAL NO. BIRTH DATE NAME OF INSURED`' INSURED'S SDC.SEC.NO. 2, DO YOU HAVE DENTAL INSURANCE?".. ......... ..::.. ....,-ID YES O NIO AIV NE o INSUFIANOE COMPANY ADDRESS OP ieN6URANCE COMPANY POLICY NO LOCAL NO*. BIRTH DATE. NAME OF IrLSUREL �' - INSURED'$SOC.SIO.Tip. '.zsz1' 0iZ jnoanzaZg Fy :WrH: ^:Z=.b.T. N0W T0-O.T-d3S s- . .. �: � "..:��. .. y-f a..F f9;c �•.: - �� £s:�p' � r•,.y ;:yi,9?� `,`:fir' '_�i `.y" sk .. .... ��:}� ::k..y C .. :7i a � :.. ,t Y N i%L e _ r � .i�� 11 !� �� � �i ., .y .,. �> ;':'� .. '..s.'�.�.. Qac ' .. ;� }t. -`—" � .::. .. .,�:: � '.' :> :..r.�,i ,..:. k � _ ' :�q�'� 'ftp rt�i.. .:S�i' .Fs: _.y�. :e.F.:.�. i f,. : .'.ice/ 3 ;�: .�±,.•• r '.� � o ,:j. �� � %.... ������b ,'.?s�C�r E:..�.' ��....�.:__\tyV ,may` r o_. s '� �yYJ \ �'�.,r .\ � • \ � � /i r��S _ '1��. \ � � \\` � �� r. -r _ '; {{.. -�}� ��`a!�:s -.. sqµ ..:,� ... .y �,:a: ���' }figs:.• i _ZCd' � .ti•trot. � _ t ID �. o IN- a...�. ,l t � •l.�t 1 y`�,2,�. �Y hi . .ISE. �•.'. `\ly .7.. 1. ' �\\\L `i�� � ;,Yet.. ..l'T:r;•;f i AST•{ � �� �.1,,r ':e: s .: ..�r-• 'ate. •o:. -�` �a iisW;. 4,t _tea' �3. t 4 ,�,�r���t r 17 � •�� le cam: r �',,�;.-'��./.n,�t �' may} �� '�� ►��t�;`?���^ ..SL.,yfrr.• y:ti• C r t �r r c.\ ON 14 Iv too All � Sr k. 4 �• , t +! F- { i Ar CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Sept 25, 2001 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 document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and GI-_--II�_VX_ vA)5.4. Please note all "Warnings". AMOUNT: $1,000,000 SEP 13 2001 COUNTY COUNSEL CLAIMANT: Sean Shields MARTINEZ CALIF ATTORNEY: NONE DATE RECEIVED: September 10, 2001 ` ADDRESS: 1330 Broadway# 833 BY DELIVERY TO CLERK ON: September 10, 2001 Oakland, CA 94612 BY MAIL POSTMARKED: September 7, 2001 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE Dated: September 12, 2001 By: Deputy I II. FROM: County Counsel TO: Clerk of the Board of Supervisors (V 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: By: SDeputy County Counsel III. FROM: Clerk of the Board TO: County 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: 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: C9.• JOHN SWEETEN, CLERK, By , Deputy Clerk WARNING (Gov. code s i n 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 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 clai ant as shown above. 1 i Dated: C JOHN SWEETEN, CLERK By Deputy Clerk 1 This warning does not apply to claims which are not subject to the California Tort. Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. Clalihi to: r 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 100`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 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 .5P G 11olds RECEIVED (11 L,1,f 0 f SEP 10 2001 Against the County of Contra Costa or ) CLERK BOARD OF SUPERVISORS District) CONTRA CTA CO. (Fill in name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$1.000 o oy and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) re c, c,roL4od S-/- o( arid . i it s �;(1 �ob�!� o � G� 44)t 2. Where did the damage or injury occur? (Include city and county) of r+I,n Z )-2 -1 3. How did the damage or injury occur? (Give full details; use extra paper if required) � cw, c CJ oa" 1 1 / J ! kA, wk1r(�h GC. )iL.T kr0PeU,n d15&e LAO, .� 5��. w�(I n� Gl�o�. Y"49 yes Scnc S'te�i� al�c� Blr,�k Ocau�'y Or �..�FS�,Z,nc1 1'�.a / G(<�,'�� a{Lj y 0 Lo�or St,t.c.�+ 01J L�,f « O N jtc ^ . Sorg o� M.t/ � . e ... �t+�-" 111;st of Si h. TW 1J CCAttJ(-1 ►^� e ✓eti dt�l a S �cSJ a � a( rn-C ak%,l N/.l 4. What particular act or omission on the part of county or district officers, servants, or employees caused�he r; injuryor damage? Lost r Jv/,�So_r S +,?(t 1,i r✓1Oiq ri 2 Nt by 5. What are the names of county or district officers, servants, or employees causing the damage or injury? Ltiv, Vloh o , c . Th f- x,07 10 . wma 6. What damage or injuries do you claim resulted? (Give full extent off injuries or damages claimed. Attach two estimates for auto damage.) S tr t JJ , I, aN.19LA, -r n , a d lo-it0 f -Fti^ - SPCV�t C2V1 MC, oivid 5�;�►�;�� K� �c�l r�� . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) R,,71, atr . 8. Names and addresses of witnesses, doctors, and hospitals. 9. List the expenditures you made on account of this accident or injury. pDATE TDVM- AMOUNT ****************************************************************************************** ) 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 ) AtA o��c y s t CJs ) 1330 P r-,2c d t-,,-,Y ti,'l �33 ) (Claimant's Signature) 901 C4 4LI 's (Address) A) oc2 �Ck 9y5-5 3 Telephone No. )Telephone No. M NOTICE Section 72 of the Penal Code provides: Every person who,with intent to defraud,presents for allowance or the payment to any stats 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(S10,000),or by both such imprisonment and fine. PAPER WINGS Ltd. Affiliate of KOMAR Publishing Co. August 6, 2001 Dear Mr. Shields: The 7 magazines that your institution returned without comment contained no stickers. A copy of the front panel of your priority mail package is enclosed. We can inform you that all of these magazines conform to the present California code as defined in the Miller vs. California Supreme Court Case. It will be up to you to exercise whatever legal means are at your disposal to protect your first amendment rights. We will await your further advice in the event you want a refund. Kind regards, Paper Wings Q T� PAPER WINGS , Ltd. ACA Serving the Institutionalized Population ` MEMBER Ac.�..d�n�a w.wn..wwn ewv^ �rwar 3300 CLIPPER MILL ROAD * P.O. BOX 4855 * BALTIMORE, MD 21211 AMERICAN FAX (410) 889-3450 EMAIL: pwings@charm.net CORRECTIONAL ASSOCIATION G "\ a C. o Fe. G m Do yv o { 10 ' C M a � � �+ N IN t •. o �^ cz �' \\ O O'-F 53 ;v t p-a.W 9.a Ulp . . , -n Q mF � , z .o b-. m . � . w SL CL CD Fb oo 2 FSI: m o } . o CA � CDLEO o m ol c CD 3 27 0 �. •- o . p...0 .-. c -m ....: o CD C Z OL 3— CD m 3. (D CD O. m Z CD O it CD'67z C ' 0 . 0 ,- N o y � s C83 CO z CD Z wCD CDy Z. o m N v O O>. c m ,. v D R,— Z o m v � ...o ^ n c O.. v 3 art, CDCD _ Aoa m x Z R nQ m -� o � CD m i 1 \ CCD Ci M o �` _ •n o - or CD cD cQ —D-I S 0 OM y � m }:.... CDl 1 ...... Fn CD CDCo CD \ m 3 CD Cl) 46 AQ A. v. r 0 � � v CD So . L :i• 3 C - ti m . , cD: Nw .v' Li - - V - , CO N r,.". .-. .., ,. ... _ -. .. .6 v �; :w •.�..•.?.'moi'":' O a• O o m J g L3 0 �o � O : Q CID m �` �� O D cu O 0 3 c,, (D y ' m 1 °4' v p w o, m , m :•- Co 9 f� r' o !':. CIDo C t ou- S e41 aoar 6Y CAf oll �? r \ u i- D v1 /�.�A V�1'2_� U�t - P 1 -e j2 P114 I Ple.cr , YOUR SECOND ISSUE 3-3 WAS MAILED OUT THE END JUNE YOU WOULD HA VE6EE1�Ifi-901VfETIYou NEED-T6-CHECK�lIYOUR - BOOK REVIEW BOARD OR MAILROOM SUPERVISOR. 1 ,I (S r wa y -=--- -. _ 0-—CQ i u Yp ✓-v_�J o�J_ r --�- -- -(apo" YL' C_c cq- �,f S_cC.O�n.d_ 6v 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 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 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 Reserved for Clerk's filing stamp r ) .5 G 0 �ti Against the County of Contra Costa or ) 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$1 oo Q 0o and in support of this claim represents as follows: L. When did the damage or injury occur? (Give exact date and hour) Z ;r, nnf 44rL of ePac_f 0[4 tti r"t bVl f 1 + b�yGn Sc� nroL4od 5-/- o( arid . ;4- � 1 S �, (� goj'A� 0 -1 CTT J'� C �►rCf�.,]` 2. Where did the damage or injury occur? (Include city and county) _ A Y +^e 2 , L �'�v l n. (l P i s Z e T-t',4-;o h �-o. I t/ Lo�`��� U-1,stq G.oL',� f��� 3. How did the damage or injury occur? (Give full details; use extra paper if required) Awe JC ,n7 J aCJ Aq ,��,.I i �Jf LgUJcern(,,�,r G��ow Cr�w11� J I�naPn�r �C✓�1r�UIc t✓�nr[�h kroPeGh disci.. _� 5H+ w�j� no+ 9 s s�� c,-� 3Jc,�.�C oJ Bir-ck 3tL or �aS�ZncJ f�.af !�< r'v� of o �-�' �.L o '11ff'' I 11 'I t C.�10 SLA c, d1J G � µsla�. . Sore 04 �� Mar,-L tJ In/n Ej, wel"c. -f 1+ �, t o o r S f ole r s: h. TlGaulr rte, r�f d c_rj are I f S+rt.JJ 0,-1 d ►nt^-� Ok'I 11AI'A �I FFA J S F FP- /Y 0,S F 0 ' r 4. What particular act or omission on the part_ of county or district officers, servants, or employees caused he injury or dams e? rL , < r✓�c,q 2 ��I 5y 5. What are the names of county or district officers, servants, or employees causing the damage or injury? Q kv)ow,k to 1-1C . i ;y w: (I vivT .r =', � 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) Srrts�, ,, fyl o,�,9U s � , aId ���f- of -Fu^c(1 SPevAt Ute. Mcl,e,'L— .1<; DIod 5�;���,�� (!c���lr �lG7 • 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) o in 9 e st i 8. Names and addresses of witnesses, doctors, and hospitals. i 9. List the expenditures you made on account of this accident or injury. f DATE TME AMOUNT 16 e ) 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 ) 13 30 j3' w ay 5 LA X33 ) (Claimant's Signature) (Address) CA 7y5"53 Telephone No. )Telephone No. M 114 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(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(S 10,000),or by both such imprisonment and fine. o Q h CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Seat 25, 2001 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 document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given �G7 Cj;.� giant to Government Code Section 913 and llu 91 A. Please note all "Warnings". AMOUNT: Unknown SFP 2001 COUN'T`(COUNSEL CLAIMANT: Argentina Davila-Luecano MARTINEZ CALIF. ATTORNEY: NONE DATE RECEIVED: September 12, 2001 ADDRESS: 4525 Steed Way BY DELIVERY TO CLERK ON: September 12, 2001 Antioch, CA 94531 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEft Dated: September 12, 2001 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. ( 4,-fhis 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: '�� By: Deputy County Counsel III. FROM: Clerk of the Board TO: County 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: ( 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 mi utes for this date. oe Dated: & HN SWEETEN, CLERK, By J► , 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. 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 ertified copy of this Board Order and Notice to Claima ddressed to the c aim nt as shown above. Dated: JOHN SWEETEN, CLERK By Deputy Clerk This warning does not apply to claims which are not subject to the CaliforniaTort .Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. r I "Office of the County Counsel Contra Costa County 651 Pine Street, 9th Floor Phone: 335-1800 Martinez, CA 94553 Fax: 646-1078 Date: August 23, 2001 To: Gina Martin, Clerk of the Board From: Silvano B. Marchesi, County Counsel <;CR By: Gregory C. Harvey, Assistant County Counsel Subj: Claim of Argentina Davila-Luevano Please treat the attached letter as a government tort claim and handle in the usual manner. Thanks. HAMEMO-STDIMEMO-FRM.WPD d CONFIDENTIAL ATTORNEY CLIENT COMMUNICATION 1 RECEIVED AUG 2 3 2001 Argentina Davila-Luevano CLERK BOARD OF SUPERVISORS 4525 Steed Way CONTRACosraco. Antioch, CA 94531-7640 925 522-0324 August 21, 2001 Andrea W. Cassidy, DCC AUG 2 3 2001 Contra Costa County Counsel COUNTY COUNSEL County Administration Building MARTINEZ,CALIF. 651 Pine Street, 9th Floor Martinez, CA 94553-1229 RE: NOTICE AND (CLAIM FOR DAMAGES) regarding the County's Breach of Settlement Agreement in resolution of EEOC charges #376 99 0172. Dear Ms. Cassidy, This letter is to inform you regarding the above referenced NOTICE AND CLAIM for the County's Breach of Settlement agreement entered into June 22, 1999. My current employer called me into a private meeting (August 21, 2001) to inquire about what had happened in my employment with the County. Specifically, my employer decided not to place me in Hercules because of concerns that had arisen stemming from my past employment there. It is apparent that County Officials have divulged confidential information to third parties in violation of my settlement agreement with the County more than two years ago. Through this letter I am requesting that the EEOC open an investigation into this matter and pursue any and all claims against the County on my belahf. Sincerely, _ +, 8enti/na Davila-Luevano CALWORKS Domestic Violence Liaison STAND Against Domestic Violence cc: Denise M. Barnard, ADR Specialist - U.S. Equal Employment Opportunity Commission- San Francisco, District Office. .SILVANO B.MARCHESI DEPUTIES: % PHILLIPS.ALTHOFF COUNTY COUNSEL 5F__-L� JANICE L.AMENTA NORA G.BARLOW -= � B.REBECCA BYRNES SHARON L. ANDERSON . /�'' i _;_�' ANDREAW.CASSIDY ASSISTANT COUNTYCOUNSELCON f.RA COSI"ACOIJNl"Y MONIKAL.COOPER GREGORY C.HARVEY 1� VICKIEL.DAWES OFFICE•OF--T-KE-C�OUNTM19C,OUNSEL MARKES.ESTIS F=_.. I. LILLIAN T.FUJII ASSISTANT COUNTY COUNSEL _ In .L•1N^T.'�JADMINISTRATIOMBUIL9NG,� JANET L.HOLMES DENNIS C.GRAVES fi5133P, IIVE>STEtEETl9tfi•FLOOOR KEVINTKERR �•��7 L .L - rte,{++L-y `L./ BERNARD L.KNAPP SENIOR FINANCIAL COUNSEL MARTINE¢Z;'CALIF-4 Ir.: -455 =1229 EDWARD V.LANE.JR. BEATRICE LIU GAYLE MUGGLI �•"�'~ MARY ANN MASON OFFICE MANAGER PAUL R.MUNIZ VALERIEJ.RANCHE PHONE (925) 335-1800 NOTICE OF----* I.CIENCY STEVEN P RETTIG DAVID F SCHMIDT FAX (925) 646-1078 AND/OR DIANA J.SILVER JACQUELINE Y.WOODS NON-ACCEPTANCE OF CLAIM PAMELAJ.ZAID TO: Argentina Davila-Luevano 4525 Steed Way Antioch, CA 94531-7640 RE: CLAIM OF: Argentina Davila-Luevano 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: [ ] 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. [XX] 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. [XX] 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. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. [ ] 7. Other: Page 1. SILVANO B. MARCHER COUNTY COUNSEL By: L_fl&2 4C a�x� Deputy 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: September ��2001,at Martinez,California. cc: Clerk of the Board of Supervisors(original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,910.8) Page 2 APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA BOARD ACTION September 25, 2001 Application to File Late Claim ) NOTICE TO APPLICANT Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and Board Action.) notice of the action taken on your application by (All Section References are to ) the Board of Supervisors (Paragraph III, below), California Government Code.) given pursuant to Government Code Sections 911.8 and 915.4. Please note the "WARNING"below. Claimant: Federico Pastori Attorney: None SEP 13 2001 COUNTY Address: P.O. Box 4000 MARTINEZ�CALIF.L Vacaville, CA 95696 Amount: $600,000 By delivery to Clerk on: _September 12.2001 Date Received: September 12, 2001 By mail,postmarked on: September 1§.2001 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted Application to File Late Claim. DATED: September 12. 2001 JOHN SWEETEN, Clerk,By: DEPUTY II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6). (ate The Board should deny this Application to File Late Claim (Section 911.6). DATED: �' ���� SILVANO B. MARCHESI, County Counsel, By: --DEPUTY 111. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted (Section 911.6). (Q This Application to File Late Claim is denied(Section 911.6). I certify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATE:JU 6L_JOHN SWEETEN,Clerk,By: DEPUTY WARNING (Gov. Code §911.8) If you wish to file a court action on this matter,you must first petition the appropriate court for an order relieving you from the provisions of Government Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the court within six (6) months from the date your application for leave to present a late claim was denied. 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. IV. FROM: Clerk of the Board TO: (1) County Counsel (2) County Administrator Attached are copies of the above Application. We notified the applicant of the Board's action on this Application by mailing a copy of this document,and a memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED: JOHN SWEETEN, Clerk, By: DEPUTY V. FROM: (1) County Counsel (2) County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel,By: County Administrator,By: 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 the Board Order and Notice of Claimant, addressed to the claimant as shown above. Dated: LV 9c By: John Sweeten,Clerk By AAU DEPUTY Office of the County Counsel Contra Costa County 651 Pine Street, 9th Floor Phone: (925) 335-1800 Martinez, CA 94553 Fax: (925) 646-1078 CONFIDENTIAL Date: September 12, 2001 To: Brett Horton, Deputy Clerk BOARD OF SUPERVISORS From: Silvano B. Marchesi, County Counsel By: Monika L. Cooper, Deputy County Counsel Re: Government Tort Claim of Federico Pastori Please treat the enclosed claim as an Application to File a Late Claim. You may call me at 335-1862 with any questions. CONFIDENTIAL ATTORNEY-CLIENT DOCUMENT FEDERICO PASTORI P 68940 2 CSP SOL 7- 112L 3 !i P . O. BOX 4000 4 �iij VACAVILLE , C ALIF . 95696-4000 li 5s j. 6j TO MONIKA L . COOPER: 1` 7 � 81; BORD OF THE SUPERVIOSRS OF CONTRA COSTA COUNTY ;c 9 '.! APPLICATION FOR PERMISSION FOR FILING LATE CLAIM . i 101; THE CLAIMANT COMES BEFORE THE OBARD WITH A MOTION TO FILE 11 11 CLAIM THAT IS SUBJECTED TO PORTIONS BEING VERIFIED IN ti 12 A LATE MANNER. THIS REQUEST .IS MADE BASED UPON EXIGENT 13 ? CIRCUMSTANCES WHICH NECESSITATE THAT THE BOARD ACT TO ii 14j� GRANT A LEAVE TO FILE. LATE CLAIM AS PROVIDED FOR IN GOVT 15 (x . CODE SECTION 910 . 920 ETSEQ. i? 16 ; FACTS ;i 17 'f WHILE AN INMATE IN THE CONTRA COSTA COUNTY DETENTION FACILITIES , i 1$ if THE PLAINTIFF REPEATEDLY REQUESTED LEGAL DOCUMENTS FOR 191: FILING LEGAL ACTION AND FILING A CLAIM. DUE TO THE FACT 2011:1 THAT THE DETENTION FACILITY DID NOT HAVE ACCESS TO A LEGAL 21 ' ii LIBRARY AND DID NOT HAVE HE REQUIRED FORMS , AND DID NOT 22 (f . GIVE OUT INFORMATION HOW A CLAIM COULD BE PRESENTED THE i 23 i PLAINTIFF WAS UNABLE TO FILE A CLAIM WITHT HE OBARD OF 24 ,' SUPERVISORS AS REQUIRED AS A PERQUISITE BEFORE LEGAL ACTION . i' 25 PLAINTIFF HAS HAD TO WAIT UNTIL HE HAS ACTUALLY ACCESSED 26 ° THE FACILITY AT SOLANO STATE PRIOSN IN ORDER TO FILE A 27 I': CLAIM . r ONE OF THE GROUNDS THAT THE PLAITNIFF SEEKS TO FIEL A 'R"i'PAPER 1.OF CALIFORNIA ' is ,AES. R-'z' GROUND ON AND CLAIM ON "`IS THE FACT THAT HE WAS DENIED i ;7FJ �I 1 1 THE OPPORTUNITY TO FILE A CLAIM BY THE SHERIFF AND THE 2 BOARD OF SUPERVISORS WHO. SHOULD HAVE KNOWN THAT THE INMATES 3 OF THE DETENTION FACILITY HAD A RIGHT TO FIEL CLAIMS WITH 4 THE BOARD OF SUPERVISORS . 5 IT IS IN THE BOARD"S. INTEREST : TO . GRANT LEAVE TO FILE THIS 6 CLAIM SINCE , IN ANY CASE , THE CLAIMS WILL BE ADDRESSED 7 BY THE COURT •DUE TO THE CLAIMS TO BE PLEAD AS GROUNDS 8 FOR RELIEF WHICH INCLUDE A VIOLATION OF THE RIGHT TO FILE 9 A CLAIM. THE SHERIFF HAD '•NO PROCEDURE FOR ALLOWING INMATES. 10 TO FILE A COUNTY CLAIM. WTIH THIS IN MIND , IT IS EVIDENT 11 THAT THE TIME OF CLAIM STARTS AT THE END OF THE CONFINEMENT 12 AND AT THE TIME RESPONSES HAVE BEEN GIVEN TO THE COMPLAINT 13 FILED WITH THE SHERIFF . . AS WE SPEAK, NO SUCH RESPONSE 14 HAS BEEN FORTHCOMING FROM THE SHERIFF OF CONTRA COSTA . 15 THIS CLAIMANT DOES NOT , IN LEGAL FACT, NEED TO APPLY FOR 16 LEAVE TO FILE A NEW CLAIM THAT IS LATE SINCE THE CLAIM 17 IS NOT LATE, BUT, IN AN ABUNDANCE OF CAUTION , THE CLAIMANT 18 SEEKS THE PERMISSION TO FILE A LATE CLAIM THAT IS BASED 19 UPON THE EVENTS DESCRIBED IN THE CLAIM FORM. 20 NOTE : THE DISCREPRANCY AS TO THE UNSIGNED NATURE OF THE 21 FORM HAS BEEN REMEDIED SINCE THE CLAIMANT HAS ATTACHED 22 A SIGNED COPY. 23 THANK YOU, 24 25 F RICO PASTORI . . 26 27 28 OUP.-f PAPER >T A'rr Di C:AL!FoRNIA REV. (,7.721 Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY i INSTRUCTIONS TO CLAFAANI"T 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 100th 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 Reserved for Clerk's filing stamp FEDERICO PASTORI P 68940 ) ) ) Against the County of Contra Costa or ) SHEIRFF OF CONTRA COSTA 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$ 6 0 0 , o o o .and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) FROM 1 -21 ,-,-00 TU 8-01 -01 . 2. Where did the damage or injury occur? (Include city and county) CUNTItA COSTA DETENTION FACILITIES . CONTRA COSTA , CALIF. IN MARTINEZ . 3. How did the damage or injury occur? (Give full details; use extra paper if required) WHILE I WAS IN THE CUSTODY OF THE SHERIFF AT CONTRA COSTA COUNTY DETENTION FACILITES I WAS DENIED ACCESS TO LEGAL`.•LIBRARY AND I WAS DENIED ACCESS TO A CLAIM FORM AND THE FORMS WITH WHICH TO FILE A CLAIM WITH THE COUNTY SUPERIOR COURT . I REQUESTED AND WAS TOLD THAT THEY UID NO",' HAVE THE FORMS . i REQUESTED AGAIN AND WAS TOLD THE SAME THING . I WAS INJURED BY BEING UNABLE TO FILE A CLAIM AND BEING UNABLE TO SEEK REDP.ESS FROM ACTIONS THAT HARMED ME IN AN ACTUAL SENSE , SUCH AS MEDICAL MALPI;.AC`I'ICE AND DENIAL OF DUG PROCESS ON COMPLAINTS . 1 4. What particular act or omission on the pari of county or district officers, servants, or employees caused the injury or damage? I CLAIM THAT THE SHERIFF ' S POLICY TO NOT GRANT ACCESS TO LEGAL LIBRARY . IS A DENIAL OF THE SIXTH AMENDMENT RIGHT TO COUNSEL AND THE FOURTH AMENDMENT RIGHT TO DUE PROCESS AND RENDERS THE INCARCERATION TO BE §RVk-1 at are the nal�nes�df county or district officers, servants, or employees causing the damage or injury? THE SHERIFF OF CONTRA COSTA COUNTY FROM 1 -21 -99 AND ANY NEW SHERIFF WHO HAS TAKEN OFFICE SINCE THAT TIME . 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) I WAS DENIED AN OPPORTUNITY TO FILE A CLAIM AND TO SEEK REDRESS . IT DENIED ME AN OPPORTUNITY TO ASSIST IN MY DEFENSE AND TO FILE EX PARTE MOTIONS TO THE COURT AND TO FILE CIVIL ACTION SUCH AS .A IE"W%k(As the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) IT WAS CALCULATED BASED ON THE DAMAGES I HAVE BEEN SUBJECTED TO BY BEING UNABLE TO . FILE ACLAIM FOR THOSE DAMAGES . 8. Names and addresses of witnesses, doctors, and hospitals. ALL MY WITNESSES ARE IN THE DOCUMENTS THAT ARE CALLED CONTRA COSTA COUNTY DETENTION FACILITIES REQUEST FORMS . 9. List the expenditures you made on account of this accident or injury. DATE TIME AMOUNT NOT APPLICABLE TO THIS ACTION . ) 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 ) FEDERICO PASTORI P 68940 CSP 7-112-L P . O . BOX 4 0 0 0 ) (Claimant's Signature) VACAVTLLE , CALIF. 95696 ) PO BOX 4000 (Address) vacavil.l.e , :-Calif . 95696 ) Telephone No. MAIL ONLY Telephone No. MAIL ONLY 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(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($10,000),or by both such imprisonment and fine. ' SILVANO B.MARCHESI DEPUTIES: -" PHILLIPS.ALrHOFF COUNTY COUNSEL �' '' 1 �� JAIJICE L.AMEN'TA �� . NORAG. BARLOW SHARON L. ANDERSONB.REBECCA BYRNES !� ANDREAW.CASSIDY ASSISTANT COUNTY COUNSEL CONTRA COSTA.. UNTY MON IKAL.COOPER o \' VIC,KIE L.DAWES GREGORY C.HARVEY OFFIC�-OF THE--coU. r- MUNSEL MAHKE S.ESTI$ ASSISTANT COUNTY COUNSF_I. .� .1; LILLIAN T.FUJII ".r.; YADMINtSTRATIb1'18UI G•--: JANETL.HOLMES DENNIS C.GRAVES ;'t;S,I:FIIVE STREWE-F� JW+? BERNARDL.K •�' BERNARD L.KNAPP SENIOR FINANCIAL COUNSEL MAF#;nNF,Z CALIF 'j3;1229EDWARD v.LANE.JR. �;�! BEATRICE LIU +:' i! GAYLE MUGGLI •.. r'. ;.. `�?,: �, MARY ANN MA$ON OFFICE MANAGER PAUL R.MUNIZ VALERIE J.RANCHE PHONE (925) 335-1800 NOTICE O'V VrFICIENCY STEVEN RETTIG DAVIF. FAX (925) 646-1078 DANDJ.SILVERIDT AND/OR JACQUELINE Y.WOODS NON-ACCEPTANCE OF CLAIM PAMELAJ.ZAID TO: Federico Pastori, P 68940 CSP 7-112-L PO Box 4000 Vacaville, CA 95696 RE: CLAIM OF: Federico Pastori 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: [ ] 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 claim would rest in municipal or superior court. [XX] 6. The claim is not signed by the claimant or by some person on his or her behalf. [XX] 7. Other: Portions of the claim are late. The claim is only timely as to those claims occurring on or after February 28, 2001. Any claims Occurring prior to February 28, 2001 are untimely, and Page I an Application to File a Late Claim must be filed. See Government Code sections 9.11. 1 - 912.2, and 946.6. SII.VANO B. MARCHESI COUNTY COUNSEL By: Deputy County Counsel CERT1"FICATE 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;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. I scrved 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: August 3,2001,at Martinez,California. cc: Clerk of the Board of Supervisors(original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM:GOVT.CODE§§910.910.2,920.4.910.8) Page 2 y (!2 H c H to 0%. :•ijj'4,•• r 0 t7 > L-4 x m til -J 1-3 0 o F-t > O N w� s t7' 'TJ d1 - • 07 .P O In t, o r~' • ita r f� - If: 1u.. -- y Ln O m O H zC. H rGR,: H ro �3 .H.N �. �_. z til m 0 0 t-I ; ro O Q" i n y z � ��+6 > � - 7d 0 O H 0 O t-+ t1i z �< 0 H tTi H ro 11 H x C) tT] � > 0z - H �-3 n to %-0 x O tTjLrl 11 1-3 , w0 �' r � O i CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: Sent 25, 2001 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 document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given _ Pursuant to Government Code Section 913 and Please note all "Warnings". AMOUNT: $600,000 SEP 13 2001 COUNTY COUNSEL CLAIMANT: Federico Pastori MARTINEZ CALIF. ATTORNEY: NONE DATE RECEIVED: September 12, 2001 ADDRESS: P.O. Box 4000 BY DELIVERY TO CLERK ON: September 12, 2001 Vacaville, CA 95696 BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN SWEE oNA Dated: September 12, 2001 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors urh al,� ( 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). (�6 Other: A n td C IA t+'Y)S ap1r 1 O►r'-fp .Fe I D ry" 2_2-�Z CSD 1 Ccy n-h rn (q i h CIO +ms w ill I-e- + n woo.-- 40 -f`i d et i n) -PA Lem q I 10',10- . Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ()k Claim was returned as untimely with notice to claimant (Section 911.3). IV. 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: JOHN SWEETEN, 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. 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 th ;claimant as shown above. Dated: L��Q5,Lj_ JOHN SWEETEN, CLERK By i Deputy Clerk This warning does not apply to claims which are not subject to the California TortClaims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of.Contra Costa does not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. SILVANO B.MARCHESI DEPUTIES: PHILLS. COUNTY COUNSEL 5_G11.t JANIC L.ALTHOFF , AMENIA NORANORA G. BARLOW SHARON L. ANDERSON -` B.REBECCA BYRNES SHA ./j F=' \=�� ANDREAW.CASSIDY .:�SISTANTCOUNTY COUNSEL C NIRA COSTAL' .LINTY MONIKAL.COOPER ,iy - �� ,,, VICKIE L.DAWES GREGORY C.HARVEY OFFIC •OFT , EOUNSEL MARKES.ESTIS ASSISTANT COUNTY COUNSEL LILLIAN T.FUJII I(� 07YyADMINISTRAYIONEILDj,N.,� 5-II JANET L.HOLMES DENNIS C.GRAVES 6�j•IpRINE=ST. i Ep: �9tti�.F _©A KEVINT.KERR «•'`' } �+ri? �'.'" BERNARD L.KNAPP SENIOR FINANCIAL COUNSEL MA ,EZ;-GALI F. A _ ��-122.9 EDWARD V.LANE,JR. • _ �y BEATRICE LIU GAYLE MUGGLI MARY ANN MASON OFFICE MANAGER Usj9?��.t PAUL R.MUNIZ VALERIE J.RANCHE PHONE (925) 335-1800 STEVEN P DAVID F SCHM DIT FAX (925) 646-1078 DIANAJ.SILVER NOTICE OF UNTIMELINESS JACOUELIPAMELA J.ZAIY.D ODS AID AS TO A PORTION OF THE CLAIM TO: Federico Pastori, P 68940 CSP 7-112-L P.O. Box 4000 Vacaville, CA 95696 Please Take Notice as Follows: In regards to the amended claim you submitted on September 12, 2001, portions of your claim are timely and portions are untimely. The portions of your claim prior to February 27, 2001 that you presented against the County of Contra Costa governed by the Board of Supervisors fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2 because they were not presented within six months after the event or occurrence as provided by law. Those portions of your arnended claim prior to February 27, 2001. not presented within the time allowed by law will be addressed in your Application To File Late Claim which you submitted on September 10, 2001. Your arnended claim was forwarded to the Board for action only on the timely portions of the claims. You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately. SILVANO . MARCHESI COUNTY OUNSEL B : Y RY d HARVEY Alssist �t County Counsel Page 1 Federico Pastori Re:-Amended Claim /Page Two 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; 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. I served a true copy of this NOTICE OF UNTIMELINESS AS TO A PORTION OF THE CLAIM by placing it in an envelope addressed as shown above,scaled 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. Executed in Martinez,California. Dated: September 19,2001 Ka hleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 Office of the County Counsel Contra Costa County �r651 Pine Street, 9th Floor Phone: (925) 335-1800 Martinez, CA 94553 Fax: (925) 646-1078 CONFIDENTIAL . Date: September 12, 2001 To: Brett Horton, Deputy Clerk BOARD OF SUPERVISORS From: Silvano B. Marchesi, County Counsel By: Monika L. Cooper,Deputy County Counsel Re: Government Tort Claim of Federico Pastori Please treat the enclosed claim as an Amended Claim. You may call me at 335- 1862 with any.questions. CONFIDENTIAL ATTORNEY-CLIENT DOCUMENT Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY t INSTRUCTIONS TO CLAMIANT 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 100th 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 Reserved for Clerk's filing stamp FEDERICO PASTORI P 68940 ) Against the County of Contra Costa or ) SHEIR.FF OF CONTRA COSTA 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$ 6 0 0 , 0 0 0 .and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) FROM 1 -21 --00 TO 8-01 -01 . 2. Where.did the damage or injury occur?(Include city and county) CONTRA COSTA DETENTION FACILITIES . CONTRA COSTA , CALIF. IN MARTINEZ . 3. How did the damage or injury occur?(Give full details; use extra paper if required) WHILE I WAS IN THE CUSTODY OF THE SHERIFF AT CONTRA COSTA COUNTY DETENTION FACILITIES I' WAS DENIED ACCESS TO LEGAL'.,LIBRARY AND I WAS DENIED ACCESS TO A CLAIM FORM AND THE FORMS WITH WHICH TO FILE A CLAIM WITH THE COUNTY SUPERIOR COURT. I REQUESTED AND WAS TOLD THAT THEY DID NOT HAVE THE FORMS . I REQUESTED AGAIN AND WAS TOLD THE SAME TF].L I WAS INJURED BY BEING UNABLE TO FILE A CLAIM AND BEING UNABLE TO SEEK REDRESS FROM ACTIONS THAT HARMED ME IN AN ACTUAL SENSE , SUCH AS MEDICAL MALPRACTICE AND DENIAL OF DUE PROCESS ON COMPLAINTS . 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? I CLAIM THAT THE SHERIFF ' S POL:LCY TO NOT GRANT ACCESS TO LEGAL LIBRARY IS A DENIAL OF THE SIXTH AMENDMENT RIGHT TO COUNSEL AND THE FOURTH AMENDMENT RIGHT TO DUE PRO .CESS AND RENDERS THE INCARCERATION TO BE �x` iat are the natnes��df county or district officers, servants, or employees causing the damage or injury? THE SHERIFF OF CONTRA COSTA COUNTY FROM 1 -21 -99 AND ANY NEW SHERIFF WHO HAS TAKEN OFFICE SINCE THAT TIME . 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) I WAS DENIED AN OPPORTUNITY TO FILE A CLAIM AND TO SEEK REDRESS . IT DENIED ME AN OPPORTUNITY TO ASSIST IN MY DEFENSE AND TO FILE EX PARTE MOTIONS TO THE COURT AND TO FILE CIVIL ACTION SUCH AS A IE143w�hs the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) IT WAS CALCULATED BASED ON THE DAMAGES I HAVE BEEN SUBJECTED TO BY BEING UNABLE TO FILE ACLAIM FOR THOSE DAMAGES . 8. Names and addresses of witnesses, doctors, and hospitals. ALL MY WITNESSES ARE IN THE DOCUMENTS THAT ARE CALLED CONTRA COSTA COUNTY DETENTION FACILITIES REQUEST FORMS . 9. List the expenditures you made on account of this accident or injury. DATE TIME AMOUNT NOT APPLICABLE TO THIS ACTION . ****************************************************************************************** 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 ) FEDERICO PASTORI P 68940 CSP 7-112-L ) P . O . BOX 4 0 0 0 ) '(Claimant's Signature) VACAVILLE , CALIF. 95696 ) PC) BOX 4000 (Address) vacaville , ;:.Calif . 95696 ) ) Telephone No. MAIL ONLY )Telephone No. MAIL ONLY ****************************************************************************************** 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(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.