HomeMy WebLinkAboutMINUTES - 09162008 - C.23 (5) APPLICATION TO FILE LATE CLAIM ,
BOARWOF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
BOARD ACTION
Application to File Late Claim ) NOTICE TO APPLICANT SEPTEMBER 16 2
SEPTEMBER 16; 2008
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. . n pursuant to Government Code Sections 911.8
15.4. Please note the"WARNING"below.
Claimant: . AHMED 1CABIR AUG 8''2008
Attorney: UNMOWN COUNTY COUNSEL
MARTINEZ CALIF.
Address: 1432 MARCLAIR DRIVE, APT. B
CONCORD, CA 94521
Amount: UNKNOWN By delivery to Clerk on: , AUGUST-08,. 2008
I
Date Received: AUGUST 08, 2008 By mail,postmarked on: HAND DELIVERED
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: AUGUST 08, 2008 JOHN CULLEN Clerk,By: DEPUTY
Il. FROM: County Counsel TO: Cler of thejBoard of Supervisors
( ) The Board should grant this Application to File Late Claim (Section 911.6)
(vy< The Board should deny this Application to File Late Claim (Section 911.6).
DATED: b SILVANO B. MARCHESI, County Counsel,By: �� DEPUTY
III. BOARD ORDER By unanimous vote of Supervisors present
(Check one only)
( ) This Application is granted (Section 911.6).
( VThis 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.
DAVID TWA
DATE: , 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 ap0cation 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: 2JAOeDAVID TWA -,.Clerk, By: DEPUTY
V. O : (1) County Counsel (2) County Administrator TCF: Clerk of the Bo rd of Supervisors
Received copies of this Application and Board Order.
DATED: County Counsel, By:
County Administrator, By:
APPLICATION TO FILE LATE CLAIM
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Ahmed Kabir
1432 Marclair Dr. Apt.B
Concord, CA 94521
(925) 459-0900
°F 44,
O
August 8, 2008O
q�O SGa e
The Board of Supervisors sTco9`�sO�s
Contra Costa County
County Administration Building
651 Pine Street, Room .106
Martinez, CA 94553-4068
Dear Board of Supervisors:
This letter serves to give you notice that I wish to apply for leave to present a late
claim (Government Code §§911.4 to 912.2, inclusive, and §946.6) since under
some circumstances leave to present a late claim will be granted (Government
Code §911.6).
My claim was filed late because the hospital was helpful to me and I thought I
would get over my injury and I didn't pay attention to the time requirements of
any claim.
Very truly,
1q;6IF,D
Ahmed Kabir
The Board of Supervisors Contra Johncullen
Clerk of the Board
County Administration Building Costa Bad
County Administrator
651 Pule Street,Room 106 C0Unty (925)335-1080
Martinez, California 94553-4068
John Gioia,District 1
Gayle B.Uilkema,District 11
Mary N.Piepho,District 111
Mark DeSnulnier,District IV .
Federal D.Glover, District V
00•.,
July 25, 2008
TO: David Timko
Timko and La Sorsa
540 Lennon Lane
Walnut Creek, CA 94598
RE: CLAIM OF AHMED KABIR
NOTICE TO CLAIMANT
OF LATE-FILED CLAIM
(Government Code Section 911.3)
The claim you presented to the Board of Supervisors of Contra Costa County,.California, as
governing body of the County of Contra Costa on April 14, 2008, has been reviewed by County
Counsel and is being returned to you herewith because:
✓ Your claim relating to a cause of action for death or for injury to person or to personal
property or growing crops was not presented within six months after the event or occurrence as
required by law. (See Govenmient Code sections 901 and 911.2)
_ Your claim relating to a cause of action for anything other than injury to person or to
personal property or growing crops was not presented within one year after the event or occurrence as
required by law. (See Goveriment Code sections 901 and 911.2.) .
Because the claim was not presented within the time allowed by law, no action was taken on the
claim.
Your only recourse at this time is to apply without delay to the Board of Supervisors of Contra
Costa County for leave to present a late claim. (See Government Code sections 911.4 to 912.2,
inclusive, and 946.6.) Under some circumstances leave to present a late claim will be granted. (See
Govemmient Code section 911.6.)
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 irmnediately. .
Date: JULY 29, 2008 JOHN CULLEN, Clerk of the Board
of Supervisors and County Administrator
By:
Dep ty Clerk .
Enclosure
CERTIFICATE OF SERVICE BY MAIL
(Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664)
I am a resident of the State of California and over the age of eighteen years, and not a party to the
within action. My business address is Clerk of the Board of Supervisors, 651 Pine Street, Room 106,
Martinez, CA 94553. On iuLY 29, 2008 , 1 served a true copy of this Notice to Claimant
of Late-Filed Claim by placing the document in a sealed envelope with postage thereon fully prepaid,
in the United States mail at Martinez, California addressed to AHNM KABIR , as set
forth above.
I declare under penalty of perjury under the laws of the State of California and the United States of
America that the above is true and correct. Executed on . JULY 29, 2008 at Martinez,
California.
Deputy lKerk
I:\TORT\RISK-MGT\CLAIMS\L ATE\HO W ARD.wpd
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
BOARD ACTION: AUGUST 19, 2008.
Claim Against the County, or District Governed by )
tine Board of Supervisors, Routing Endorsements, ). NOTICE TO CLAIMANT
and Board Action. All Section references are to ) The copy of this document mailed to
California Government Codes. ) you is your notice of the action taken
on your claim.by the Board of
Supervisors. (Paragraph IV below),
given Pursuant to Government Code
AMOUNT:
UNKNOWN ,J(J� T' 8 ZOOS J Section 913 and 915.4. Please note all
"Warnings".
CLAIMANT: AHMED KABIR COUNTY COUNSEL
MARTINEZ CALIF.
ATTORNEY: 'DAVID.TIMKO DATE RECEIVED; JULY 18, 2008
TIMKO AND LA SORSA
ADDRESS: 540 LENNON LANE BY DELIVERY TO CLERK ON: JULY 189 2008
WALNUT CREEK, CA 94598
BY.MAIL POSTMARKED: HAND?%DEE,ITERED
FROM: Clerk of the Board of Supervisors TO; County Counsel
Attached is.a copy of the above-noted claim.
JOHN CULLEN, .ler
Dated: iZULY.:18, 2008 By: Deputy
11. FROM.: County Counsel TO: Clerk of the Board of S pervis rs
O 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).
(t,YClaim 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).
O Other:
Dated: -7By: A Deputy County Counsel
I/ROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( Claim was returned as untimely with notice to claimant (Section 911.3).
I.V. BOARD ORDER: By unanimous vote of the Supervisors present:
O This Claim is rejected in full.
O 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 CULLEN, CLERK, By Deputy Clerk
WARNING (Gov. code section 913).
Subject to certain exceptions,you have.only Six(n) months from the date this notice was personally served ,
or deposited fn 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 fn connection witir this matter. If you want to consult art
attorney,you should do so immediately. *ForAdditiaial Warning See Reverse Side of'ThisNotice.
AFFIDAVIT OF MAILING
[ declare under penalty of perjury that.[ am now, and at all times herein mentioned,'have
been a citizen of the United States, over age 18 and that today ] deposited in the United
States Postal Service in Martinez, California, postage fully prepaid a eertitled copy of_this
Board Order and Notice to Claimant, addressed to the clainian-t as shown above.
Dated: 0600f/JOHN CULLEN, CLERK By. Deputy Clerk
This warning does not apply to claims which
are not.subjec,t 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 isnot exhaustive and legal
consuttatio'n is essential to understand all the
separate limitations periods. that may apply.
The limitations period within which. suit must
be tiled maybe 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
Por does it waive rights under the statutes of
limitations :applicable to.actions not subject to
the California Tort Claims Act
INSTRUCTION'S TO CLAIMANT
A. A claim relating to a cause of action for death or for injury to person or to personal property or
growing crops shall be presented not later than six months after the accrual of the cause of
action. A claim relating to any other cause of action shall be presented not later than one year
after the accrual of the cause of action.
(Gov. 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.
..............................................................................1
RE: Claim By: l t h iV eet Reserved for Clerk's filing stamp
cyi rq
b RECEIVED
NU2 � 1'i��� �
Against the County of Contra Costa or
JUL 1 8 2008
District)
Fill in the name ) CLERK BOARD of SUPERVISORS
( ) ) CONTRA COSTA CO.
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
district in the sum of$ M1Vknj9Vd in support of this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
2. Where did the'damage or injury occur? (Include city and county?
1�1CL► n-ez� CA C'vw- ty o ' C �ntrn Ct>�s/
3. How did the ydamage or injury occur? (Give full details; use extra paper if required)
4. What particular act or omission on the part.of county or district officers, servants, or employees
caused the injury or damage?
1e
Le. � n.
e u-re sinJec� d
d fie r,&&dle, tcSe '� Aelll-wta�
.
5 What are the names of county or district officers,se�ants, or employees causing the
damage or injury? P<c `'`L
IC,— LV til'
5. What damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto damage.)
fes-cLrfiti ( 5is -(rz�m _�- -f-Des fc) Ic nem # I �� I ler �7;tplat
pGiinJ�Ssi� ; n IZ � ij,1bi jI4y, loss, oecir r��n'S lost lt �e� (,
7. How was/XC amount claimed ab a computed? (include the estimated anioufit o any
prospective injury or damage.)
8. Names and addresses of witnesses, doctors, and hospitals:C-Dri ,Ma (u5f-e,- ZeA i Grl6t- ( M eAl CA
CPa , 1e,- ; •Erne, f�Pme Rc�brn, s�� A lh vr, �r,l- Ave_ "-0-4^til,ez .Grq
Jllr- P� fr�'c�z oa �.cc,,- rBrad fz}sk -, Lv/V + ox-bo a.kbd ess '
9. List the expenditures you made on account of this accident or injury:
DATE TIME AMOUNT
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Gov. Code Sec. 910.2 provides"The claim shall be
signed by the claimant or by some person on his
behalf."
SEND NOTICES TO: (Attorney)
Name and address of Attorney )
(Claimant's Signature)
M Ko ars C, i^ Jar. 4--
(Address)
l t)Q 1rL c+ Cveetc, C� r )
q q sq ) tie), �,�, C1 Ns a 1
Telephone No-0--?5)a(33-3 ffto i_) Telephone Nora;t
SEVEN 0 0 me
PUBLIC RECORDS NOTICE:
Please be advised that this claim form,or any claim filed with the County under the Tort Claims Act, is subject to
public disclosure under the California Public.Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any
attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to
public disclosure.
....ee..... ....................e.................................................. ..1
NOTICE:
Section 72 of the Penal Code provides:
Every person who,with intent to defraud, presents for allowance or for payment to any state board or officer, or
to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or
fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a
period of not more than one year, by a fine of not exceeding one thousand dollars (51,000.00), or by both such
imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars
($70,000), or by both such imprisonment and fine.
RE: Claim By: Ahmed Kabir
3. I had a toothache and swelling in my face so I went to the emergency unit of Contra
Costa County Regional Medical Center. I saw Dr. Patrice Ringo and,she gave me an
injection in my guru near the painful tooth: She prescribed an antibiotic and told me a
nurse would come to administer it. About 15minutes later the nurse carne in and gave
me 2 injections one in my right hip and one in my left hip. The first injection was fine.
The 2"d injection in my left hip he told the would make me feel 'Twiny", but I would be
all right in a few minutes. After he gave me the injection, I innrtediately felt as if fluid
went directly to the bottom of my foot. The nurse left the room, and I left the ER. When
I was walking to my car my foot was becoming more and more numb and I had the
feeling as if my foot and leg were asleep. This feeling has never gone away, in addition,
I now experience constant pain.
Ahmed Kabir
1432 Marclair Dr. Apt. B
Concord, CA 94521
July 11, 2008
To: Board of Supervisors of Contra Costa County
RE: NOTICE OF INTENTION TO COMMENCE MEDICAL MALPRACTICE
ACTION
This letter shall serve as notice, in accordance with California Code of Civil
Procedure section 364; that Mr. Ahmed Kabir will file suite against you for
damages resulting from the personal injury he sustained on June 29th, 2007. The
legal basis of this action will be .the negligent failure to properly. supervise and
monitor the individual(s) responsible for injection of the pain medication and/or
the injections :of the antibiotics. Mr. Kabir continued to treat with the same
doctors at the same facility until approximately February, 2008. Each time the
treating doctor(s) encouraged Mr. Kabir that his condition would gradually
improve. More than six months after Mr. Kabir realized that he was not
improving and that his condition was permanent. The effects were the total loss
of feeling in the left leg and foot from the top of the ankle to the toes.
Mr. Kabir-Ahmed will allege and provide the following losses and injuries as a
proximate result of the professional negligence:
1) Partial paralysis;
2) Loss of earnings;
3) Compensatory damages;
4) Medical,bills; and
5) (jeneral damages for pain and suffering.
Very truly yours,
cc: Medical Board of 1'aliforni''-.
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0(925) 957-7400
CONTRA COSTA HEALTH SERVICES PRIVATE PAY
595 CENTER AVENUE, SUITE 300
MARTINEZ, CALIFORNIA 94553
> ;,,a:,,::.;x,PATIENT.:NAME .::FATIENTiNUMDER>.. SEXP4.'AGE
6285 KABIR, AHMAD 76420645 MI 5
"•' is#i;=f�rSr: :')ADMISSION'.DATE; '•, , S
Y ..,M J�t '.i� ISCHf!:RGEIDAl1=!q,r� - :.DAYS;:i
0101 06/27/07 06/27/07 11
-dPAGE NO :u{'vu;rTY.P•E9FSIL4 3Tr".�T$n'Y-i*DATE':OF;BILLh`:#''x.S AMOUNT ENCLOSED
PATIENT NAME: KABIR, AHMAD 1 FINAL 07/12/07 $
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AHMAD KABIR CONTRA COSTA HEALTH SERVICES
1432 MARCLAIR DR B 595 CENTER AVENUE, SUITE 300 PO
CONCORD, CA 94521-2827 MARTINEZ, CALIFORNIA 94553
8285•S4RO8NX WTOOOO60
Fl Please check box if address is incorrect or insurance STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
LJ information has changed, and indicate change(s)on reverse side. '
801395(10N41
pA "" Ik"` "{ DESCRIPTIOIJ'OF1 4t�! "�,`u> T"3 i=a ESTsCOVE;RAGE' EST.COVERAGEEST'COVEFiAGEt �FgTIENTr
zw fb TE OFOl'/Y s< ,Pd'f% .,r a, d isw.
SERVICL `°m .i ' x f`i ,GOOE !;�`,,:: CHARGES`�'p4,.`LSINS COzN0.7., lv a
5Tt p ' ro SERVICE .vl aTOTA7.� ¢s' E,
s, vvu-.cHOSPITAL`SERVICES„-r,;,A�„ .� ,§� - :„A.a INS..CO^NO 2 E 1z WS;GO.aN073„ „f?MOUNTTa!^3'„
062707 2 PEN VK 250MG 41704222 1.04 1.04
IP01975381
062707 1 ALBUTEROL HFA 6.8GM 41723834 58.23 58.23
IP01975383
062707 1 KETOROLAC 60MG INJ 41727397 22.44 22.44
IP01975382
** TOTAL PHARMACY
062707 1 EMERGENCY ROOM 45300050 1000.00 1000.00
062707 1 ER COMPREHEN VISIT 45324431 F;;. :'soo::oo,,. 500.00
** TOTAL EMERGENCY ROOM VISITS-
' '5
ISITS•;
062707 1 OXIMETER CHECK 454905,05 ' 14:00 14.00
** TOTAL EMERGENCY ROOM PROCED.:' `
SUB-TOTAL CHARGES -+ '” 1595.71 1595.71
TOTAL LIABILITY 1595..71 4 1595.71
SUMMARY OF CHARGES BY,MEPARTMENT � -
r .
PHARMACY e1.71
EMERGENCY ROOM VISITS ;_ . 1500.00 r �Pr � 1500.00
EMERGENCY ROOM PROCED *V 19.00 (w' 14.00
+ I i,.k�
SUB-TOTAL CHARGES lYet ti:jg
1595.71 a r'I: 1595.71
n „
TOTAL LIABILITY 1595.71
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entre las horas de la officin de 9:00 a.m. a las 5:00 .m..
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5225 3895737-02-0057 1595.71 1595.71
14''it51?ATIENTiNUMBER `-fit; PLEASE REFER TO PATIENT ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR ANY m �a Y
NUMBER ON ALL INOUIRIES CHARGES NOT POSTED WHEN THIS BILL WAS PREPARED,OR OLE-
645 PAY;THIS AMOUNT
7 6 4 2 0 AND CORRESPONDENCE. IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE i{ L 1595.71
AMOUNTS SHOWN UNDERESTIMATED INSURANCE COVERAGE. -
im�lilmimolmlmim�uunmlommm�mumllmllolnmll�uli Make checks payable'to:CONTRA COSTA HEALTH SERVICES
!F,LkI\lY DF THE FCL L-:-ANN I_.. H=�_, CHANGED SiiJ.,c YOUR LAST STATEMENT, PLEASE INDICATE .
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,IS'ARY INSURANCE COMPANY'S NAME EFFECTIVE DATE
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STAT!. :
' .,_..., I IrILDER'S IG HUMBER -- GROUP PLAN N1419F R
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Notification'of Financial Assistance for Financially Qualified Individuals
and Self-Pay Patients Effective January 1, 2007.
You are receiving this bill for medical treatment that you or a member of your family received from Contra
Costa Health Services. At the time you received medical treatment, you did not provide evidence that you
have health insurance or other program coverage to pay for these services. If you have health insurance
benefits to pay for this service, please contact the Patient Accounting Department immediately at
(925) 957-7400.
If you do not have health insurance or program coverage for you and your family, you may be eligible for Medi-
Cal, Healthy Families, California Children's Services, the Basic Health Care Program, or other health coverage
programs. If you are not eligible for any of these programs, you may qualify for a discount on your bill based
on family income limitations and/or high out-of-pocket medical expenses. Contact the Financial Counseling
Department immediately at 1-800-771-4270 for further information and application assistance. Financial
Counselors are available Monday-Friday from 7 A.M.to 6 P.M.
Aviso de ayuda financiera para individuos que califiquen financieramente y para
pacientes que.pagan las cuentas por si mismos Enero 1, 2007 sera efectivo.
Usted esta recibiendo esta factura por tratamiento medico que usted u otro miembro de su familia recibio de
Contra Costa Health Services. En el momento en que usted recibio tratamiento medico, usted no proveyo
evidencia de tener seguro de salud u otro programa de cobertura para pagar por estos servicios. Si usted
tiene beneficios de seguro de salud que paguen por este servicio, por favor pongase en contacto con el
Departamento de Contabilidad de Pacientes inmediatamente al (925) 957-7400.
Si usted no tiene seguro de salud o un programa de cobertura para usted y su familia, usted'puede ser
elegible para-Medi-Cal, Healthy Families, California Children's Services, el Programa Basic Health Care, u
otros programas de cobertura de salud. Si usted no es elegible para ninguno de estos programas, usted
puede calificar para un descuento en su factura en base a las limitaciones de ingreso de,la familia y/o altos —
gastos medicos que salgan de su bolsillo.Pongase en contacto con el.Departamento de Consejeria Financiera
inmediatamente al 1-800-771-4270 para obtener mas informacidrf y ayuda con la solicitud. Los Consejeros
.Financieros se encuentran disponibles de lunes a viernes de 7 a.m. a 6 p.m..
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