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MINUTES - 11281989 - 1.25
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to GoaeMM i6qu n s el Amount: $80. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: HENRY SR. , Jeffrey M. l�Qv Martinez. CA P4553 ATTORNEY: Date received October 31 , 1989 ADDRESS: 8 Meadowbrook Avenue BY DELIVERY TO CLERK ON Pittsburg, CA 94565 BY MAIL POSTMARKED: October 30, 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: November 3, 1989 IVIL BAATTCYELOR, Clerk epuAnn Cervelli II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: J Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County A ministrator (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: N O V 2 S 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the. mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N O V 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator / + BOARD 'OF OF SUPERVISORS OF CONTRA CO Taur �PA �g \ y. i appllentlan t0, Instructions to Claimant Clerk of the Board P.0. Box 911 A. Claims relating to causes of action for death or far in�uryn to4533 person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims' relating to any othe-.r cause of action must be presented not later than one year after the accrual of the cause ,.)f action. (Sec. 911. 2 , Govt. Code) B. Claims must be filed with the Clerk of the Board of Supervisors at its officL:! in Room 106 , County Administration Building, 651 Pine Street, Martinez , California 94553. C. If claim is against a distmrict 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 end of this form. RE: Claim by ) Reserved for Clerk' s filing stamps -j RECEIVED Against the COUNTY OF CONTRA COSTA) OCT311989 or DISTRICT) PHIL BATCHELOR CLERK BOARD OF SUPERVISORS (Fill in name) ) CONTRA COSTA CO. D22U . The undersigned claimant hereby makes claim ' against the County of Contra Costa or the, above-named Distric in .the sum 'of $ ` ��( � r and in support of this claim represents as follows.: 1. When did the damaage- or injury occur? (Give exact date and hour) ' -------------------------------------•------------------------------ -_-_ 2.' Where did the damage or injury occur? (Include city and county) ----------------------------------------------------------- d - - - - 3. How did the amage or occur? (Give full details--, -us--e-e-xt-ra--- sheets if required) ------------------------- ----------.-------------------------------------- 9 . What particular act o�- ofnis:,ior: on the part of county or district officers , servants or employees caused the injury or damage? C�.n- �Q (over) :�:;5..:.:•, zat; ar.e..te.;names of co .nty or district officers, servants, or' employees:causing the damage or injury? - - - - - ------------- - -------.-------------- - - -- --------------- 6.--W-h-at-d-amage-----o-r-injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) 7. How was the amount claimed above computed? (Include the estimated amount of any prospecitiven injury or damage. ) / 8. Names �nd_h-and addresses of witnesses , doctorsospitals. ------------------- ----------------------------------------------------•-- 9 . List the expenditures you made on account of this accident or injury: DATE---, n ITEM AMOUNT 21 t i *****�cia**,ic'.*�r�c'**•'*'***#**�****�c***** k**�kati*�Y*ir•k******k*is*********�c**�F�ic********* Govt. Code Sec. 910..2 provides : "The claim signed by the claimant SEND NOTICES T0: (Attorney) or by some person on his behalf. " Name and Address of Attorney �/ _,j lai nt' s 1 ignatur _ .Acids e s s Telephone No. - _ Telephone No t7OTICE Section 72 of the Penal Code provides: "Every person who, with intent to defr_a�ud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or of U cer, authorized to allow or pay the same if genuine , any false or fraudulent claim, bi1.1 , account , voucher, or writing , is guilty of a felony. " f:5..:.�•,f zat; are._tbe...:names of coL.nty or district_ *officers, servants or'' 1. employees ,causing the damage or injury? 6------------g------- --------- --------•------------Give full extent --- What dama a or in uries dA you claim resulted. of injuries or damages claimed. Attach two estimates for auto damage) GSC,( Gr ��G �1t,t�2o j�Jz�� •-��� -� Y .- _ _ _ __ ---- - 7. How was the amount claimed above computed? (Include the estimated amount �of/> any prospective injury or damage. ) �1 8. Names ana-aadresses of witiiesses, doctors and hospitals ----------------------------------------------------------------------- -- 9. List the expenditures you made on account of this accident or injury: DATE- III.'EM AMOUNT *!c*t.ir*dc***yt�tirk*�k**dc***�t#dc�Y�c***** k***dc**ic*•k***�ri�*lydr**ic�rdcdc***oF�k**at at tic*lc�cir*tt** r Govt. Code Sec. 910.2 provides :. "The claim signed by the claimant SEND NOTICES T0: (Attorney) or by some person on his behalf. ' Name and Address of Attorney ai nt' s , ignatur Address Telephone No. _ Telephone No. t1,1T I CE 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, town, city district, ward or village board or of*icer, authorized to allow or pay the same if genuine , any false or fraudulent claim, bill , account , voucher . or writing, is guilty of a felony, " �¢ CQNTRk;CLI5 A DIETEPITEf�h! ACIL�'TY L as S.) 1 CLOTHING RECEIPT % `DATE 1 d'-/ 69► REC : X453 .. . TIME: •C9f3 FACILITY:'' MDF . NAME (L, F ?M}* 1��''#!11 . EEElY D.O.B h ° i 4 BOOKING2. .J. [�"SHIRT/BLOOSE TS/SKIRT [� COAT/JACKET ES/BOOTS , •. ,..: [� S/PANTIES T-SHIRT/BRA j' SOCKS NYLON HAT/PURSE 1, . SWEATER/SWT .SHIRT DRESS ' OTHER � t 9� BKG OFC: r ,'INMATE SIG ATW 9 s1 p 'I DATE ; ` . I HAVE RECEIVED ALL. 6F m,Y I ° , CLOTHING' REL QFC:' i_ J INMATE SIGNATURE '... �> CLAIM �•�j� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all ftaim?"Eounsel CLAIMANT: ROSS, Viola Emeline NOV iflg1_. J8 ATTORNEY: Donald K. Bussiere, Esq. 7 Weinberg, Campbell & Stone Date received � :t�i18.' � �' ADDRESS: 765 Bridgeway BY DELIVERY TO CLERK ON October_ 30, 1989 Sausalito, CA 94965 BY MAIL POSTMARKED: October 26, 1989 CERT # P 116 979 664 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. November .3, 1989 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy _ am/h An Cervelli II. FROM: County Counsel TO: Clerk of the Board of Supervisors \( ) This claim complies substantially with Sections 910 and 910.2. (V ) 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:��C'nn„'a�wt� Dated: 11 � `� 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 minutes for this date. Dated:N O V 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the .United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N O V 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator NOTICE OF INSUFFICIENCY AND OR NON-ACCEPTANCE OF CLAIM TO*Claim Bussiere, Esq. g, ampbell & Stone dgewa to, CA 9 65 Ref VIOLA EMELIE ROSS 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: _1 . 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. x 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. x 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 behalf . 7 . Other: VICTOR J. WESTMAN, County Counsel By:_ ' - Deputy Countylcunsel CERTIFICATE OF SERVICE BY MAIL C.C.P. §§ 1012, 1013a, 2015.5; Evid. C. §§ 641,_664) My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and 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(s) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelopes) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: �� at Martinez, California. cc: Clerk of the Board of Supervisors (original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910. 2, 920 .4, 910.8) CLAIM AGAINST THE COUNTY OF CONTRA COSTA FOR EQUITABLE INDEMNITY CONTRIBUTION AND APPORTIONMENT To: COUNTY OF CONTRA COSTA 1' `-� Board of Supervisors 651 Pine UUT 30 1999 Martinez, California 94553 Fiz'fIL BATCHELOR CLERK BOARD OF SUPERVISORS CUNTOSTA CO. 8 Depcuy 1. This claim is made by Viola Emeline Ross, 4220 C1 ton Road, Concord, California 94518. All notices representing this claim should be sent to her attorneys, Weinberg, Campbell & Stone, 765 Bridgeway, Sausalito, California 94965 . 2 . The date and place of the incident giving rise to this claim is September 10, 1988, on Willow Pass Road near its inter- section with Galindo Avenue, City of Concord, County of Contra Costa, State of California. See plaintiff's com- plaint filed in the Superior Court of the County of Contra Costa, a copy of which is attached hereto, action number C8903763, entitled John E. Hosman v. Viola Emeline Ross, et al. for full details. 3. The exact name or names or the public entity or entities or their agents and employees involved in this action are not known at this time and claimant asks to be permitted to insert their names when discovered. 4 . Claimant was served with the complaint on October 11, 1989 . 5. The exact nature and amount of damages are for equitable indemnity, contribution and apportionment and are presently unknown. Dated: October 25, 1989 WEIYBE:RG, CAMPBELL . & STONE By: DONALD K. BUSSIERE, ESQ. Attorneys for Claimant VIOLA EMELINE ROSS ' fY0 R1"(1<44'"1E4.rr g. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "Warn i s" Counsel CLAIMANT: MC KAY, Keith NOV 3 1vd9 ATTORNEY: Date received Ma tnez. CA fNS-53 ADDRESS: Address Not .Given BY DELIVERY TO CLERK ON October 31, 1989 BY MAIL POSTMARKED: Hand delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. November 3, 1989 PpHHIL BATCHELOR, Clerk DATED: BY: DeputyJi,,e 0a, Ann Cervelli II. FROM: County Counsel TO: Clerk of the Board of Supervisors —�( ) This claim complies substantially with Sections 910 and 910.2. Zv ) 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 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 (11� This Claim is rejected in full . ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: N O V 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N 0 V 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: ith McKay Ad s not given Re: Claim of KEITH MCKAY 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: x 1 . The claim fails to state the name and post office address of the claimant. x 2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. x 3 . The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. x 4 . The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. x 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 behalf . 7 . Other: VICTOR J. WESTMAN, County Counsel By: /J �Jj� Deputy Count C unsel CERTIFICATE OF SERVICE BY MAIL C.C.P. 55 1012, 1013a, 2015 .5; Evid. C. r4P4 641, 664) My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and 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(s) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelope(s) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: q \�� , at Martinez, California. cc: Clerk of the Board of Supervisors or ginal) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910. 2, 920 .4, 910.8) i RECEIVED OCT 31, 1989 PHIL BATCHELOR CL CO RA OF S E O 1SORS 8 �/�'T�1cT ATTO�NE kl> A or C bin l Dw v av% com?kct)� � \ed w��k U. Coal . 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Gt Bare, � a (n v v-es YN _ • _ _;` s : a� r _ A ) .-.. _ . . ti _ or1 � ps ►haat_._. . _ 6u tis •-+'; _ c� CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $101000. 00+ Section 913 and 915.4. Please note all "Warnings". CLAIMANT: HAYNES, Taz, a minor, by Byrdie Haynes ATTORNEY: Leandro H. Duran Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Road BY DELIVERY TO CLERK ON November 2, 1989 Suite 58 Richmond, CA 94806 BY MAIL POSTMARKED: November 1, 1989 CERT # P 159 025 901 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. November 3, 1989 PpHHIL BATCHELOR, Clerk v DATED: BY: Deputy n Cervelli II. \FROM: County Counsel TO: Clerk of the Board of Supervisors (�+ ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: I, /, BY: I - / J 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 ( VYThis Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy o.f the Board's Order entered in its minutes for this date. Dated: NOV' 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N O V 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator RECEIVED 21989 TOXIC TORT CLAIM BATCHELOR D OF SUPERVISORS This claim is submitted against CONTRA COSTAA COSTA CODeto Section 910 et seq of the California Government 1 . Claimant (name & address ) : TAZ HAYNES , a minor, by BYRDIE HAYNES , 429 S. 24th Street, Richmond, CA 94804 2 . Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5. Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant 's body or by inhalation- of toxic gases and fumes released from the substances, or both. The excavation and storage. of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation .of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing , and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entty. in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant , respecting such toxic and hazardous' was.tes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of. the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is : Temporary Persistant , ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( �) Bleeding, nasal (vl ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) _ ( Cold & flu symptoms .vf ( ) Constipation y ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( Diarrhea ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) Eye irritation/inflammation ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) (c'Headache ( ) ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) (Medical expenses ( y' Pain & suffering ( ) ( cam ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8. Amount claimed at present, including estimated amount of any prospective loss : [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 3/ , 1989 Signature of Claimant / or Person Acting on Claimant ' s Behalf: AN RAN, Esq. 2 e. CLAIM 1• ;. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA . � P Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $10, 000. 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: HAYNES, BYRDIE County Counsel N 0 V 31°89 ATTORNEY: Leandro H. Duran Attorney at Law Date received Martinez, .��► ��5'J3 ADDRESS: 3150 Hilltop Mall Road BY DELIVERY TO CLERK ON November 2; 1989 Suite 58 Richmond, CA 94806 BY MAIL POSTMARKED: November 1, 1989 CERT # P 159 025 901 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pH gg DATED: November 3, 1989 BYIL DeputyLOR, Clerk AA_ Of J,.. r�, n Cerv.elli I1. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: I �� : Deputy County Counsel )�)J 0- \U 111. 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: N O V Z 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sects 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:—NOV 2 9 17989 BY: PHIL BATCHELOR by Deputy Clerk Aw CC: County Counsel County Administrator NOV 21989 PH!! BATCHELOR OTOXIC TORT CLAIM CcRR ZARU FR VISORS NT4A De ut This claim is submitted against CONTRA COSTA C Y pursuant to Section 910 et seq of the California Government Code. 1 . Claimant (name & address ) : BYRDIE HAYNES , 429 S. 24th Street, Richmond, CA 94804 2. Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. . 5. Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the above-described site, which is within a populated urban neighbor- hood, in such' a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of :.this contaminated dirt in this manner was either approved and. authorized by the above-named public entity in violation of ` prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing , and in violation of said entity 's duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in .the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant , respecting such toxic and hazardous wastes . and said public nuisance. 6 . Description of loss ,. damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant L4-"'Anemia/chronic fatigue ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( ) ( ) ( ) Cold & flu symptoms ( ) ( ) ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) ( c�! iarrhea Dizziness ( ) ( tam ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( -KHeadache ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ('Medical expenses ( c-Pain & suffering ( ) Reduced market value, real ( ) ( ) property 7 . Name(s) of public entity employees causing the injury, damage or loss: Unknown. 8 . Amount claimed at present , including estimated amount of any prospective loss : [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 3/, 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: O H , Esq. 2 CLAIM / a� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $10, 000. 00+ Section 913 and 915.4. Please note all "Warrs�,'l1 � CoUII$e) CLAIMANT: HAYNES, Cynthia N O V � 1 J ATTORNEY: Leandro H. Duran Martinez. GA fk ,50 Attorney at Law Date received November 2, 1989 ADDRESS: 3150 Hilltop Mall Road BY DELIVERY TO CLERK ON Suite 58 November 1, 1989 Richmond, CA 94806 BY MAIL POSTMARKED: CERT # P 159 025 901 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pH gg DATED: November 3, 1989 gYIL DeputyLOR, Clerk n Cervelli II. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 3 / 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 minutes for this date. Dated N V 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N O V 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator DECEIVEJeu NOV 21989 TOXIC TORT CLAIM rHn BATCHELOR p �BOA This claim is submitted against CONTRA COSTA to Section 910 et seq of the California Government Code. 1 . Claimant (name & address ) : CYNTHIA HAYNES , 429 S. 24th Street, Richmond, CA 94804 2. Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5. Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the . above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant 's body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes , which the entity is charged with administering and enforcing, and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting, such toxic and hazardous wastes and said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant )' Anemia/chronic fatigue Bleeding, oral Bleeding, nasal Bleeding, rectal Bleeding, vaginal Blisters Breathing difficulty Y L-) Cold & flu symptoms A,)ec Constipation Coughing Chest pain/angina 0"'Diarrhea Dizziness Drowsiness Eye irritation/inflammation Fainting. Fever Headache Laryngitis Loss of appetite Loss of memory Loss of sleep/insomnia Lymphatic swelling Muscle spasms Nausea , Nervous distress/anxiety Nervous seizures Sinus irritation Skin rash Skin sores Sore throat j �)-` Stomach cramps Vision. impairment Vomiting Vomiting blood },,.Business loss ( L-) medical expenses 0--'Pain & suffering Reduced market value, real property 7 . Name(s ) of public entity employees causing the injury, damage or loss: Unknown 8. Amount claimed at present , includingestimated amount of any prospective loss : [Exceeds $10 ,000 Jurisdiction is in the Superior Court of California] Date of Claim: October 1989 Signature of Claimant or Person Actina on Claimant ' s Behalf:- LWAaDA6' URAN, Esq. 2 CLAIM A 1;L S— ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Agai* t the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $101000. 00+ Section 913 and 915.4. Please note all " r 1 1 '�'U&rvy' -Counsel CLAIMANT: REAVES, Margaret 1983 ATTORNEY: Leandro H. Duran �, Attorney at Law Date received M,?ur; the .,,CA, 5:3 ADDRESS: 3150 Hilltop Mall Road BY DELIVERY TO CLERK ON November 2, 1989 Suite 58 Richmond, CA 94806 BY MAIL POSTMARKED: November 1, 1989 CERT # P 159 025 901 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. Of JA DATED: November 3, 1989 &YIL BATCYELOR, Clerkepu e CL W. Ann Ceryell.i I FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: (� /3 J�r1 BY: I / 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 ( his Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: N O V Z 8 1989 PHIL BATCHELOR, Clerk, By _ Deputy Clerk WARNING (Gov. code se /n913) 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N 0 V 2 9 1989 BY: PHIL BATCHELOR bynk.-E�� Deputy Clerk JI CC: County Counsel County Administrator d v a�� • o �Ul gt5� � Z tr d 3 `r a a N �ORry� N F+ w ri .9 W N o vi W N N .:ca�,�✓� � Nu=ts Sir apt 0 'q ,p� F A lam? IP c a - . .om a r � �.a TOXIC TORT CLAIM Nov. 71989 BA HELOR This claim is submitted against CONTRA COSI RD A.bVAt to Section 910 et seq of the California Governm co. 1 . Claimant (name & address ) : . MARGARET REAVES , 317 S . 18th Street, Richmond, CA 94804 2. Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road, Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5. Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the above-described site , which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances , or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in the . reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes ..and. said public nuisance . 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing (difficulty ( ) ( ) ( Cold & f lu symptoms /,),� /�r�°t�tee/( ( ) Constipation 12. �y eV.ce ( ) ( ) ( ) Coughing ( ) Chest pain/angina ( ) ( ) ( 'Diarrhea ( c )- Dizziness ( ) Drowsiness ( ) ( ) ( vYEye irritation/inflammation ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( L-KHeadache ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( )- Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) . Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) Vomiting blood ( ) ( ) ( ) Business loss (c-)"Medical expenses ( ) ( 4—Pain & suffering ( ) ( L4Y ( ) Reduced market value , real ( ) ( ) property 7 . Name(s) of public entity employees causing the injury, damage or loss: Unknown 8 . Amount claimed at present, including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October 31, 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: "(If L DRO . DURAN, Esq. 2 �y o m 3 C 2 x t a rm 0 RECEIVED A " M 0 Ul NOV 21989 PHI! RAT-HE!OR r CLERK G-ARD OF SUKRVISORS �s CON--,-COSTA CU U., r0 p 0 t1J o Ln r FJ• rd Fi F- PJ N (D (] b7 0 0 CJ rt rt ,d � (Dad ko (Dn0 A. cro ro L Ln (n � ro tlj c H CD —(M " C. hoop t'.d � rom DO p�9 d m ` CLAIM �• BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $17. 00 Section 913 and 915.4. Please note all "Warnin s" - couilly COU11SG1 CLAIMANT: WILSON, Jeanine «oV i°89 ATTORNEY: Date received yunez:'0,A i!N5553 ADDRESS: 1928 Garvin Street BY DELIVERY TO CLERK ON November 2, 1989 Richmond, CA 94801 BY MAIL POSTMARKED: No Postmark 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: November 3, 1989 Jy1L BATTCHELOR, Clerkeuty a (11VM 01,f A I J n c&-216blli I1.\FROM: County Counsel TO: Clerk of the Board of Supervisors jam ) 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: 11 BY: Deputy County Counsel 111. 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: N O V 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec ion 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N 0 V 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator r IM)TO.: TtAur�g BOARD OF SUPERVISORS OF CONTRA CO� ' e i i�TI�I�� application to; Instructions to Claimant Clerk of the Board P.O. Boz 911 A. Claims relating to causes of action for death or for� injurynto,5�3 person or to personal property or growing crops must be presented not later than the 100th day rafter 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. (Sec. 911. 2 , Govt. Code) 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 , California 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. ntity. -E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end FF this form. RE: Claim by ) Reserved fjer filing stamps RECEIVp 31 Against the COUNTY OF CONTRA COSTA) 1989 - or� � ��- DISTRICT) co H C Vlsoits A. (Fill in name) ) e oeputy . The undersigned. claimant hereby makes claim against the ountyj of Contra Costa or .the above-named District in the sum of $ , 0 ®6;" and in support of this claim represents as follows : ------------------------------------------------------------------------ 1. When did the damage or inj• ry occur? (Give exact date and hour) 41 mw 2. where did the damage or injury occur? (Include city and county) ------------------------------- - -- --- - --- -- --------- ---- _ 3. HOW . dld the damage or injury occur? (Give full details us extra sheets if re wired) IA" L 11 '10 4 What particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? 1010 OIW4� � (over) , �: 5..:,�•,� Zat: ar.e,_the..:names of county or dist-Lict mffIcers, sexv=,is or employeescausing the damage,or injury'? ._ fr ^,�r�:,.,,�r/ On 6. What •damage or injuries do you claim dare + �e.xtent -- of in ' rie or damages claimed. Attach twn est tez :fmr u ata damage) 6 � Cz �41710 7. How was the amount claimed above conpu ? (I the estimated amountof any 1, injury or Zamage4) � 8 . Names and addresses of witnesses , doct�oa:s hvspf.tzis.. 9 . List the _expenditures you made on acc t of- thiz amcc.=Idem-t cor injury: r DATE !TM-1 A-MO 'T r r;l�„ra provides • "'21e alalmi •sii. B& by the claimant SEND NOTICES TO: (Attorney) cor Im score pe—som nm his behalf. ' Name and Address of Attorney A a;wi n: ll s signa-pare IPA I Telephone No. G � re-ILePIMre mv., i V *********************************..*****�t"Ll•�'7�:'7d"}k'71�:'/�:'A:":�':'�I7C�"A°:�,�i']�'�7�C*t7rt7r:�"��•!k'Sk'�",�('�'******* NOTICE; Section 72 of the Penal Code provides: "Every person who, with intent tc, ZIETMaMe, Present-%, f.= allowance or for payment to any state board or offices,, or. , to alr�r c=Mty, it an, city district, ward or village board or offIcez, amsthurized to aL11�� ar pay the same if genuine , any false or fraurllemt c° �, hj_*T ]L,, avcn'unt, voucher or writing, is guilty of a felonv. " ' w� a 0 y �. 7. 7 9� cfl a t�7t W GO W cf? 6 dr P �., S oi l44 ayAQ^ A�p� CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $10, 000 . 00- Section 913 and 915.4. Please note all Tr1 .Counsel CLAIMANT: MC LEAN, ANTHONY CdJY 3 1°8 ATTORNEY: Leandro H. Duran Mertine7; 0A..f',*563 Attorney at Law Date received ADDRESS: 3150 Hilltop Mall Road BY DELIVERY TO CLERK ON November 2, 1989 Suite 58 Richmond, CA 94806 BY MAIL POSTMARKED. November 1, 1989 CERT # P 159 025 901 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: November 3, 1989 JYIL BATTCYELOR, Clerk epuy_ (14-. n Cervelli II. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: JU 9- _J A 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 minutes for this date. e. Dated: N O V 2 8 198 q PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sect 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:_ W O V 2 9 7989 BY: PHIL BATCHELOR by Deputy Clerk 7*:z CC: County Counsel County Administrator RECEIVED NOV 21989 TOXIC TORT CLAIM PHII BATCHELOR CIFRK BOARD OF SUPERVISORS This claim is submitted against CONTRA COSTA COU TY ff Dei to Section 910 et seq of the California Government Co 1 . Claimant (name & address ) : ANTHONY McLEAN, 317 S. 18th Street, Richmond, CA 94804 2. Name & address of person to whom any notices concerning the claim should be sent: LEANDRO H. DURAN Telephone: 415/970-7658 Attorney at Law 3150 Hilltop Mall Road , Suite 58 Richmond, CA 94806 3 . Date when damage or injury occurred: April 15 , 1989 through June 19 , 1989 . 4 . Location of occurrence: A lot at the northeast corner of South 23rd Street and Cutting Boulevard ( formerly the site of a Chevron service station) , City of Richmond, California. 5 . Circumstances of occurrence: PWS , Inc. , a California corporation, excavated and stored toxic-contaminated dirt at the above-described site, which is within a populated urban neighbor- hood, in such a manner as to negligently and tortiously expose the residents of said neighborhood, including claimant, to dangerously toxic substances contained in said dirt, with resultant harm and injury to claimant. Members of the neighbor- hood were exposed to these substances , including claimant, either by direct physical contact with claimant ' s body or by inhalation of toxic gases and fumes released from the substances, or both. The excavation and storage of this contaminated dirt in this manner was either approved and authorized by the above-named public entity in violation of prescribed standards and procedures of statutory and regulatory control of toxic and hazardous wastes, which the entity is charged with administering and enforcing, and in violation of said entity ' s duty to control a public nuisance , or, if not so approved and authorized by said entity, said excavation and storage should have been prohibited and prevented by said entity in .the reasonable and ordinary exercise of its regulatory function and public safety responsi- bility to the public, the community, and to claimant, respecting such toxic and hazardous wastes and said public nuisance. 6 . Description of loss , damage or injury: Claimant has suffered personal injury and/or damage as a proximate result of the above-described occurrence as is hereinafter indicated: Injury/Damage/Loss Which is: Temporary Persistant ( ) Anemia/chronic fatigue ( ) ( ) ( ) Bleeding, oral ( ) ( ) ( ) Bleeding, nasal ( ) ( ) ( ) Bleeding, rectal ( ) ( ) ( ) Bleeding, vaginal ( ) ( ) ( ) Blisters ( ) ( ) ( ) Breathing difficulty ( Cold & flu symptoms �-�/ /�i•�a•G� ( ) ( �� ( ) Constipation ( ) ( ) ( ) Coughing ( ) ( ) ( ) Chest pain/angina ( ) ( ) (vYDiarrhea ( ) ( ) Dizziness ( ) ( ) ( ) Drowsiness ( ) ( ) ( ) Eye irritation/inflammation ( ) ( ) ( ) Fainting ( ) ( ) ( ) Fever ( ) ( ) ( Headache ( ) ( �-)— ( ) Laryngitis ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) Loss of memory ( ) ( ) ( ) Loss of sleep/insomnia ( ) ( ) ( ) Lymphatic swelling ( ) ( ) ( ) Muscle spasms ( ) ( ) ( ) Nausea ( ) ( ) ( ) Nervous distress/anxiety ( ) ( ) ( ) Nervous seizures ( ) ( ) ( ) Sinus irritation ( ) ( ) ( ) Skin rash ( ) ( ) ( ) Skin sores ( ) ( ) ( ) Sore throat ( ) ( ) ( ) Stomach cramps ( ) ( ) ( ) Vision impairment ( ) ( ) ( ) Vomiting ( ) ( ) ( ) Vomiting blood ( ) ( ) ( ) Business loss ( ) ( ) ( LYMedical expenses ( c-Pain & suffering ( ) Reduced market value, real ( ) ( ) property 7 . Name(s ) of public entity employees .causing the injury, damage or loss: Unknown 8 . Amount claimed at present , including estimated amount of any prospective loss: [Exceeds $10 ,000 -- Jurisdiction is in the Superior Court of California] Date of Claim: October -31, 1989 Signature of Claimant or Person Acting on Claimant ' s Behalf: O . DURAN,: Esq. 2 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors 7 0 . 0 0 (Paragraph IV below), given pursuant to Government Code Amount: Section 913 and 915.4. Please note all "Warnings". CLAIMANT: PURCELL, Michael & Joseph County Coons.aP ATTORNEY: GC.T 0 Date received p_ ,,___ e-.,- ADDRESS: 5121 Black Oak Road BY DELIVERY TO CLERK c�-;6Lt"obor' `'27`;}" 989 Concord, CA 94521 hand delivered BY MAIL POSTMARKED: I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. October 30 1989 PPHHIL BATCHELOR, Clerk DATED: BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 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 minutes for this date. Dated: N O V 2_8 1989 PHIL BATCHELOR, Clerk, ByDeputy Clerk WARNING (Gov. code sec 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N O V 2 9 1989' BY: PHIL BATCHELOR byA&4ra4— Deputy Clerk CC: County Counsel County Administrator ,77 *Vaim 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 per- sonal 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. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Res::E filing stamp ED OCT Against the County of Contra Costa ) � or ) R RVISORS District) O Fill in name ) De ut The undersigned claimant hereby makes claim against the County of Contra Costa'-or the above-named District in the sum of $ and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) --afD-hc/_-1-?f-/fes---- ----_2=00_X_L7Z-------------------------------------------- 2. Where did the damage or injury occur? (Include city and county) ---- g�s� en-esk _ T((1 _G'1/ 'L,! __ b� Cl lOn .i! Gil-1ic_ _�fc._ �-Ov/l ---------- ---- ----- ------------- ------- T 3. How did the damage or injury occur? (Give full details; use extra paper if required) --f=�,n or, Ing ----------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? /1/ots;nL7 O°5f61 10 540,W 94&;,j /oc k �.i� Aat G/ec,/ Rorlk5 �rorn rla�- /o4.d (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? AA> G ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. --------See ---------------- ------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ------��-P------ ---- ---------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. ------= -- ------------ _-------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT /o pa�.,.w. _...y..w .., .:: 5a od C7/I LID r� Gov. Code Sec. 910.2 provides: .-;.;: << "The claim must be signed by the claimant SEND NOTICES,TQ,:.,., (Attorne'y) ' ' ' ; or by some person on his behalf." Name and Address of Attorney- Claimants Signature Address Telephone No. Telephone No. 7'n-,!5 r) 5 l N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. CtA IPA, AL ov a� u53 Gp yet cam �t�h . CLAIM A o;S . BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 2 8 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice 'of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $127 . 00 Section 913 and 915.4. Please note all "Warn' s ' "U ty.coclnsel CLAIMANT: HARRISON, Edward William ATTORNEY: Date received c'1Ctltl_e"4 G"` �`•AA ADDRESS: 6433 Flanders Place BY DELIVERY TO CLERK ON October 25 , 1989 Newark, CA 94560 BY MAIL POSTMARKED: October 20 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 25 , 1989 JyIL BeputyLOR, Clerk Il. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: Ia/�S� q B< 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 ( 1,<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. 0 n Dated: N O V 2 8 1!98 9 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: R O V 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator j '^��AINi{ TCS• BOARD OF SUPERVISORS OF CONTRA CO%Te&Rffi i�vftl application to: Instructions to Claimant Clerk of the Board P.O.Box S11 A. Claims relating to causes of action for death or tortrnlnjurynto4533 person or to personal property or growing crops must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to arty other cause of action must be presented not later than one year after the accrual of the cause of action. (Sec. 911.2, Govt. Code) 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; IMartine7 ; California 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 end of -his form. RE: Claim by ) Resery crk��+ stamps .MkkrAf�-Q � RECEIVED vl OCTA5 t Against the COUNTY OF CONTRA COSTA) or' DISTRICT) CLERK BOARO OF SUPERVISORS By CO R COSTA CO. (Fill in name) ) p� t . The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ _ and in support of this claim represents as follows : ------- --------------------- --- -------------------------------------- 1. When--did the damage or injury occur? (Give exact date and hour) -------------------------------'-------c---------------------------------- 2. Where did the damage or n�ury occur? (Include city and county) �o� DOO tom�-10 ST _ -awAefi "Ls k CA _Coil __CosT_�_ - L6.U1 Gi�e-u 3S , use ei 'Lra shee•t':.s if required) �. w►4s 1 A CU S�O �vt- S t t.e gyp, Ztk What-particular act or omission on the part of county or district officers , servants or employees caused the injury or damage? (over) iat� are...the,..names of county or district officers, servants or,- �' ' I employees.-:causing the damage or injury? te( .- -- ------ --------- ------ ----------------------------------=-- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage) OF7 -a� _. � Ste____ ________ __ �_�_n_ . -------------------- ---- ------ S _ __ _ � 7. How was the amount claimed above. computed? (Include the estimated amount of any prospective injury or damage. ) G45,�- Lc-- �'t" S , y►nb wit-� -It� 'CO s - - ��- - -- ------ - ----- -- ------------- 8. Names and addresses of witnesses , doctors and hospitals 9 . J- st the� experid 'tures you made on account of this accident or injury. DAA ,r = _` ITE2d AMOUNT r, Sh�rl` Z6. 00 De�r�,r,er Jeans ys.00 p� shams -,mak.+OP z aro —I i44t is*�t�t**is•**�t*�r�Y is#�c x is�c�c�r*�c is is it�:�t is*�c is�tl is i��=�c**�r�c�h*�c is is is�c�k �s4�tfri�f i ._•.;n:.�^.:.a:sr.,,.: .•�zi-:w�"m+.,,:.,,.,ad Govt. Code Sec. 910 . 2 provides : "The claim signed by the claimant SEND NOTICES TO: (Attorney) or by some oerson on his behalf. " Name and Address of Attorney, Claimant' s Signature Address Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who., with intert to defraud, presents for allowance or for payment to any state board or officer, or to any county, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine , any false or fraudulent claim, bill , account , voucher, or writing , is guilty of a felony. " ` �i RECEIVED aG�C3� 1989 � � pt'ttL(X #ATCNEL4'Ft U+ RK A �(SORB Tf COST,A 101, .0 d r oaf -v 1x i; 3 ``jam�,1 ��• �, ul ~a� N ti Ofx 00 m-� 2 tt} ro 3 C O O q � ya L..,. C? ;F �� j sr ir m I CLAIM /f 5 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1, 192 . 30 Section 913 and 915.4. Please note all "Warnings". county Counsel CLAIMANT: NARDO, Mil a O C T 25 10?9 ATTORNEY: State Farm Mutual Automobile Insurance CompanRate received Martinez, G A ADDRESS: 6400 State Farm Drive BY DELIVERY TO CLERK ON October 24 , 1 QRQ Rohnert Park, CA 94926 BY MAIL POSTMARKED: October 23 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ��IL gATCH-LOR, Clerk DATED: October 25, 1989 : Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: r Dated: 10 2 5 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 minutes for this date. Dated: N O V 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec 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. 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 claimantas shown above. Dated: N O V 2 9 1989 BY: PHIL BATCHELOR by _ Deputy Clerk CC: County Counsel County Administrator STATE FARM State Farm Insurance Companies INSURANCE OO Nn.rnar�n Ca�i� fi� Office October 19, 1989 6400 State Farm Drive R15cr , L Contra Costa County 0C T,:;V q 1989 Clerk Board of Supervisors Administration Bldg. Mott AATCHELCR CLOW 80ARU OF SUKAVISORS 651 Pine Street, Suite 106 CONT COSTA CO. Martinez, CA 94553 •••••••• t Il�OR PLEASE MITE OUR CLAIM NUMBER* ON YOUR REPLY -- OR PAYMENT. THANK YOU. - Re: Our Claim Number: *05 0268 668 Our Insured: Mila Nardo Date of Loss: 8-7-89 State Farm Mutual Automobile Insurance Company on behalf of Subrogee Mila Nardo hereby makes claim for $1,192.30 and makes the following statements in support of' the, claim. 1. Notices concerning this claim should be sent to State Farm Insurance Companies, 6400 State Farm Drive, Rohnert Park, California 94926, referencing the above claim number. 2. The date and place of the accident giving rise to this claim are; on August 7, 1989 ori Eighth Street and Ohio in Richmond. 3. The circumstances giving rise to this claim are as follows: Our policyholder, Mila Mardo, was operating his/her vehicle, when your vehicle, a 1978 Chevrolet, license #E464373, driven by Kurt Hoffman, negligently collided with our insured causing vehicle damage. 4. Our insured's injuries are to the neck. 5. Our total claim is as follows: Ccimpany's Net Payment $ 942.30 Insured's Deductible Interest 250.00 Total Property Damage $1,192.30 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 • STATE FARM State Farm Insurance Companiesam INSURANCE OO Northern California Office Page 2 6400 State Farm Drive Rohnert Park CA 94926.0001 NOTICE: This form is to provide notice of our claim for damages in accordance with the six (6) month statute. If this form is not acceptable for ccnpliance with the statute, please rush the necessary forms to my attention for proper filing. -- ST FARM INSURANCE COMPANIES -- ° Dated: t� %�— By: Sandie Schel Claim Specialist R0AC (707) 584-6425 TP:pn/19-026 AC-51 Encl: Supporting Documents cc: 2731 HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 NORTHERN CALIFORNIA OFFICE • ROHNERT PARK CA 11-4/121( STATE FARM MUTUAL AUTO INS.CO. ®STATE FARM flRE AND CASUALTY CO. FILE COPY r STATE FARM GENERAL INS.CO. FiSTATE FARM LLOYDS NOT NEGOTIABLE 102053768 STATE FARM COUNTY MUTUAL INS.CO.OF TEXAS CAR NO. 004694 CLAIM NUMBER 05-0268-668 PLII,,eY S916-460-05A b01 onrE 08-31-99 p•AVNRTM� DANTE'S BODY SHOP 1405 23RD STREET SAN PABLO GA 94806 ,......__ _ **,,;�**„ «««*+�*++�«,�+►«*+++NINE HUNDRED FORTY—TWO AND 30/100oouARs $*******942 . 30— COVERAGE DATE OLL,I$ION . (L'OMU) 1 08-07-89 wsuREo NAR , ILA ,. 400-1—$ .942. 30 CAL aAUA (J. r } - COOS REPRESENTATIVE ��.. t STATE T.UV. CL UNIT com- ,T 1 941530754 ILHAWK 1169 APPROVED BY _ i ��K�i•1'1�T t aaP_...y g a.;.:, � k:»}+ `rift I 4Te�;f,}+Y.� S �Z:�S,I��;Y�`-�1T�a �i.°�3` +5�t}�Yy+ 't'f1k a i A 31J j�..�{'y..•. is 4 i x+ t J,`sa.. 1�Ti i ��w'��'`�:s� }>usr r uv,w�1.t�-, x.:.<. rw k.Mbx....'-+s,a .Y `S '+�r#h K*•'.' "h �{�s Ar a+it.M a".rM`#w+w+.cw..+�>a—..•. !r .� *t-'!^}+'�F�r A!:TS��rV'. R #�i°ait law"i sy➢.�e�i3 �Wi++i-k �.. }4 ;Lh�I 17i' ;t:.tW r?.'/ .i'ci.:. a,.,i� e i •it � i4 ��,,Y�,s,pp -t7 k s .. _. ....... . ..� , _..,�,,�.:r s. ., �.h`- Ct+?;7 �,. 1 ;�.sfr.r;Ytyrr.: •c wcs A `',+.,,,#g:dx" x`ti�.?,.n :��'.�t to�,.,*;., 'p•; CLAIM NO`/ (o �s �/i/J �� _ ^� X� 5 DATE OF INSPECTK)N&ESTIMATE WHERE WSPECTED/BY WHOM [NUMZ::� - --,INSURED !�,_�{� / T� � �, �+ / (PLEASE PFOM ADDRESS HOME PHONE WORK PHONE EXT. MAKE YEAR SERIES BODY STYLE DATE MANUFACTURED MILEMGE VN 3 �4 - �'zZ-)V RE- oEsal�TloN PMTS LABOR BERN. REPAIR RACE (SEE ABBREVIATION LST ON REVERSE) A UST ms, HRS, $ 3 7'�'. / L D 3 !i g i 9 S i 10 • 12 • 13 . -- 14 • - TOTAL S144 Co = GAO 6111 y '•i. ice. L _ ✓• ♦' CLAIM r (�Z LABOR HRS. S" I AIlT}IORIZE TO VE REAUR HICLE ACCORDING TO REPNR COST AS ITEMIZED./�SCI t t1D r '''�4��,t REF-HRS D THIS APPRaSAL To FF-PMRER BEF "'. ...Z S'�AFTTED TOmL ��-Z PERLABOR HRS X s�HR. -s� DA 'ti PARTS 3 ,.� .,�• OUST s LESS_e") x Disc. SALES we 32-'Z S; WE ACCEPT REPAIR COSTS ASMMLMD, TAX c PAINT.MATERIALS.3 NET ITEMS s 2 DA �^ S1GNA HAVE BEEN THE I �TIE coMPANY 7O MAKEP0rrMErtr �$LESS •- �- Tout REPAIR COST sLL1 Z3 OF s� O TO THIS REFW SHOP ON MY BEHALF. RMENT S DO NO SIGN UNTIL REPAIRS EN COMPLETED TO YOUR SATISFACTION. IOR DAMAGE $ ` ATE— DUCTIBLEI PATE THIS FORM ISSUED TOTAL DEDUCTIONS$ _ STATE FARM CL IM (fA + COMPANY TO PAY s/ REPRESENTATIVE SIGNATURE REPAIR SHOP.RETURN THIS OFifGWAI-F Rg1/InENT 70 CLAIM OF' J OWNER TO PAY� c — NOTICE - REPAIRS TO THIS VEHICLE MA SEE REVERSE FOR STATE FARM'S AUTO DAMAGE CCAf `ICY RTGME SPECIFIC WELDING EQUIPMENT -A RECOMMENDED BY THE MANUFACTUREI `yet\ t,:.•. ?r� map eW s a �y OD (ITS own IBM 813 z ; b CS1 3� C-) n — Q a m `5 fD n, C7 c+ C+ Q r+ Z �' App �, QA 1 ' (D O O n ;-4 A" n Q Z Vi (/> 0 G1'O c'+ WGLO (DtG m D2 C.,. -5 7D A to ice._ i N• 0 �,✓IrYdn ali�}1} o s n CD i�rt of CD Zi a � N aaaauuua - caapg I r,. r�f j •t�, a y CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 281 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $53 . 00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: COX, George A. ATTORNEY: Date received ADDRESS: 510 Winston Drive BY DELIVERY TO CLERK ON October 24, 1989 Pleasant Hill , CA 94523 BY MAIL POSTMARKED: hand delivered 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ee g9 DATED: October 25 , 1989 BtIL DeputyLOR, Clerk I1. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: to bed q BY=- I Deputy County Counsel 111. 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 0R DE By unanimous vote of the Superviscrs present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:N O V 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se ' A13) 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: Nov 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator J. Claim, to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY L• INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal 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. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Rese ____ k's ___ tamp V -) RECEIVED dd�v� OCT -OL/1989 Against the County of Contra Costa ) 62:?S P./;I PHIL BATCEL HO.^. or BOARD C :SU RVISC:ii District) YJ Fill in name ) The undersigned claimant hereby makes clagn against the County of Contra Costa or the above-named District in the sum of $ c� and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) x � 2. Where id the damage or injury occur? (Include city and count ) / 3• How did the damage or injury occur? (Give full details; use extra paper A53 ,required) ------------------------- ------ --- ----- -- 1__� _�" T ---- ---------- --- 4. What articular act or omission on the art of c my or strict officers P P , servants or employees caused the injury or damage? , ---- / (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? --------- ---��-- - ------------------------- 5. What damage or injuries o you claim sulted? (Give full extent of injuries or damages claimed. Attach two estimat4s for auto damage. ----------------------- - - 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) x -------------------------- --- =- .-�'------------------- ----------- 8. Names and addresses of itnesses, doctors and hospitals. �z c� ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney laimant's ig ture Address Telephone No. Telephone No.�/ � L * * * * V N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state.prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. AmENDtO CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 2 8 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $ 50 , 000 . 00 Section 913 and 915.4. C6kjhtall "Warning t vs". urs�0 CLAIMANT: WAPNIARSKI , Bogdan and May OCT 3 1 �3 ATTORNEY: Michael J. Cochrane Nelson & Leighton Date received ADDRESS: 665 South Hartz Ave . , Ste . 210BY DELIVERY TO CLERK ON October 27 , 1989 (via Cnty Danville , CA 94526 Counsel) BY MAIL POSTMARKED: October 26 , 1989 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. October 30 1989 PpHHIL BATCHELOR, Clerk DATED: , BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: 1)•-i 1 dh;- \1 'MQ� �-! Deputy County Counsel Dated: `� BY: III. FROM: Clerk of the Board TO: County Counsel (1) County inistrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (k 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:—NOV 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sectn 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: N O V 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator . � MICHAEL J. COCHRANE County counsel 1 NELSON & LEIGHTON OCT 2 j 1989 665 South Hartz Avenue, Suite 210 Martinez, 2 Danville , California 94526 �a 94-5,53 3 Telephone : ( 415) 837-80197. 7 f1 LL 4 Attorney for Claimants Bogdan and May Wapniarski OCT 2 71989 5 �11L BATCHELOR CLERf(BOARD OF SUPERVISORS 6 Cor.::>n csTA co. 7 AMENDED CLAIM AGAINST PUBLIC NTITY 8 9 TO CITY OF MARTINEZ AND COUNTY OF CONTRA COSTA : 10 Bogdan and May Wapniarski hereby makes claim against the City 11 of Martinez and the County of Contra Costa for the sum of Fifty 12 thousand dollars and makes the following statements in support of 13 the claim: 14 15 1 . Claimants ' address is 568 Sherree Drive, Martinez , 16 California 94553 , in the County of Contra Costa. 17 18 2. All notices concerning the claim should be sent to 19 Michael J. Cochrane, Nelson & Leighton , 665 South Hartz , Suite 20 210 , Danville, California 94526 21 22 3 . The place of the occurrence giving rise to this claim is 23 568 Sherree Drive, Martinez , California 94553 , in the County of 24 Contra Costa. The date of the occurrence is ongoing: the claim 25 is made for damages sustained to the subject property as a result 26 of an active landslide . This claim is made for damages sustained 27 28 -1- as a result of a landslide which occurred on or about October 1, 1 1989 . 2 4. The circumstances giving rise to the claim are as follows: 3 (a) Inverse Condemnation: As one theory of recovery , 4 5 — claimants assert that the circumstances giving rise to the claim are as follows : Claimants are the owners of the property located 6 7 at 568 Sherree Drive, Martinez , California 94553 . Claimant is 8 informed and believes , and thereon claims , that the City of 9 Martinez and the County of Contra Costa planned, approved, 10 constructed , maintains , and operates the public roadway , drainage 11 improvements , and adjacent easement known as Reliez Valley Road, 12 which roadway , drainage improvements , and easement adjoins the 13 subject property. An active landslide has formed within the 14 easement maintained by the City of Martinez adjacent to the 15 subject property. The landslide has intruded into claimants 16 property causing actual physical damage to the subject property 17 and its appurtenances , as well as causing damages in the nature of 18 diminution of value of the subject property. The proximate cause 19 of the damage is the City of Martinez and the County of Contra 20 Costa actions and failures to act in planning , approving , 21 constructing, operating and maintaining the roadway, drainage 22 improvements , and the adjacent easement . Claimants have met and 23 conferred with various members of the City of Martinez , several of 24 whom have admitted that an active landslide exists in the City of 25 Martinez owned easement adjacent to the subject property. In 26 addition, various members of the City of Martinez have admitted 27 28 -2- 1 that the active landslide has intruded onto and is causing damage 2 to the subject property. 3 (b) Private_Nuisance : As one theory of recovery, 4 claimants assert that the circumstances giving rise to the claim 5 are as follows : Claimants are the owners of the property located 6 at 568 Sherree Drive , Martinez , California 94553. Claimant is 7 informed and believes , and thereon claims , that the City of 8 Martinez and the County of Contra Costa planned , approved, 9 constructed, maintains , and operates the public roadway, drainage 10 improvements , and adjacent easements known as Reliez Valley Road , 11 which roadway, drainage improvements , and easement adjoins the 12. subject property. An active landslide has formed within the 13 easement maintained by the City of Martinez adjacent to the 14 subject property. The landslide has intruded into claimants 15 property causing actual physical damage to the subject property 16 and its appurtenances , as well as causing damages in the nature of 17 diminution of value of the subject property. The proximate cause 18 of the damage is the City of Martinez and County of Contra Costa 19 actions and failures to act in planning, approving, constructing 20 and maintaining the roadway , drainage improvements , and the 21 adjacent easement. The active landslide is injurious to the 22 health of claimants , and is an obstruction to the free use of 23 property, so as to interfere with the the claimants ' right to 24 comfortable enjoyment of life and property. 25 (c) Public Nuisance : As one theory of recovery, 26 claimants assert that the circumstances giving rise to the claim 27 are as follows: Claimants are the owners of the property located 28 -3- 1 at 568 Sherree Drive, Martinez , California 94553. Claimant is 2 informed and believes , and thereon claims , that the City of 3 Martinez and the County of Contra Costa planned, approved, 4 constructed , maintains , and operates the public roadway , drainage 5 improvements , and adjacent easements known as Reliez Valley Road, 6 which roadway , drainage improvements , and easement adjoins the 7 subject property. An active landslide has formed within the 8 easement maintained by the City of Martinez adjacent to the 9 subject property. The landslide has intruded into claimants 10 property causing actual physical damage to the subject property 11 and its appurtenances , as well as causing damages in the nature of 12. diminution of value of the subject property. The proximate cause 13 of the damage is the City of Martinez and the County of Contra 14 Costa' s actions and failures to act in maintaining the roadway, 15 drainage improvements , and the adjacent easement . Claimants 16 assert that the inadequately planned , approved , designed , 17 constructed , and maintained improvement , roadway, drainage 18 improvements , and easement adversely affects all private 19 properties owned adjacent to the roadway, drainage improvements , 20 and easement by threatening the aforementioned privately owned 21 properties with inundation from earth, debris , water and the 22 removal of lateral and subjacent support . Claimant is informed 23 and believes , and thereon alleges , that the only known active 24 landslide along the roadway is located in the easement adjacent to 25 their property, and has in fact entered across their property 26 line , causing claimants direct physical injury to their property 27 different from that suffered by the general public. 28 -4- 1 (d) Negligence : As one theory of recovery, claimants 2 assert that the circumstances giving rise to the claim are as 3 follows: Claimants are the owners of the property located at 568 4 Sherree Drive, Martinez , California 94553. Claimant is informed 5 and believes , and thereon claims , that the City of Martinez and 6 the County of Contra Costa planned , approved , constructed, 7 maintains , and operates the public roadway, drainage improvements , 8 and adjacent easements known as Reliez Valley Road , which roadway , 9 drainage improvements , and easement adjoins the subject property. 10 Claimants ' are informed and believe , and thereon allege , that the 11 City of Martinez and the County of Contra Costa have a duty to 12 inspect and maintain the roadway , drainage improvements , and 13 easement collectively known as Reliez Valley Road. Claimants ' are 14 informed and believe , and thereon allege , that the City of 15 Martinez and the County of Contra Costa have breached this duty by 16 allowing the roadway , drainage improvements , and adjacent easement 17 to fall into a state of disrepair . That as a proximate cause of 18 this state of disrepair of roadway , drainage improvements , and 19 adjacent easement , an active landslide has formed, said active 20 landslide intruding into the Claimants ' private property and 21 physically damaging same and its appurtenances , as well as causing 22 damages in the nature of diminution of value of the subject 23 property. 24 (e) Trespass : As one theory of recovery, claimants 25 assert that the circumstances giving rise to the claim are as 26 follows : Claimants are the owners of the property located at 568 27 Sherree Drive, Martinez , California 94553. Claimant is informed 28 -5- and believes , and thereon claims , that the City of Martinez and 1 2 the County of Contra Costa planned , approved , constructed, 3 maintains, and operates the public roadway, drainage improvements , 4 and adjacent easements known as Reliez Valley Road , which roadway, 5 drainage improvements , and easement adjoins the subject property. That an active landslide has formed in the easement owned and 6 7 maintained by the City of Martinez adjacent to Reliez Valley Road, 8 and said active landslide has physically trespassed into the 9 Claimants ' private property and that said trespass has physically 10 damaged Claimants ' private property and its appurtenances , as well 11 as causing damages in the nature of diminution of value of the 12 subject property. 13 (f) Dangerous Condition : As one theory of recovery, 14 claimants assert that the circumstances giving rise to the claim 15 are as follows : Claimants are the owners of the property located 16 at 568 Sherree Drive , Martinez , California 94553. Claimant is 17 informed and believes ,- and thereon claims , that the City of 18 Martinez and the County of Contra Costa planned , approved, 19 constructed, maintains , and operates the public roadway, drainage 20 improvements , and adjacent easement known as Reliez Valley Road , 21 which roadway, drainage improvements , and easement adjoins the 22 subject property. An active landslide has formed within the 23 easement maintained by .the City of Martinez adjacent to the 24 subject property. The landslide has intruded into claimants 25 property causing actual physical damage to the subject property 26 and its appurtenances , as well as causing damages in the nature of 27 diminution of value of the subject property. The proximate cause 28 -6- 1 of the damage is the City of Martinez and the County of Contra 2 Costa ' s actions and failures to act in planning , approving , 3 constructing , operating and maintaining the roadway, drainage 4 improvements , and the adjacent easement . Claimants have met and 5 conferred with various members of the City of Martinez , several of 6 whom have admitted that an active landslide exists in the City of 7 Martinez owned easement adjacent to the subject property. In 8 addition, various members of the City of Martinez have admitted 9 that the active landslide has intruded onto and is causing damage 10 to the subject property. Claimants assert that the City of 11 Martinez and the County of Contra Costa , with actual and 12 constructive notice of the condition , have caused a dangerous 13 condition to exist ; to wit ; an active landslide in an easement 14 owned and maintained by the City of Martinez . 15 5 . Claimant ' s injuries are as follows : 16 (a) Damage to real property in an amount in excess of 17 twenty-five thousand dollars . 18 (b) Damage due to diminution of value of real property 19 in an amount in excess of than twenty-five thousand dollars . 20 (c) Engineering costs and legal fees in an as yet 21 unknown amount . 22 23 6 . The names of the public employees causing the claimants ' 24 injuries are unknown. 25 26 7 . The claimant ' s claim as of the date of this claim is 27 fifty thousand dollars . 28 -7- 8. The basis of computation of the above amount is as 1 2 follows : Estimating the total of 5 . (a) , 5 . (b) , and 5 . (c) . 3 DATED : to a5/31 NELSON & LEIGHTON 4 � 5 6 By: Michael J. Cochrane On Behalf of Claimants 7 Bogdan and May Wapniarski 8 9 10 11 12. 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 -8- DECLARATION OF SERVICE BY MAIL 1 2 I , the undersigned , declare: 3 That I am a citizen of the United States , over the age of 4 eighteen years , and not a party to the foregoing action; that my 5 business address is 665 South Hartz Avenue , Suite 210 , Danville, California. 6 7 That on October 26, 1989 , I served copies of the foregoing 8 AMENDED CLAIM AGAINST PUBLIC ENTITY by placing them in envelopes addressed as follows: 9 Philip Althauf 10 Office of County Counsel County of Contra Costa 11 P. O. Box 69 12 Martinez , California 94553 13 Jack E. Garner City Manager 14 City of Martinez 525 Henrietta Street 15 Martinez , California 94553-2394 16 which envelopes were then sealed and deposited, postage 17 prepaid , in the United States mail at Danville , California; 18 that there is regular service by mail between the place of 19 deposit and each of the foregoing addresses . 20 I declare under penalty of perjury that the foregoing 21 is true and correct . 22 Executed October 26, 1989 at Danville, California. 23 24 Lisa McNeil 25 26 27 28 -9- VICTOR J. WESTMAN TO CONTRA COSTA COUNTY COUNSEL �• P.O. Box 69, CO. ADMIN, BLDG., • MARTINEZ, CA 94558 DATE SUBJECT_ ` 1 Y ! OCT,2 7 1989 i h?.St,TCt- OR s AMENDED _ CLAIM �•�� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November, 28, 1989 and Board Action.. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $150 . 00 Section 913 and 915.4. Please note all "Warnings". Counsel CLAIMANT: WILLIAMS, Eugene NOV 1°8,g_ ATTORNEY: Date received artq 8Z9 .CA+f;V4�,15A ADDRESS: P.O. BOX 1504 BY DELIVERY TO CLERK ON October , Pittsburg, CA, 94565 BY MAIL POSTMARKED: October 27, 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. November 3, 1989 PpHHIL BATCHELOR, Clerk a DATED: BY: Deputy rL 00 vu, Anh Cervelli 11. 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: 11 13 171 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 minutes for this date. NOV 2 8 1989 Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se on 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:— NOV 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator � � \ "-04 Or r w ƒ I 4 \ 4 ® \0 # \ a » ^ � ct e g > 9 t \ 0 Oo > ® ° ^ / %/ o < � � \ ^ J ® @ / o b � � G A ® z Z.,A � e �4 `tea t h � V K4 c 0 CLAIM r; N BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 281 1989 and Board Action. All Section references are to } The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $ 8 5 0 . 0 0 Section 913 and 915.4. Please note all "Warnings". ` County GounsciE CLAIMANT: DAWSON) Ricky Leon OCT 3 L' IV01,23- ATTORNEY: Date received a I .:-:"+3 ADDRESS: 1641 Vincent Street BY DELIVERY TO CLERK ON October 27 , 1989 Pittsburg, CA 94565 BY MAIL POSTMARKED: October 26 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. October 30 1989 PpHHIL BATCHELOR, Clerk DATED: : Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �LQ 121 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 ( his Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy o.f the Board's Order entered in its minutes for this date. Dated:N OV 2 8 19R9 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: NOV 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator T- NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Ric y Leon Dawson 1641 Vinc-bRtSt. Pittsburg, CA 4565 Re: Claim of RICKY LEO DAWSON 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: 1 . 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. x 6 . The claim is not signed by the claimant or by some person on his behalf . 7 . Other: V--I-C 7 WESTMAN, County Counsel By: _P Deputy County C 1 CERTIFICATE .OF SERVICE BY MAIL C.C.P. §§ 1012, 1013a, 2015.5; Evid. C. 99 641, 664) My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and 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(s) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelope(s ) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: �! _ ` \��,� , at Martinez, California. y 0 1 cc: Clerk of the Board of Supervisors (ori final) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910. 2, 920 .4, 910. 8) • 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 per- sonal 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 ca ise of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than.one year after the accrual of the cause of action. (Govt. Code §911.2. ) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp > RECEIVED (ARrAgainst the County of Contra Costa ) Via- -,-r or ) OCT-3- 1 M9 PHIL BATCHELOR Q District) CLERK BOARD OF SUPERVISORS C T COSTA CO. Fill in name ) o The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum-of $ / U, and in support of this claim represents'�as follows':,. ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) --- -S- - --------------------------------------------------------------------- 2. ere did the damage or injury occur? (Include city and county) -____J14-1u/________________________ ____-__________ 3. How did the damage 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? (over) 5. What are the names of county or district officers, servants or employees causing: the damage or injury? ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. - ----------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) - ----------------------------------------------------------------------------------- 8.. Names and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------------------- 9• List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT ` Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: ....(Attorney'), _ or by some person on his behalf." Name and Address of.--Attorney Claimant's Signature Address 4g2 Telephone No. Telephone No. # # # # # # # # # # # # # # # I V # # # N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, ,voucher, or. writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. '+ - ,AIM,/TCS,.,:_1, BOARD OF SUPERVISORS OF CONTRA 'COC y §3T urR2Ryi4 application to: ter'^�" ,• Instructions to Claimant Clerk of the Board j P.O.Box 911 A. Claims relating to causes of action for death or tr neinGurynrlo�533 person or to personal property or growing crops must be presented not later than the 100th day 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. (Sec. 911. 2, Govt. Code) 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 , California 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. ntity. -E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at end of this form. RE: Claim by ) Reserved for Clerk' s filing stamps / i I. ..�. ;� ,, Against the COUNTY OF CONTRA COSTA) OCT2 �11989 °r �jNL-Z CD-�K�f DISTRICT) , n-ii,l f%1airica _'1111_11 r`:`;SL CC (Fill in name) ) � oeo,, . The undersigned claimant hereby makes claim against the Cou ty of Contra Costa or .the above-named District in .the sum of $ d1 00 and in support of this claim represents as follows : c f --leu.�2AJ ------------------------------------------------------------------------ 1. When did the damage or injury occur? (Give exact date and hour) 2AWOre—Cd the damage or injury .occur? (include city and county) C 0_L_CS,_Cate- - - 3. How did the damage or ry occur? (Give full detai , use extra sheets if required) t3 l�1ner� -tl�e. � ecLr\SPo2:�e.J �� Pica- _bAWSON ~I-�® ` 1 �' Q4 t2ee _L-jo' V1 _ fib_ ci►�_Glo - 4 . What particular act or omission on the dart o :�un or district ; - officers , servants or employees caused the injury or d ag . (over) :;►: �..::• zat; are...tie...;names of county or district officers , servants or employees-:causing the damage or injury? 6-I� ---- -- -- -- -. What� i damage or • n uries----do----y-ou---claim------resul----t-ed?-- {Give--- -full--- extent- ---- of injor damages claimed. Attach two estMaAZLur 'es es or uto ge 41 7 . How was the amount claimed above computed? (Include the estimated amount of any ospective inju y or damage. ) Wel's 6:erVkLk_e_2e_� _ ---- - --------- ------------------------�� -- -------- 8. Nam-es and addrE!sses of witnesses , doctors and hospitals . �k, 6AJOAeR. _ 130c) �lo•erL �cr� AB�y� Cam) ------------------- --------------------------- -------------------------- 9 . List the expenc".itures you made on account of this accident or injury: DATE ITEM AMOUNT Govt. Code Sec. 910 .2 provides : "The claim signed by the claimant S-END NOTICES TO: i:Attorney) or bv some person on his behalf. ' Name and Address of Attorney Clai ant' s S •_)ITg ture Ce 6L4 t Address Telephone No. Telephone No. (Ll/5-� q.�g 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, town, city district, ward or village board or officer, authorized to allow or pay the same if genuine , anv false or fraudulent claim, bill , account , voucher. or writing , is guilty of a felony. " r �- W) Ilic- h e� Twass +P-a )1s o r tJOe-OL nd eDQDR- W , at e,+� �►- � � ®n O r2 c� 1'5 coo ee-ed. w e.,rc-,e--- e "A co-[L tea, + j Tina o cc+ I ��_d kn d e.�,7 _e S, She �atl-ed 4 k f- L a -Lka+- 0-nscv Lai Q,,sKed wharf uj&s n . Y",Qrn - wh Y P rn- �-- J Cc 11 1 . t,3�ie ei� LA-� ren- din % P 0� 1 tjo-he-.g 1 v rn &+e- c c-)Uk e sh u�� rn jcn+Q-P-e-s • �o a 5-i C � �� -Eh-e- 6L6�'*- CZ. l 16i 5u-pPo5e- -moo. -, b1cod Lo enuf t.y Q,nd 66(A)h . T e..ou"16,n'A vvp cd oy, . m •- X I i CL�h� t,-,Ip •1-0���. mac , � � �h�e� • t • AMENDED CLAIM ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $850.00 Section 913 and 915.4. Please note all "Warnings". (county Counsel CLAIMANT:. DAWSON, Ricky Leon NOV 13 1989 ATTORNEY: Date receivedppez. CA x'4553 ADDRESS: 1641 Vincent Street BY DELIVERY TO CLERK ON November 13, � Pittsburg, CA 94565 BY MAIL POSTMARKED: November 9, 1989 1. FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above-noted claim. DATED: November 13, 1989 gaIL DeputyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors � ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 11 119 BY: Deputy County Counsel 111. 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 (kel 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. n Dated:N O V 2 8 19 89 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se - n 913) Subject to certain excpW ons, 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 0 V 9 198 9 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Y Claim to: BOARD OF' SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to cause. of action for death or for injury to person or to per- sonal property or growing; crops and which accrue on or before December 31, 19879 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 r.,(ot 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 Administr ,ion 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 c:lalii, i8 again iiil7r c tr;ari 011e 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 A&,&,& n )) Rll,,�=VED Aa ins the Ccu ty-of_.nn1 r8. Cost - or ) NOV 1 ;7 1989 `�Y7 • `n�?1 Qt�n lr: District) Pr,_. (;h:-4oR < t near.�o. :, suPFRvisoas Fill in named J p De The undersigned claimant hereby makes claimagainst the Co ty of Contra Costa or the above-named District in the sum of $ !S(>- o and in support of this claim represents as follows: TSI--PP• 9- ----------------------------•----------------y2s 1__t&_----------•--------------------- 1. When did the damage or injury occur? (Give exact date and hour) -- =- -- ----- - -3.Do 5= ------------------------------- 2. Where did the damage or injury occur? (Include city and county) A- 2f aE --------------------------- ----- 3 How did the damage oinjury occur? (Give full details; use extra paper if required) LA,en A-'h-ej IMZou.�h Ja'd 0. hd h e- Qhtkn �_J -P-rcon, +2,°e+ c I ai_r,_e_S _F0 /Ofk-es u n of fih e 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? I17ey `tn PIA+ ')n� c2 a� t2►cky'S Pegs ,�(. (over) 5. What are the names of county or district officers, servants or employees causzg the damage or injury? -TA e y � ;d n`j -"f I l h e (C r)O-h es. ------------------------------------------------------------------------------------ 6. What damage or in;uries do you claim resulted? (GiveTait 11 extent of injuries or damages claimed. Attach'two stimates for auto damageI d n'4- �ew Ropt wi�kowt l,rs �<e l-1. -eA{LL2�es) fl,%5 C&UStd kiS Sfax zo10od. 5bi4e- t, n 4AP1-dmv��• u5it.cs 0.".c- tow�OL-'i hoI cl an���„n -------------------- ----------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) C-t pp-e je AnA-('e�s �1��S o o �o �'SD- 60 low,ea 014N-k(?'e s 'Ll ----------------------I--------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. 12 a—O6 ����sa�, g�Od ------------------------------------- 9. List the expenditu:^es you made on account of this accident or injury: DATE ITEM AMOUNT ON ,,. ...M ,. Gov. Code Sec.' 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) -, or by some,person his behalf." Name and Address of Attorney aimantIs Signature TV-1 4 ! _�- Address Telephone No. I Telephone No. 3 .. tW'V ` N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state bcard or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and -fine. pox � mA � .a co fl �... f\ dt` t CLAIM / a� BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $384. 49 Section 913 and 915.4. Please note all "Wao.ibgfjly Counsel CLAIMANT: RENNER, Colleen B. NOV 3 1089 ATTORNEY: Me.Aim, CA,N4,553 Date received ADDRESS: 2209 Pine Avenue BY DELIVERY TO CLERK ON November 2, 1989 San Pablo, CA 94806 BY MAIL POSTMARKED: No Postmark I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. H gg DATED: November 3, 1989 JYIL DeputyLOR, Clerk An rL 01 yAt i Cervelli II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: I� ' BY: 1 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 minutes for this date. Dated:,N 0 V 2 8 1989 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code sec 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:—NOV 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal 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 Boardoof 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 xg_ RE IJE Against the County of Contra Costa ) NOV or ) aATCHDistrict) ERK ooFSC ACOSFill in name sr The undersigned claimant hereby makes claim ainst the County of Contra Costa or the above-named District in the sum of $ g and in support of this claim represents as follows: IF ----------------------------------- When did the damage or injury occur? (Give exact date and hour) --------- ---------------------- ----------------------------------------------------- 2. Where did the damage or injury occur? (Include city and county) &1417-,,-4 Cel'-57_13 3. How did the qmage or injury occur? (Give full etails; use per if required) _2�a2� 4 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? 5. What are the names of county or district officers, servants or employees cads the damage or injury? ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 4 ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT a + k. ` ` IF yk Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES 70:'!'..;(Attorriey). or by some person on his behalf." Name and,�Address of`Attorriey .f:'.Ycw•..-..r..iwiiK....ra.':6N✓a'sC%>':N .11.9.vY.�Y.V6?R:� Claimant's Signature Address Telephone No. Telephone No. * * * * # * V it * * * * * * * N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. -�i�3s-��� 9S'�6_ CLAIM / BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Cla4m Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $6,540. 00 Section 913 and 915.4. Please note a ' ������Sunsel CLAIMANT: FARMER, Johnny Lee. uv 1 t ATTORNEY: Date received h4artlnez CIN*55 ADDRESS: 2946 Clearland Circle BY DELIVERY TO CLERK ON November 1, 1989 Pittsburg, CA 94565 BY MAIL POSTMARKED: Hand delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. November 3, 1989 PpHHIL ATCHELOR, Clerk DATED: BY: Deputy am 014 AIJ Ann Cervelli I4, FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: )) r a BY:— Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Adminis ator (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: N n v 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code sec 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:—NOV-.2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator Ij Alti u c dam; lr��!� 10 r Css 10 !(A Azi ,a tv, ----------- 0,0 0 YIu It 7L,' 10 v __.- Yv i .I .. _ I i �I �I` �� ' L. I �I. I ! r i. i. i i I ! I I :I V 5 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 per- sonal 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 iswagainst 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 j Reser �� Clerk's fling stamp tit ) RECEIVED 2,410 Against the County of Contra Costa ) NOV Or ) PHIL BATCHELOR CLERK BOARD OX SUPERVISORS District) A� BDeputy U TRA $� C. Fill in name ) c((la, The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ S�(�• D U and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) l g 3; PM ------------------------------------------------------------------------------------ 2. Where did the damage or injury occur? (Include city and county) a,3 VC_ C-/(f.Qv/a - - s�u t� 96,5---`'�'� =�_�Qslc_Co u t,4 --- 3. How did the damage or injury occur? (Give full details; use extra paper if required) a S Ind 6� Floo� - C' a��� be ecrl ,,-e_ I /©�,�eo� f(�/iGfo�P e cc iq.or4l rs ��� �v �Yo�-►� - -dk S0(44G 1&1 0-�' oly pyo �rfy -7-A,< fd tvl loc�� ��sr . Av,J_ L_ct s-= ° d cif__ �_ a h__t ��OV , ------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? � e Ca"V, q ( t S A sa l/Y C' 1 P4� ��/ �e 6 Y l I G� 1 k S' (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? -----�-QJA -t ----- ��- __ �, ------------------------------------- 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages G1 imed. Attach two pstimates for auto damage. f ford pic .t{r - ( OAeve.y Oheve.Ht 0aw,aye fo lApWSfer� (AvI l /MecG701CS -- yG -erL ---- i�,�t�,rs� l��CUi��_C41�S',�tGl. _��� _vt _/D(f�©r=1i�tHrzs_a"ITa��e� 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 1H-5--------- 8. Names and addresses of witnesses, doctors and hospitals.o CdfeV-JC,5 e�, o�rn-i a�Col�e.►-fs Lou�l�� d�-Cae c� /� �-riSo Cle�rlotir�� r d1955c1eOLI—k CfCti, ' a-9. Z C( C�YL�.�,�DC` r 4#5-tLlk7C1� S65 �� to ars gvS �S N�tfSbkr7 eggqscs p�'-tjs�Lj-yggg6� � ------------------------------------------------------------------ Va s ------,Y 9. List the expenditures you made on account of this accident or injury: DATE ITEM - AMOUNT ' I Gov. Code Sec. 910.2 provides: .O'N "The claim must be signed by the claimant SEND k or by some person on his behalf." Name and Ad ryes f,`A,-tQ ne) �w€ (glaimantis Signature kctYIQt, J ri,I- (Address) 5�S Telephone No. Telephone N O T I C E 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 comity, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. I I ! F/OI � '� C� .W)of Y�Ut <<� ,►' lit) , . OI S i v 0., Lu I � , i .... i L. 1 yt it PICTURES WITH ORIGINAL CLAIM IN THE OFFICE OF THE CLERK OF THE BOARD % t '1 r - . % r -- -_....r...__._ _ —_� Fit O!STRATIOI!EXPIRES TYPE LICENSE NUMBER. AUTOMOBILE 03/22/90 ,;.11 f 181V058 A 592032089070103F004G11400 * :0,16895 t 3� i .x L a t it $( I ( r , T ;. .. , F t MAKE _MO .. 'F VEH ID 1G1A808948A127449 1..a; " 0) .._# CHEV•3 BUD s �� ."YEAR MODEL SHOW IS BAS D ON MANUFACTURE(R AND EALER EPRE ENTATIO � 1 ' x ! 1. R S` r BODY TYPE MODEL CYLS.�' DATE FIRST SOLD I:I CLASS 'YR R MODEL TYPE VEH MP NI I 100/00/81'I BF . '' 81 120 G 1 S0 f j . I T., .yL' , i,t_. �`UNLA6 N 3 I Y : ) ° 6 1 t i, a. y .DATE ISSUED ( Ax WC w„WEIGHT ( I-1. e ( TOTAL FEES 1 yAf 04%01/89 " � , " ,, ,. k(; *ft I X5114 t1 a1 �.. 1{ •• 1 +,+ t o f t iii :fi E e ' ,FAR1 IME'R' ,-JO MAUREEN ): ,; ..a... x( .'`07003 R t. 0 1, tl ,s „ �,( :T I:, I G d ; %4 s, I +2 ,.. , L z -� r 94b CLEARL•AND IR ; i' I WF d �F t_ E `z Tei `s. I . 1,1 1. I i ( f. RF1 I.t `, 'c = o PI 7TS'BURG CA 94565 <. 1 LF " 'q = D I t ' �, i� s -:T t a W 1 s Y":.(4 t .-.:+ - .. ! 11 I - PEN -.t N ' 1. E _'� E - ,SIGNATURE-(S)RELEASES INTEREST IN VEHICLE 0- : - (DAT,E) I. I �� + 1 3 4 5' 9. ->i 4.. R -UPON SALE,SELLER MUST SUBMIT NOTICE OF TRANSFER REG.138 •(c F ' 0 It Ij � :i f(i.R_ I' ( ; I oz II F a L ? �1 03 •' �' ;1' T E I �ts a N I II I 3 Iu ;I < .'Yl rl c,H Ij -�1 I '' I)� '}}� '1 1_).j t 05 , TG -"O I (I - Tl1;I (i 1': 1�'� . I 1;t L IR ;L c,. L t E 1• c t t J UT l i R' .D 1 i o I'', I .t y .. t :1 E 3 , E n U Tor �) .j t 1' {'Z'�,� SIGNATURE(S)RELEASES INTEREST IfJVEHICLE DATE 2.3 O 2 717 4 . ,. . . .; .. . . . .t,. - ��SMOG —`R,^,GIS I1 T O E%PIRES•`1T TYPE - LICENSE NU�.IB EN CALIFORNIA 2 1 x I ow Rs IP �EB8 78 31 Q19 f'C'E RTI FICATE '+DO NOT-CARRY IN VEHICLE ° -° t�: -,VERIFY CURR.UI NO 1'�I ',I", - C ";�, ,ENGINE OR 10 NUMDER •MANE Mb ° S�TAPSq I 12585 I GO�JR�' GA M - YEAR MODEL SHOWN'IS BASED ON MANUFACTIIR ER AND DEALER REPRESENTATION :11, -' M - BODY T'!PE MODEL CYLS DATE FIRST SOLO CLASS •Yfl TYPE VEH• MP 9. - R Pu i }L0��08�7�A1 AY:I �� 13zP I 1. tl CA% WC UNLADEN WEIGHT •TAB.NUMBER TOT' L FEE . A DATE IS5UED r . • t; L .; ax I21 � IOZb7,0IR0714?54I � 0 . 3 ' ° E FARMER 'JOHNNY L .t G t W F j T. 16 WAWI]NA CIR �` RF t' i E ,d.(. (x,x`x LF, f� - MARTINZ Cq g455� ;�T. 61, s PEN t� . �r ..: m N' a D1' k I. —i E SIGNATURE 151 RELEASES INTEREST IN VEHICLE x 'DATE tI , N R- 02 L- 2T a 9" -r-w SUB ! I I, ':x , y D'ma TOTALi' v ' . ' , o m O I ':nliJ �� �t ;11 vrtivr If"fVI'Sr3 IE ) . c E.o: L` J `.... <S A` .ct � J J :�l�`G- Gad 1 n TOTAL r;' -(: .. S g ° . c v S(GNATURE:(S)RELEASES-IN o E 2 .. D o '� " ., .. L,o r ATE . ',- INTEREST IN VEHICLE R� c '' ,D . . . ,.RR ..- .H.,. 'WI I .V . 1 4 - 1T. �. .. .. . t I "• .. 'RECORDING REQUESTED BY JUL12 1`+79 Bu-,,, 9437 PAGE169 � RECORDED AT REQUEST OF 96 10 INESTE N TITL_E17.�1ylN, tP!�M� AAND WHEN RECORDED MAIL TO VVL MFJohnny Lee Farmer tAT O'CLOCK NAME �= CONTRA COST/? COUNTY RECORDS c/o Century 21-Barmore Re lty ADDRESS . 2678 Somersville Road FEE $ J. R. OLSSON �- COUNTY RECORDER CITY& Antioch, Ca. 94509 CO!`]TRA COSTA CO. STATE _j TRAIgSFER TAX Titic Order No E-39 219 2 Escrow No. PAID $ g a C() SPACE AB E FOR.RECORDER'S USE MAIL TAX STATEMENTS TO ' Documentary transfer tax :.5 Z r.$ .: NAME ✓Johnny Lee Farmers :Computed on full value of property conveyed, or 2946 Clearland Circle ❑ Computed on full value less liens and encumbrances ADDRESS Pittsburg, Calif. 94565 remaining thereon at time of sale. CITY& Western Tieafi* a Insurance Company STATE y�/jjrZZ '(l/+, Tax Bill No. 097-291-010 Signatureofdeclaranto a nngt fiirm, a C....... 30ibibua l Ora:ut �Drrb , WESTERN TITLE FORM NO. 104 FOR VALUE RECEIVED, Eddie Lee Reames and Vanessa Reames, his wife GRANT-to /Johnny Lee Farmer, an unmarried man all that real property situate in the UNINCORPORATED -- County of Contra Costa ,State of California,described as follows: Lot 10, map of Subdivision 2868, filed November 14 , 1960, Map Book 80, page 3, Contra Costa County records. Dated July 9 19 79• In Z ' Eddie Lee Reames Vanessa Reames STATE OF CALIFORNIA County of Contra Costa On Tuly 9 , 19 79 ,before me,the undersigned, a Notary Public, in and for said State, personally appeared FOR NOTARY SEAL OR STAMP Eddie Lee Reames and Vanessa Reames known to me to be the person S whose name S are subscribed to the within instrument,and acknowledged to me that t heY—executed the same. rr, k 4F OFFICIAL SEAL JUDIT1:1 A. SHELTON NOTARY PUDLIC- CALIFORNIANCONTRA COSTA COUNTY N+y comm. expires OCT 6, 1900 Notary Public l/ MAIL TAX STATEMENTS AS DIRECTED ABOVE END OF DOCUMM, ��y s .............. - - ----- —v--..� CLAIM `R10ARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28, 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "WaredNty G��slTaG^f CLAIMANT: SONGCO, Stephanie OCT 2 S 1989 ATTORNEY: e!grit1sr1,�z,,��%A;'-X*' ' Date received ADDRESS: 2821 Mary Ann Lane #249 BY DELIVERY TO CLERK ON October 23, 1989 Pittsburg, CA 94565 BY MAIL POSTMARKED: October 20, 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 24, 1989 EVIL BATCHELOR, Clerk eputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ) This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 2 5� � BY: I 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 (per This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy o.f the Board's Order entered in its minutes for this date. Dated: NOV 2 8 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code se 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. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shownabove. Dated: N O V 2 9 1989, BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator � � � J�` � T �N ♦iii ''�" ' ' i ,. '�� ������., 5 �,� _ '� •w 1. •, r �"�` v �...,, � f . ''` � ,� 4 �t ++�� r 'n•e • r 'Y t i t 1 • '" r ''i i SSA i i i+ i tE i. i - ,� .. -� , �, � ,�L r.,�_ _, .. *...`.•� rr. 'a. \� �" rr r;'�,�� A ` ate 1'N. � LL r lel ,.aye ,\ \� ..��y \� � � ' � �'� �,,. � ,., s .� � � � � �',a w• i � � � ,� . � �.1'��'f`,.' :' ' v +/ '� t ,` i' 1' ,'� ,' � � ���_ 'i _' � -�: � �.; ..,, y -� � - .� .,,.,,,..= 1 .,.. �, .� he � �� �h` � '' ii SCC .,;"� � - � R 'f ..��ll►► ��t r �.♦ f.�4,r�� �y ..w ' I ~a, . . � -:±: . . � © ©\^ � \ k r/ ». . �� � ��� � �� , d�� ��� ,- , ��" © ' f:� . © . 2 � �\.�_�®\ - : � � y \ / . ��® :� .w>�~� � ^ . w . . . � y/>y��� � ~ y d � © . \ \_ < \»\} \y : / \\ƒ\\ / � - : < 4 . - - \\�»: . \§ ~\� \��«§1 . � li I' � __ � II �I '�� � � � a - '. I �I e Z � �k'�R � � ���� . , �, _ � � �� _ �, «, , _ � �� � �e � �� M I!, � ISI � ��, <# :i i y�y�y{Tji �� gyp, {� Y1f^ l d 1� R �� �, R A y� III '. '� � �� , . � , x �, I i ' � � 11` i r 4 \ ��..,=�' .,• ��, R ` yp R r \,�!' •�,V `f w y} ���*- ��'�` T` � ,\� �pry- ����..'Y` �� �:�♦ F, qty � I�'��'r.7♦ ..,1 y� ,�> v° ��� �k' fi l/Y� � � ,�C 1 3t �` ��, �jr+t ,til r ``: �� a. r Y y rr � � L tis t ��a�J�' $ y�`xd �o s. f � ' � y'r �'+a �G.: ', �w-�_ �~ �� ,' .�� ' ��• t f r,_ -r Lam, s4�y '�'T-•-.�' -� _ y� _ - N Grog ®► MWLIUM ;� 1 ,v oil k S i t 'f i -.3v �� �� �' I _M �� ', 1 I 1, , _ _ - , � �_�_ 0 I � �, ., i .} � � �� �� {S � r'"� ,y ���r v e I �i '�... v SSS +�b#1 1 ���:,r ' i �� i � � i tl �. 1 ,S / - l �, _ I� � .Y 1 � :'� � 7 _ �• �. �, "o- r�; o i' _� �, �� ,.rf ^4 3} Xb,..� '`..Ir " .'.fit iY s � '\ vr ti �� -�..�,�� -mow P� �n k ,�� y -�ar. �,.`14� ' �.: "'�,,��, $"°`N'� T'Q �' t''c,ice'-'`�1yi.7�` p�,Y �t:�L �,:L :..� f � yy .+.'��a.s yam.: k�,+.�`i i,€"—r,,"',4�R��''Rw �i .r'.7 "r `R' —�Y1":._Z,yl:;" t �' �� n. ^,,�,,o r �� q ,L �. _ �: r \ _ a �. ., s� � -�J � .; C .. P_ _. .�. �r" _%r. ��4 te�ee. � .� _� .� `� 'OM1. o �- i — � � _ _A� � �- -_.�- F —\ � � _ yf�: �cq ..__. -... C4�,,.�.7 � `- � fir. :� � _ � � r' ,. � \ rJ )`` �1 `^1 r .£ u . , � j kc s'zc'r��� 9 '�`#3 p ,�_ �'�, � - §. x4� � � � � � / � ~ \�\. � -. �/. \< y y� � » . � : 2 w<» «. , . � ; y. . m�<�K\w � » � . � t2 \°±�> . . c ; \\� <» > �� . �. . � . \�� . . . \ . . . �/�\_ \ � ° �� \a d % � . 1 . ��?. w < /y� . � \ � ��\\ < � . : . . p : . . . � ° � � f � < .� v .a . . � . . . �v . :z�; . , : � \d�« _ : . w�\ � \y� � � ° ` °\ ` � - \\\\��±� z : °® �\���\ r . . ��: .� a � : . : �/«| G \ � � � . . � �t w:. t �� � � '����� %\ � � \«. /�\.\ &�� � _ . � � ����% § � » ? / � \\a � .» � © . .� . . . . . > \ 1 �- ♦i i r�••+, 1 ..M .✓ fin.. 4 •\ �04im 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 per- sonal 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 bytthe 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 ) Reserve or Clerk's filing stamp I AV LCLEFRI ECE11f ) Against the County of Contra Costa ) E' 0CT a3 IJ61) or ) BOARO T SUPERVISORS District) CONTRA OSTA Co. Fill in name ) ep�ty The undersigned claimant hereby makes claim against the. County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: ------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) ----- -"lcr�o►3 ------------------ ---------- -22. Where did the damage or injury occur? (Include city and county) . � Ca t�vT� �Z.aS -------------------------------------- ------------- -------------------------------- 3. ------ -------------p--------- 3. How did the damage or injury occur. (Give full details; use extra paper if 4:_ required)"IV-x� \40WO (HJ 44n� dr�\Je_-Lk),a.L> c4c:t� -{-ham -- U-P -f-h f CI c � � d rl�➢� -w a nd Leo-,�,1 ed c->n -i o� ICI Vv hax( • M� Cam -E-1 +�..D�� � m�,_(c( . ------------------------------------------------------------------------------------ 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? -The 'D-r�n�•-� ��� Lv�-� ��Ge l..t�-�-� (over) 5. What are the names of county or district officers, servants or employees causing• the damage or injury? Cin fra Co—r=-4 . C-our4j --aa nci A - u;> . Sem o ------------------------------------------------------------------------------------ 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. ------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ov , act 4c> ------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. -------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO:. . (Attorney) or by some person on his behalf." Name and Address of Attorney _ . ,.. . . .. .... Claimant's Signat e) address 'p�-I-��bur•-� , Ca ��� Telephone No. Telephone No.(415 5S- �- pp NOTICE �S .W �- Inca G�'Ue -�►'��� Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the-- same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by 'a fine of not exceeding one thousand ($1,000) , or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. n os 0 .A. a c N � O• \ N nN3• s C- m O 7 N m c c� rn � ° 'ZIAN •moo rt ..C, Sv ON I Vol ATO IA �! ist �f� L 4.1 V\ ,o y r � � A CO tl cp �cl r CLAIM J. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against+the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unspecified Section 913 and 915.4. Please note all "Warnings". CLAIMANT: O ' SHEA, Norman and Betty County Counsw ATTORNEY: Jacques Bloxham OCT 3 Q Attorneyat Law Date received ADDRESS: 43 Panoramic Way BY DELIVERY TO CLERK ON Walnut Creet, CA 94595 BY MAIL POSTMARKED: October 25 , 1989 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 30 1989 PpHHIL BATCHELOR, Clerk BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. �v ) 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: �0 f �(a ' `� BY: 0:M 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 minutes for this date, q o Dated: N OV 2 g 1989 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. 'You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: NOV 2 9 1989 BY: PHIL BATCHELOR Aby6]�g" Deputy Clerk CC: County Counsel County Administrator i NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Jac s Bloxham Attorne at Law 43 Panoram Way Walnut Creek, 94595 Re: Claim of NORMAN`. AND BETTY O'SHEA 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: 1 . 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. x 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. 6 . The claim is not signed by the claimant or by some person on his behalf. 7 . Other: VI 0RJ.J. MAN, County Counsel I J By: /� Deputy County C CERTIFICATE OF SERVICE BY MAIL C.C.P. 99 1012, 1013a, 2015.5; Evid. C. §§ 641, 664 My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and 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(s) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelope(s) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: \. 22� at Martinez, California. s cc: Clerk of the Board of Supervisors (orig-inal) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910 . 2, 920 .4, 910 . 8) JACQUES BLOXHAM ATTORNEY AT LAW 43 PANORAMIC WAY • WALNUT CREEK, CALIFORNIA 94595 • (415) 934-6647 • FAX: (415) 947-0172 MVaV ED October 25, 1989 OCT 271989 County of Contra Costa PFUATCHELOR ISQRSUFAS1.RKEOOFERV C? Board of Supervisors A f co. 625 Court Street e Room 106 Martinez, California 94553 Re: Formal Notice of Claim against Contra Costa County Government Code Section 810 et seq. Dear Sirs and Madams : I represent Norman and Betty O' Shea, who reside at 3010 Roundhill Road, Alamo, California. This is a notice to the County, required by the Government Code, that my clients are claiming damage resulting from your employees negligence and disregard of County Ordinance 74-3. 311, UBC Sec. 305(a) . In July, 1988 , Esmail and Fatemeh Behnam bought the home at 3022 Roundhill Road Alamo, California, which is next door to my client 's home. In August 1988 , Mr. Behnam applied for a variance to exceed the side set back in preparation for an addition to his home. In September, my clients sent a letter to Mr. Tony Bruno and followed up the letter with a telephone call requesting that a survey be made before plans or any permits were approved. This was important , because all parties had been informed by my clients that an existing fence between the two homes was not on the property line. In October,1988 Mr. Karl Wandry of the County issued a variance and a permit to build to the contractor, Hossein Khodadad. No survey was required by the county and none was performed. No boundary markers were placed as required under the above code sections . As a result, the plans submitted to the County were inaccurate and did not reflect the actual property line between the two homes. The County approved the inaccurate plans, a permit was given to the contractor, and a structure was built that encroached four feet into the setback granted by the variance. Contra Costa County Board of Supervisors October 25, 1989 Page two In July, 1989, my clients had a survey performed at their own expense which confirmed the above encroachment . Mr. and Ms . O' Shea have been damaged by the proximity of the new structure to their home. They have suffered a loss of their property value. The new structure is a nuisance, as it iterferes with the use and enjoyment of the rural setting of their home. The amount of their damage is within the jurisdiction of the Superior Court . Please send all notices to me at the above address and telephone. Thank you. Siy, 1- /,UELOXHAM J and Betty O' Shea CLAIM. I � BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT November 28 , 1989 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuantve}}rn�ment Code ,Amount: Unspecified Section 913 and 915.4. Please note all ar"rliqOU(naf CLAIMANT: SPECTRUM EMERGENCY CARE INC . CC 7- V J� AND PHILLI-P MOODY M.D. ATTORNEY: Nancy E . Hudgins �y Date received ADDRESS: 605 Market Street, Ste. 700 BY DELIVERY TO CLERK ON October 27 , 1989 San Francisco , CA 94105 hand delivered BY MAIL POSTMARKED: 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: October 30 , 1989 RYIL DeputyLOR, Clerk [I. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). Other: .\s / I� Dated: BY: 1 Deputy County Counsel T � 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: N O V 2 8 19$9 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age .18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: NOV 2 9 1989 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Nanc Hudgins 605 Mar St. , Ste. 700 San Francis CA 94105 Re: Claim of SPECTRUM EMERGENCY CARE INC. and PHILLIP MOODY, M.D. 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: 1 . 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. x 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 ($10,000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. 6 . The claim is not signed by the claimant or by some person on his behalf . 7 . Other: VICTOR J. WESTMAN, C unty Counsel Y' B Q,.- Deput C unty Coun 1 CERTIFICATE OF SERVICE BY MAIL C.C.P. 99 1012, 1013a, 2015.5: Evid. C. SS 641, 6 4) My business address is the County Counsel's Office of Contra Costa County, Co. Admin. Bldg. , P.O. Box 69, Martinez, California, 94553, and I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non Acceptance of Claim by placing it in an envelope(s) addressed as shown above (which is/are place(s) having delivery service by U.S. Mail) , which envelope(s) was then sealed and postage fully prepaid thereon, and thereafter was, on this day deposited in the U.S. Mail at Martinez/Concord, Contra Costa County, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: JP&D\ at Martinez, California. cc: Clerk of the Board of Supervisors iginal) - Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOV.C.§§ 910, 910.2, 920 .4, 910.8) v �. LAW OFFICES OF NANCY E. HUDGINS 605 MARKET STREET.SUITE 700 SAN FRANCISCO,CALIFORNIA 94105 415243-8118 NANCY E.HUDGINS October 27, 198.9 FA. 41$/243-8204 LAURA M.HILLENBRAND 0 3•�/*OF COUNSEL KE AN T.HUNT RECEIVED OCT 17 1989 1 CLERK OF BOARD OF SUPERVISORS PHIL BATCHE CLERK BOARD SU viSORS County Administration Bldg. , Room 106 Co oCTA CO ..�:z. 651 Pine Street a Oautyl Martinez, CA 94553 RE: SPECTRUM EMERGENCY CARE, INC. AND S. PHILLIP MOODY, M.D. Dear Sir/Madam: Enclosed please find an original and one . copy of Defendants' Claim Against the County of Contra Costa and Merrithew Hospital. Please return an endorsed copy to our messenger. If you have any questions, please do not hesitate in contacting the undersigned. Thank you for your anticipated courtesy and cooperation in this matter. Ver truly yours, Sandra Baumgarten Secretary to NANCY E. HUDGINS, ESQ. 1 IN 1 LAW OFFICES OF NANCY E. HUDGINS RECEIVED 605 Market Street, Suite 700 2 San Francisco, CA 9.4105 OCT ;7 1989 Telephone (415) 243-8118 3 PHIL BATCHELOR Attorneys for Claimants CLERK W)ARQ OF SUPERVISORS 4 SPECTRUM EMERGENCY CARE, INC. AND C RA COSTA CO. e .. S. PHILLIP MOODY, M.D. 5 6 7 RE: Claim by ) SPECTRUM EMERGENCY CARE, INC. AND ) 8 S. PHILLIP MOODY, M.D. ) 9 Against the COUNTY OF ) CONTRA COSTA AND MERRITHEW HOSPITAL ) 10 ) 11 The attached Complaint, Contra Costa Superior Court Case 12 No. 309838, is incorporated herein by reference, as Exhibit A. 13 The attached medical records from Merrithew Hospital are 14 incorporated herein as Exhibit B. 15 SPECTRUM EMERGENCY CARE, INC. and S. PHILLIP MOODY, M.D. , 16 hereby make a claim against CONTRA COSTA COUNTY for equitable 17 indemnity and contribution and medical malpractice for all damages 18 and injuries alleged and referred to in the attached Complaint. 19 The exact amount of the damages are unknown. 20 1. The damage occurred on March 4 and 5, 1987, between 21 approximately 9: 30 p.m. and 3 : 00 p.m. 22 2 . Merrithew Hospital, Martinez, Contra Costa County. 23 3 . See Exhibits A and B. The plaintiff' s baby was 24 alive when she arrived at Merrithew Hospital, but then was 25 stillborn. 26 K r N i 4. Alleged negligence by hospital personnel. 1 5. See Exhibits A and B. 2 3 6. See Exhibits A and B. The baby was still born. 7. See Exhibit A. 4 8. See Exhibits A and B. 5 9. Their claim is for equitable indemnity and 6 contribution. 7 Send notices to: 8 9 LAW OFFICES OF NANCY E. HUDGINS 605 Market Street, Suite 700 10 San Francisco, California 94105 11 12 DATED: October 27, 1989 LAW OFFICES OF NANCY E. HUDGINS 13 . BY: Abl' 14 N DGINS Attorne forlaimants 15 SPECTRUM EMERV-EE--NCY CARE, INC. 16 and S. PHILLIP MOODY, M.D. 17 18 19 20 21 22 23 24 v 25 26 -2- I CLYDE I. BUTTS LAW OFFICES OF MARRACCINI BUTTS �ECFR -7 2 1225 Alpine Road, Suite 204 Walnut Creek, CA 94596 J^h. 0LSSON. C00ty Werk(415) 943-1850 •nNITRA vos A C UNT' 4 LAW OFFICES OF JAMES J. SELTZER A Professional Law Corporation 5 2200 Powell Street, 10th Fl. Emeryville, CA 94606 (415 ) 596-2500 7 Attorneys for Plaintiff 8 SUPERIOR COURT FOR CALIFORNIA, COUNTY OF CONTRA COSTA 9 ANNA GRANT, NO: 309838 OQQ3Q 10 Plaintiff, COMPLAINT FOR DAMAGES V. 11 `„FEST CONTRA COSTA HOSPITAL 12 DISTRICT, BROOKSIDE HOSPITAL, SPECTRUM, INC. ,-PHILLIP MOODY, M.D. 13 COUNTY OF CONTRA COSTA, MERRITHEW HOSPITAL, and 14 DOES 1 THROUGH 50, 15 Defendants. 16 PLAINTIFF ALLEGES: 17 GENERAL ALLEGATIONS 18 1. At all times herein mentioned Plaintiff was and is 19 now a resident of Contra Costa County, California. 20 2. Plaintiff is informed and believes and thereon 21 alleges that at all times herein mentioned defendant WEST CONTRA 22 COSTA HOSPITAL DISTRICT (hereinafter DISTRICT) was and is now a 23 hospital district organized and established in compliance with 24 California Health and Safety Code Section 32000, et seq. 25 3. Plaintiff is informed and believes and thereon 26 alleges that Defendant BROOKSIDE HOSPITAL (hereinafter BROOKSIDE) 27 is and at all times herein mentioned was a hospital, as defined LAW OFFICES OF 28 AARAC t.INS r III,"% •j 15 At PINE pO.STE 204 -1- tN� - L-UT COEEK.CA 9496 0 IT I lin California Health and Safety Code Section 1250, located at 2 2000 Vale Road, San Pablo, Contra Costa County, California, j organized, operated and controlled by defendant District. 4 4. Plaintiff is informed and believes and thereon 5 alleges that defendant SPECTRUM, INC. (hereinafter SPECTRUM) was and is now a business entity, form unknown, providing physician's 7 services to hospitals, including defendant BROOKSIDE. Plaintiff 8 is further informed and believes and thereon alleges that 9 defendants SPECTRUM and DOES 26 through 35, and each of them, 10 were and are now in a contractual relationship, form unknown, 11 with defendants DISTRICT and BROOKSIDE, whereunder SPECTRUM 12 provides physicians to work at BROOKSIDE. li 5. Plaintiff is informed and believes and thereon 14 alleges that defendant CONTRA COSTA COUNTY (hereinafter COUNTY) 15 is and at all times herein mentioned was a public entity. 16 6. Plaintiff is informed and believes and thereon 17 alleges that defendant MERRITHEW HOSPITAL (hereinafter MERRITHEW) 18 is and at all times herein mentioned was a hospital, as defined 19 in California Health and Safety Code Section 1250, located at 20 . 2500 Alhambra Avenue, Martinez, Contra Costa County, California, 21 organized, operated and controlled by defendants COUNTY and 22 DISTRICT. 23 7. Plaintiff is informed and believes and thereon alleges 24 that PHILLIP MOODY, M.D. (hereinafter MOODY) is and at all times 25 herein mentioned was a physician licensed to practice medicine in 26 the State of California and was and is now an employee of 27 defendant SPECTRUM assigned to practice at BROOKSIDE. At all 28 times herein mentioned MOODY was on duty as the emergency room LAIN OFFICES OF 25 ALPINE RO_STE.204 -2- &LNVT CREEK.CA 94596 - r ( (, 1 physician at BROOKSIDE and in doing the acts and things 2 hereinafter alleged, acted with the knowledge, consent, 3 permission and authorization of each of his co-defendants and 4 within the course and scope of his duties as a physician. 5 8. Plaintiff is unaware of the true names and capacities, G whether individual, corporate, partner, associate or otherwise of 7 defendant DOES 1 through 50, and therefore sues such defendants 8 by such fictitious names. Plaintiff prays leave to amend this 9 complaint to state the true names and capacities when 10 ascertained. Plaintiff is informed and believes and thereon 11 alleges that each of the defendants designated as a DOE is 12 negligently responsible in some manner for the events and B happenings herein alleged, thereby proximately causing 14 plaintiff's injuries and damages. 15 9• At all times herein mentioned Defendant DOES 1 through 16 50, and each of them, were the agents, servants and employees of 17 each of their co-defendants, and in doing the acts and things 18 hereinafter alleged, acted within the scope of their authority as 19 such agents, servants and employees and with the knowledge, consent, permission and authorization of each of their co- 20 defendants. 21 22 10. Pursuant to California Health and Safety Code Section 23 32492 and California Government Code Section 910, Plaintiff 24 filed claims against defendants DISTRICT, BROOKSIDE, COUNTY and 25 DISTRICT. Said claims, attachedhereto as Exhibit "A" were 26 rejected by Defendants DISTRICT and BROOKSIDE on or about June 27 26, 1987 and by COUNTY and MERRITHEW on or about July 7, 1987. 28 11. At all times herein mentioned Plaintiff was nearing LAW OFFICES OF HARRACCINI&RI-TTS t25 ALPINE FD_STE.204 AIMUT CREEK,EA 94586 1 full term pregnancy. On March 4, 1987 Plaintiff began to 2 experience contractions and a seepage of amniotic fluid. At 3 approximately 9:00 p.m. on March 4, 1987 the contractions had 4 intensified and were occurring at regular 3 minute intervals. 5 An ambulance was summoned and Plaintiff was transported to 6 BROOKSIDE for the impending delivery. At all times throughout 7 the course of her pregnancy and labor, Plaintiff was aware, 8 through sensory perceptions of fetal movements, that the infant 9 she was carrying was alive and viable upon delivery.. 10 12. All damages complained of herein are in amounts yet to 11 be ascertained which exceed the minimum jurisdictional limits of 12 this court. Plaintiff prays leave to amend this complaint to 13 state the correct amount of damages when ascertained. 14 FIRST CAUSE OF ACTION 15 Medical Malpractice (Defendants DISTRICT, BROOKSIDE, 16 SPECTRUM, MOODY and DOES 1 through 35) 17 13. Plaintiff refers to Paragraphs 1 through 12, inclusive 18 and by such reference incorporates them herein as though fully 19 set forth. L0 14. Upon arrival at BROOKSIDE Plaintiff was taken into the 21 emergency room and placed in an examination room. Prior to any 22 examination by a physician, Defendants DOES 1 through 5, and 23 each of them, questioned Plaintiff regarding her ability to pay 24 for any expenses that would be incurred as a result of the 25 delivery of her child. Plaintiff advised DOES 1 through 5, and 26 each of them, that she was unemployed and indigent and that the 27 expenses would have to be paid by Medi-Cal. There were no UW OFFICES OF 28 WARRAf 06141 t.8QrTT\ -4- t25 ALPINE RD.STE,204 •/ •LNUT CREEK.CA 94596 further discussions pertaining to payment of expenses. 2 15. Following questioning regarding her ability to pay, 3 Plaintiff was briefly examined by Defendants MOODY and DOES 6 4 through 10, and each of them. At no time during the course of 5 the examination did Defendants monitor Plaintiff's heart rate, 6 perform an abdominal measurement to ascertain an approximate 7 fetal age, ascertain a fetal heartbeat or place a fetal monitor. 8 Rather, Defendants MOODY and DOES 6 through 10 performed only a 9 cursory vaginal examination, rupturing Plaintiff's +nater bag and 10 thereafter advised Plaintiff she was not sufficiently dilated for 11 delivery. MOODY and' DOES 6 through 10 told plaintiff to arrange 12 transportation to another hospital. Immediately following the 13 examination, Defendants DOES 1 through 5, and each of them, 14 advised Plaintiff she would not be accepted as a patient at 15 BROOKSIDE and to seek further care and treatment at MERRITHEW. 16 16. Following the examination, Plaintiff was placed in a 17 wheelchair by Defendants 1 through 25, and each of them, and left 18 in the emergency room lobby to wait for transportation to 19 MERRITHEW. Although Plaintiff advised DOES 1 through 25, and each of them, that she had no transportation or access to 20 21 transportation, Defendants DISTRICT, BROOKSIDE and DOES 1 through 22 25, and each of them, refused to provide ambulance service to 23 transport Plaintiff to MERRITHEW. Rather, Plaintiff, who had no 24 funds, was told to take a taxi. 25 17. Approximately 2-1/2 hours later, Defendants DISTRICT, 26 BROOKSIDE, SPECTRUM and DOES 1 through 35, and each of them, 27 reluctantly made arrangements to transport Plaintiff to MERRITHEW 28 via ambulance. During this 2-1/2 hour period, Plaintiff received LAWFFOCES OF 4A"ACCANI S'JIV TS 125 ALPINE p0.STE.204 -5- LLNUTCREEK.CA94596 �� I absolutely no medical attention, despite the fact she was 2 obviously in the latter stages of labor, in considerable pain 3 and experiencing intense contractions at regular and brief 4 intervals. Neither Plaintiff's condition nor the fetal 5 condition were checked again prior to Plaintiff being 6 transported to MERRITHEW. 7 18. Plaintiff is informed and believes and thereon alleges 8 that Defendants DISTRICT, BROOKSIDE, SPECTRUM, MOODY and DOES 1 9 through 35, and each of their actions and refusal to treat her 10 arose from an invidious, class based animus against Plaintiff 11 because she was an unemployed, indigent black female with no 12 readily apparent means to pay for hospitalization. 13 19. Plaintiff is informed and believes and thereon alleges 14 that defendants MOODY and DOES 1 through 35, and each of them, 15 negligently breached a duty of care of health care providers by 16 their failure to adequately and properly examine Plaintiff, 17 obtain a fetal heartbeat, place a fetal monitor and prepare 18 Plaintiff for the impending child birth. 19 20. Defendants DISTRICT, BROOKSIDE, SPECTRUM, MOODY and 20 DOES 1 through 35, and each of them, were further negligent in 21 their failure to promptly arrange for Plaintiff to be transported to MERRITHEW once it was determined that she would not be 22 23 accepted for treatment by BROOKSIDE. 21. As a direct and proximate result of Defendants 24 25 DISTRICT, BROOKSIDE, SPECTRUM, MOODY and DOES 1 through 35, and 26 each of their refusal and failure to provide medical services to 27 Plaintiff, the fetus, which had been viable throughout the period of time Plaintiff was at BROOKSIDE, was stillborn .approximately LAW OFFICES OF 28 IMWITT. X225 ALPINE RD.STE.204 _6� •d NALNU7 CfiEEK.CA SASS6 1 120 minutes after Plaintiff arrived at MERRITHEW. 2 22. As a direct and proximate result of Defendants, and 3 each of their refusal and failure to provide medical services to 4 Plaintiff, resulting in the death of the fetus, Plaintiff has 5 suffered profound shock and injury to her body and nervous system 6 all to her damage, according to proof. 7 23. As a further, direct and proximate result of 8 defendants, and each of their refusal and failure to provide 9 medical services to Plaintiff, resulting in the death of the 10 fetus, Plaintiff has suffered and continues to suffer extreme 11 mental and emotional upset and distress, all to her further i� damage, according to proof. 13 24. As a further, direct and proximate result of 14 Defendants, and each of their refusal and failure to provide 15 medical services to Plaintiff, resulting in the death of the 16 fetus, Plaintiff has incurred hospital and medical expenses, all 17 to her further damage, according to proof. 18 25. As a further, direct and proximate result of 19 Defendants, and each of their refusal and failure to provide 20 medical services to Plaintiff, resulting in the death of the 21 fetus, Plaintiff has incurred funeral and burial expenses, all to her further damage, according to proof. 22 �3 WHEREFORE, Plaintiff prays judgment as hereinafter set forth. 24 25 26 27 28 / UW OFFiC£S OF MA■RA1:('INI a-81-TTS '*25ALPINE AD.STE.?W -7 "LNUT CREEK.CA SA596 1 r f.r 1 SECOND CAUSE OF ACTION 2 Violation of Statutory Duty (Defendants DISTRICT, BROOKSIDE, SPECTRUM, 3 MOODY and DOES 1 through 25) 26. Plaintiff refers to Paragraphs 13 through 21, 5 inclusive, and by such reference incorporates them herein as G though fully set forth. 7 27. At all .times herein mentioned, California Health and 8 Safety Code Section 1317 was in full force and effect and binding 9 upon Defendants DISTRICT, BROOKSIDE, SPECTRUM, MOODY and DOES 1 10 through 35, and each of them. 11 28. Said Section provides, in part, that emergency services 12 shall be provided to any person requesting such services or care 13 without first questioning the patient or any other person as to 14 the ability to pay, provided that the patient or legally 1S responsible relative or guardian shall execute an agreement to 16 pay for services or otherwise supply insurance or credit 17 information promptly after the services are rendered. 18 29. Defendants DISTRICT, BROOKSIDE, SPECTRUM, MOODY and 19 DOES 1 through 35, and each of them, breached the statutory duty Z0 to provide emergency medical services to Plaintiff by refusing to 21 render any emergency medical treatment, other than a cursory 22 examination, during the time she was at BROOKSIDE, despite the 23 fact that Plaintiff was in the latter stages of labor as 24 hereinabove alleged. 25 30. Defendants, and each of them, further breached the 26 statutory duty to provide emergency medical services to Plaintiff 27 by initially questioning her ability to pay for the services uw OFFICES of 28 MARRACCINI k MITTS -8- 225 ALPINE AO_STE.204 O UINUT CREEK,CA 946596 1 prior to rendering any services and by failing to allow Plaintiff 2 to execute an agreement to pay for the services rendered and/or 3 by failing to allow Plaintiff to provide any insurance or credit 4 information. 5 31. Plaintiff is informed and believes and thereon alleges that Defendants, and each of their refusal to provide emergency 7 medical services to her arose from an invidious class based 8 animus because she was an unemployed, indigent black female with 9 no readily apparent means to pay for hospitalization. 10 32. As a proximate result of Defendants DISTRICT, 11 BROOKSIDE, SPECTRUM, MOODY and DOES 1 through 35, and each of 12 their breach of statutory duty by refusing to provide Plaintiff 13 with emergency medical treatment, the fetus, which had been 14 viable throughout the period time Plaintiff was at BROOKSIDE, was 15 stillborn approximately 20 minutes after Plaintiff arrived at 16 MERRITHEW. 17 33. As a direct and proximate result of Defendants, and 18 each of their breach of statutory duty, resulting in the death of 19 the fetus, Plaintiff sustained profound shock to her body and 20 nervous system, all to her damage according to proof. 21 34. As a further, direct and proximate result of 22 defendants, and each of their breach of statutory duty, resulting 23 In the death of the fetus, Plaintiff has suffered and continues 24 to suffer extreme mental and emotional upset and distress, all to 25 her further damage according to proof. 26 35. As a further, direct and proximate result of 27 Defendants, and each of their breach of statutory duty, resulting in the death of the fetus, Plaintiff has incurred LAW OFFICES OF 28 MAwKACCINt M At-TTS n _ t23 AL GINE PD_STE.204 -9-- ALNUT CREEK.CA 94596 I hospital and medical expenses all to her further damage, 2 according to proof. 3 36. As , a further, direct and proximate result of defendants 4 and each of their breach of statutory duty, resulting in the 5 death of the fetus, Plaintiff has incurred funeral and burial expenses, all to her further damage according to proof. The 7 policies and procedures further require that a fetal tone be 8 obtained. 9 WHEREFORE, Plaintiff prays judgment as hereinafter set 10 forth. 11 THIRD 'CAUSE OF ACTION 12 Violation of Express Policy ( Defendants DISTRICT, BROOKSIDE, MOODY, 13 and DOES 1 through 25) 14 37. Plaintiff refers to Paragraphs 13 through 21, IS inclusive, and by such reference incorporates them herein as 16 though fully set forth. 17 38. At all times herein mentioned, Defendants DISTRICT and 18 BROOKSIDE had in effect policies and procedures to be followed 19 pertaining to admitting obstetrical patients to the emergency 20 room. 21 39. Said policies and procedures require that all 22 obstetrical patients who present to the BROOKSIDE emergency 23 department at greater than 20 weeks gestation, with any symptoms 24 relating to the pregnancy, regardless of the payment source, will 25 be examined by the Emergency Department physician, referred to 26 the OB/GYN on-call physician and directed to the Women' s Center 27 as appropriate. Said policies and procedures further require LAW OFFICES OF 28 YARRACCINI L 111'T►J -10- 225 ALPINE PD.STE.204 +AI MUT CREEK.G 94596 1. that a fetal heart tone be obtained. 2 40. Defendants BROOKSIDE, MOODY and DOES 1 through 25, and 3 each of them, breached the express hospital policy in failing to 4 refer plaintiff to the OB/GYN on-call physician and to direct 5 Plaintiff to the Women's Center to prepare for the impending 6 delivery. 7 41. Defendants, and each of them, further breached the 8 express hospital policy by failing to obtain a fetal heart tone. 9 42. Plaintiff is informed and believes and thereon alleges 10 that Defendants BROOKSIDE, MOODY and DOES 1 through 25, and each 11 of their refusal to refer Plaintiff to the OB/GYN on-call 12 physician and direct her to the Women's Center for the impending 13 delivery arose from an invidious class based animus toward 14 Plaintiff because she was an unemployed, indigent black female 15 with no readily apparent means to pay for hospitalization. 16 43. As a direct and proximate result of Defendants 17 DISTRICT, BROOKSIDE, MOODY and DOES 1 through 25, and each of 18 their breach of express hospital policy, the fetus, which had 19 been viable throughout the time Plaintiff was at BROOKSIDE, was 20 stillborn approximately 20 minutes after Plaintiff arrived at 21 MERRITHEW. 22 44. As a direct and proximate result of Defendants, and 23 each of their breach of statutory duty, resulting in the death of 24 the fetus, Plaintiff sustained profound shock and injury to her 25 body and nervous system all to her damage, according to proof. 26 45. As a further, direct and proximate result of 27 defendants, and each of their breach of statutory duty, resulting p in the death of the fetus, Plaintiff has suffered and continues LAW OFFICES OF 28 MARLM"11.451 A1•'T1) -11- •� 224 ALPINE HO,STE.20A NALNUT CHEEK.CA 94596 I Ito suffer extreme mental and emotional upset and distress all to 2 her further damage, according to proof. 3 46. As a further, direct and proximate result of 4 iDefendants, and each of their breach of statutory duty, resulting 5 in the death of the fetus, Plaintiff has incurred hospital and 6 medical expenses all to her further damage, according to proof. 7 47. As a further, direct. and proximate result of 8 Defendants, and each of their breach of statutory duty, resulting 9 in the death of the fetus, Plaintiff has incurred funeral and 10 burial expenses all to her further damage, according to proof. 11 WHEREFORE, Plaintiff prays judgment as hereinafter set 12 forth. 13 FOURTH CAUSE OF ACTION 14 Breach of Express Policy (Defendants BROOKSIDE, DISTRICT, MOODY 15 and DOES 1 through- 25) 16 48. Plaintiff refers to Paragraphs 13 through 21, 17 inclusive, and by such reference incorporates them herein as IS fully set forth. 19 49. At all times herein mentioned, Defendants DISTRICT and 10 BROOKSIDE had in effect policies and procedures pertaining to the 21 triage categorization of Plaintiffs presenting at the BROOKSIDE 22 emergency room. 23 50. Said policies and procedures require that obstetrical 24 patients presenting with complaints of abdominal pain in 25 pregnancies with greater than 20 weeks gestation, shall be 26 classified as triage Priority I, emergent or immediate care 2p7 patients. LAw OFF1C£S OF 28 MARRA(:(:i NI t ',';7 t25 ALINE AD.SiE.?0� -12 AI NUT C PEEK.U 94596 1 51. Said policies and procedures require that patients 2 classified as Priority I patients have vital signs monitored and 3 entered on the patient's chart a minimum of one time per hour. . 4 Said policies and procedures further require Priority I patients 5 be placed in an emergency department holding bed with vital signs 6 monitored and recorded on the patient's chart and nurse's notes 7 written at least once per hour. 8 52. Defendants BROOKSIDE; MOODY and DOES 1 through 25 and 9 each of them, breached the express hospital policies and 10 Procedures by .failing to categorize Plaintiff as a Triage 11 Priority I patient, by failing to place her in a holding bed and 12 by failing to monitor hers and fetal vital signs and make 13 appropriate entries in Plaintiff's emergency department chart. 14 Rather than following the express policies and procedures, 15 Defendants, and each of them, placed Plaintiff in a wheelchair in 16 the waiting room, providing absolutely no medical attention 17 whatsoever, as hereinabove alleged. 18 53. Plaintiff is informed and believes and thereon alleges 19 that Defendants, and each of their refusal to classify Plaintiff 20 as Priority I patient and place her in a holding bed arose from 21 an invidious class based animus toward plaintiff because she was 22 an unemployed, indigent black female with no readily apparent 23 means to pay for hospitalization. 24 54. As a direct and proximate result of DISTRICT, 25 BROOKSIDE, MOODY and DOES 1 through 25, and each of their breach 26 of express hospital policy, the fetus, which had been viable 27 throughout the time Plaintiff was at .BROOKSIDE, was stillborn 28 approximately 20 minutes after Plaintiff's arrival at MERRITHEW. LAWOFF#CES OF wAKRACUi NI 4!1'TT\ t25 AIPoNE AO.STE.204 —13— ALNUT(;AE£«.C9 94596 1 55. As a direct and proximate result of Defendants, and 2 each of their breach of express policy, resulting in the death of 3 the fetus, Plaintiff sustained profound shock and injury to her 4 body and nervous system all to her damage according to proof. 5 56. As a further, direct and proximate result of 6 Defendants, and each of their breach of express policy, resulting 7 in the death of the fetus, Plaintiff has suffered and continues 8 to suffer extreme and emotional upset and distress, all to her 9 further damage, according to proof. • i0 57. As a further, direct and, proximate result of 11 Defendants, and each of their breach of express policy, resulting 12 in the death of the fetus, Plaintiff has incurred hospital and li medical expenses all to her further damage, according to proof. 14 58. As a further, direct and proximate result of 15 Defendants, and each of their breach of express policy, resulting 16 in the death of- the fetus, Plaintiff has incurred funeral and 17 burial expenses, all to her further damage according to proof. 18 WHEREFORE, Plaintiff prays judgment as hereinafter set 19 forth. 20 SIXTH CAUSE OF ACTION Breach of Statutory Duty 21 (Defendants DISTRICT, BROOKSIDE, SPECTRUM, 22 MOODY and DOES 1 through 35) 23 59. Plaintiff refers to Paragraphs 13 through 21, 24 inclusive, and by such reference incorporates them herein as 25 though fully set forth. 26 60. At all times herein mentioned, Title 22 of the 27 California Administrative Code, Section 70751(g) was in full 28 LAW OFFICES OF 4ARRA1'CINI Y 61'121 725 ALPINE RO_STE.204 —14 AUNT CREEK.CA 94b96 ''� 1 force and effect and binding upon Defendants BROOKSIDE, DISTRICT, 2 SPECTRUM, MOODY and DOES 1 through 35 and each of them. Said 3 section requires that medical records and reports be completed 4 before 14 days after a patient's discharge. 5 61. On or about March 18, 1987, Defendants, and each of b their refusal to provide medical care to Plaintiff was brought to 7 the attention of the news media. Following the media attention, 8 Defendants MOODY and DOES 1 through 25, and each of them, in 9 violation of 22 C.A.C. Section 70751(g) made late and self 10 serving entries in Plaintiff's emergency room chart and MOODY 11 made a late medical narrative report. The late chart entries 12 were made on March 18, 20 and 30, up to 26 days post incident. 13 MOODY's report was not made until March 23, 1987, 19 days post 14 incident. 15 62. Plaintiff is informed and believes and thereon alleges 16 the hereinabove alleged late entries were made in an attempt to 17 and with the intent to conceal Defendant's, and each of their . 18 refusal to provide medical treatment to Plaintiff, as hereinabove 19 alleged, and to shield each Defendant herein from liability. 20 63. As a direct and proximate result of Defendants, and 21 each of their violation of 22 C.A.C. Section 70751(g) , Plaintiff has suffered and continues to suffer humiliation and extreme 22 23 mental and emotional upset and distress all to her damage 24 according to proof. 25 WHEREFORE, Plaintiff prays judgment as hereinafter set 26 forth. 27 f 28 LAW OFFICES OF Ir A 119ACCINI A.PUTTS 17:9 ALPINE AO,STE.?O4 -4^L NUT CREEK,CA 94596 ''� 1 SEVENTH CAUSE OF ACTION 2 Intentional Infliction of Emotional Distress (Defendants DISTRICT, BROOKSIDE, MOODY 3 and DOES 1 THROUGH 35) 4 64. Plaintiff refers to Paragraphs 13 through 21, 5 inclusive, and by such reference incorporates them herein as 6 though fully set forth. 7 65.. At all times herein mentioned defendants DISTRICT, 8 BROOKSIDE, SPECTRUM, MOODY and DOES 1 THROUGH 35, and each of 9 them, refused to provide any medical services to Plaintiff, 10 despite the fact that she was at or near a full term pregnancy I1 and experiencing labor pains, as hereinabove alleged. Rather, 12 said Defendants, and each of them, told Plaintiff to seek care at 13 another hospital, as hereinabove alleged. 14 66. At all times herein mentioned, as Defendants, and each 15 of them, fully aware that Plaintiff was without transportation 16 and had no funds, refused to make any arrangements to have 17 Plaintiff transferred to MERRITHEW via ambulance despite 18 Plaintiff's requests that they do so. Rather than make such 19 arrangements, Defendants advised Plaintiff to find another form 20 of transportation, or specifically to take a taxi cab, as 21 hereinabove alleged. Defendants and each of them, reluctantly 22 made arrangements for ambulance transportation only after a 2-1/2 23 hour wait, and only when it appeared that Plaintiff could not 24 arrange any other transportation, as hereinabove alleged, and 25 would deliver her infant in the waiting room, if arrangements 26 were not made immediately to transport her to MERRITHEW. 27 67. At all times herein mentioned, Defendants DISTRICT, 28 BROOKSIDE, MOODY and DOES 1 through 25, and each of their LAW OFFICES OF MA%SLAIjCjNI&MITT] 1225 ALPINE AO_STE.204 -1 6- - VAI.NUT CREEK.CA 94596 ./ - I conduct, as hereinabove alleged, was malicious, extreme, 2 outrageous, wanton and outside the bounds of all decency, j motivated by an invidious class based animus toward Plaintiff 4 because she was an unemployed, indigent black female with no 5 apparent resources to pay for hospitalization. Said actions and conduct were undertaken with the purpose and intent of causing 7 Plaintiff to suffer humiliation, mental anguish, severe emotional 8 upset and mental distress and with a complete, conscious and 9 callous disregard for Plaintiff's physical health and mental well t0 being and the physical health of her viable fetus. 11 68. At some point following her arrival at MERRITHEW, 12 Plaintiff experienced a profound sense of shock and emotional li trauma and distress when she could no longer sense any fetal 14 movement within the womb. At that point Plaintiff perceived that 15 her baby had died. 16 69. As a direct and proximate result of Defendants, and. 17 each of their extreme and outrageous conduct, and the sensory 18 perception of the death of her child, Plaintiff has suffered and 19 continues to suffer humiliation, degradation, guilt and severe 20 mental anguish and emotional upset all to her damage, according 21 to proof. 22 70. The hereinabove alleged acts of Defendants, and each of 23 them, were willful, wanton, oppressious, malicious and motivated 24 by an intent to discriminate against Plaintiff. Such acts 25 justify an award of punitive damages against each defendant in 26 an amount sufficient to punish Defendants and set an example for 27 others. 28 WHEREFORE, Plaintiff prays judgment as hereinafter set Www OFFICES OF MAKq A('('1N1 'g1•TT] 226 ALPINE RO_STE.704 -17- 'Al NUT CREEK.CA 94596 I forth. 2 EIGHTH CAUSE OF ACTION 3 Negligent Infliction of Emotional District (Defendants DISTRICT, BROOKSIDE, SPECTRUM, 4 MOODY and DOES 1 through 35 ) 5 71. Plaintiff refers to Paragraphs 13 through 21 inclusive, and Paragraphs 65 through 6.7, inclusive, and by such 7 reference incorporates them herein as though fully set forth. 8 72. At all times herein mentioned, Defendants. DISTRICT, 9 BROOKSIDE, SPECTRUM, MOODY and DOES 1 through 35, and each of 1u them, knew, or in the exercise of reasonable care, should have 11 known that their refusal to provide Plaintiff and her viable 12 fetus with medical care and treatment, and arrange for 13 transportation to MERRITHEW, as hereinabove alleged, would cause 14 plaintiff to experience severe emotional distress, mental anguish 15 and humiliation. 16 73. Defendants, and each of them, nevertheless, refused to 17 provide Plaintiff and her viable fetus with any medical care and 18 treatment, and refused to make immediate arrangements for 19 Plaintiff's transportation to MERRITHEW, as hereinabove alleged. 20 74. At some point following her arrival at MERRITHEW, 21 Plaintiff experienced a profound sense of shock and emotional 22 trauma and distress when she could no longer sense any fetal �3 movement within the womb. At that point, Plaintiff perceived 24 that her baby had died. 25 75. As a direct and proximate result of Defendant's, and 26 each of their refusal to provide Plaintiff and her fetus with any 27 medical care or treatment and the sensory perception of the death LAW OFFICES OF 28 4ARRA4 4ANI&' NVTT\ 25 ALPtNE RO.,,SyjE.204 18 I I MUT C QE E K.CA 9a S96 I lof her child, Plaintiff has suffered and continues to suffer 2 humiliation, degradation, guilt and severe mental anguish and 3 emotional distress, all to her damage, according to proof. 4 WHEREFORE, Plaintiff prays judgment as hereinafter set 5 forth. b NINTH CAUSE OF ACTION 7 Medical Malpractice (Defendants COUNTY and MERRITHEW 8 and DOES 36 through 45) 9 76. Plaintiff refers to Paragraphs 13 through 21, 10 inclusive, and by such reference incorporates them herein as 11 though fully set forth. 12 77. Plaintiff is informed and believes and thereon alleges 13 that Defendants COUNTY, MERRITHEW and DOES 36 through 45, and 14 each of them, breached their duty of care as health care 15 providers by failing to perform all procedures necessary to save 16 the life of her viable fetus, including, but not limited to 17 performing a cesarean section delivery rather than a vaginal 18 delivery. 19 78. As a direct and proximate result of Defendants COUNTY, 20 MERRITHEW and DOES 36 through 45, and each of their failure to 21 perform a cesarean section delivery, Plaintiff's child was 22 stillborn. 23 79. As a direct and proximate result of Defendants, and 24 each of their failure to perform a cesarean section, Plaintiff 25 sustained profound shock and injury to her body and nervous 26 system, all to her damage, according to proof. 27 80: As a further, direct and proximate result of 28 Defendants, and each of their failure• to perform a cesarean LAW OFFICES OF VARRA4 CINI{ RI•TT5 I 225 AL PINE AD_STE.204 ••/ -19- I WAIL NUT CREEK.CA 94596 I section, Plaintiff has suffered and continues to suffer extreme 2 mental and emotional upset and distress, all to her further j damage, according to proof. 4 81. As a further, direct and proximate result of 5 Defendants, and each of their failure to perform a cesarean section, Plaintiff has incurred hospital and medical expenses all 7 to her further damage, according to proof. 8 82. As a further, direct and proximate result of 9 Defendants, and each of their failure to perform a - cesarean 10 section, Plaintiff has incurred funeral and burial expenses, all 11 to her further damage, according to proof. 12 WHEREFORE, Plaintiff prays judgments against Defendants WEST 13 CONTRA COSTA HOSPITAL DISTRICT, BROOKSIDE HOSPITAL, SPECTRUM, 14 INC. , PHILLIP MOODY, M.D. , COUNTY OF CONTRA COSTA, MERRITHEW 15 HOSPITAL, and DOES 1 through 50, and each of them for: 16 First Cause of Action 17 1. General damages according to proof; 18 2. Special damages according to proof; i9 Second Cause of Action 20 3. General damages according to proof; 21 4. Special damages according to proof; 22 Third Cause of Action 23 S. General damages according to proof; 24 6. Special damages according to proof; 25 Fourth Cause of Action 26 7. General damages according to proof; 27 8. Special damages according to proof; 28 LAW OFFICES OF 'JAt 61ITf� 122 ALPINE FID_STE.204 _20� ..� W& NUT C92EEK.CA 94596 . l t I Fifth Cause of Action 2 9. General damages according to proof; 3 10. Special damages according to proof; 4 Sixth Cause of Action 5 11. General damages according to proof; 6 12. Special damages according to proof- 7 Seventh Cause of Action 8 13. General damages according to proof; 9 14. Special damages according to proof; 10 15. Punitive damages in an amount sufficient to punish 11 Defendants and set an example for others; 12 Eighth Cause of Action 13 16. General damages according to proof; 14 17. Special damages according to proof; 15 Ninth Cause of Action 16 18. General damages according to proof; 17 19. Special damages according to proof; 18 Each Cause of Action 19 21. Cost of suit incurred herein; 20 22. Attorney's fees, according to proof; 21 23. Prejudgment and postjudgment interest; 22 24. Such other relief as the court deems just and proper. 23 DATED: December 22 1987. 24 LAW. OFFICES OF MARRACCINI & BUTTS 25 C�(z 4�e- 26 OetDE I. BUTTS 27 Attorneys for Plaintiff 28 LAW OFFICES OF MARRACc INI 4 Rt-TTS t275 ALPINE PD..STE.204 -21 .••/ WALNUT CREEK.CA 04596 ' uw OFFICES RICHARD E.MORRIS NORRIS AND NORMS MELANSE RETNOLO3 MORRIS* A MO/CISIONAL CORrON-TM)N M.JErrRET M1CItLAS 2366 MACOOMALO AVEMUE TEICPwOME COLIN J.COrrET (A13) 276-3666 SUSAN It.MORRIS RICHMOND, CALIFORNIA 04804.1902 JOSHUA G.GEMSER rACSIM/lE Ia131 2]a•p3]p Or COUMSCL DOUGLAS C.STRAUS CCE—rICo 1-4.1 4—S.CCuVST NO T I C E Anna Grant c/o Clyde I. Butts Law Offices of Marraccini & Butts 1225 Alpine Road, Suite 204 Walnut Creek, California 94596 Law Offices of James Jay Seltzer 2150 Shattuck Avenue, Suite 600 Berkeley, California 94704 Notice is hereby given that the communication purporting to be a claim by Anna Grant against the West Contra Costa Hospital District was denied by action of the Board of Directors. WARN .IN0 Subject to certain exceptions, you have only six (6) months from the date this notice was personally delivered or deposited in the mail to file a court action on this claim. See Government Code Section 1945.6. 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 immediately. Dated: June 26, 1987 West Contra Costa Hospital District COLIN V General Co & O!��. . .... EXHIS-1 i RETE KENNETH G. JOHNSON, 1 JONES, BROWN, CLIFFORDq& McDEVITT D 2 100 Van Ness Avenue, 19th Floor ;. San Francisco, CA 94102 ' 3 Telephone: (415) 431-5310 APR 4 - 1989 , 4 Attorneys for Plaintiff l r^'ti 7 :,:COr; a c'aTIYCQ RA jTA CCL•.;i 5 6 7 8 SUPERIOR COURT OF THE STATE OF CALIFORNIA I 9 IN AND FOR THE COUNTY OF CONTRA COSTA 10 11 ANNA GRANT, ) Case No. 309 838 12 Plaintiff, ) NOTICE OF CHANGE OF FIRM 13 V. ) NAME AND TELEPHONE NUMBER 14 WEST CONTRA COSTA HOSPITAL, ) DISTRICT, et al. ) 15 ) Defendants. ) 16 ) 17 TO: CLERK OF THE COURT, ALL PARTIES, AND THEIR ATTORNEYS: 18 PLEASE TAKE NOTICE that on January 1, 1989, the firm name of 19 CALDWELL & JOHNSON changed. The new firm name of Kenneth G. 20 Johnson is as follows: 21 JONES, BROWN, CLIFFORD & McDEVITT 100 Van Ness Avenue, 19th Floor 22 San Francisco, CA 94102 Telephone: (415) 431-5310 23 24 DATED: April 3, 1989 JONES, BROWN, CLIFFORD & McDEVITT 25 By ,�� 26 KENNETH TH G. JOHNSON Attorneys for Plaintiff LAW OIIIc Ef Jnvr;y. SRown. . Irvi-Hn &mt-Dr v rT DO VAN NEss AvENUE I 197N 1,000 FNANIS CO. CA 94102 g415 1 a]I-5]10 .. I KENNETH G. JOHNSON Law Offices of 2 CALDWELL & JOHNSON 100 Van Ness Avenue, 19th Floor = ::�:Ta a;£;ti``'T3 3 San Francisco, CA 94102 ^- Telephone: (415) 431-3200 4 Attorneys for Plaintiff 5 6 7 8 SUPERIOR COURT OF THE STATE OF CALIFORNIA 9 IN AND FOR THE COUNTY OF CONTRA COSTA 10 11 12 ANNA GRANT, ) 13 Plaintiff, ) NO. 309838 14 vs ) SUBSTITUTION OF ATTORNEYS 15 WEST CONTRA COSTA HOSPITAL ) DISTRICT, BROOKSIDE HOSPITAL, ) 16 SPECTRUM, INC., PHILLIP MOODY, ) M.D. , COUNTY OF CONTRA COSTA, ) 17 MERRITHEW HOSPITAL, and DOES ) 1 THROUGH 50, ) 18 ) Defendants. ) 19 ) 20 Plaintiff ANNA GRANT hereby substitutes KENNETH G. 27 JOHNSON of the Law Offices of CALDWELL & JOHNSON, 100 Van Ness 22 Avenue, 19th Floor, San Francisco, CA 94102, as one of her . 23 24 25 26 -r I attorneys of record in association with the Law Offices of James 2 J . Seltzer, and in place of and stead of Clyde I . Butts of the 3 Law Offices of Marraccini & Butts. 4- C 5 DATED: A ANNA GRANT 6 I consent to the above substitution. 7 DATED : Z'a Ay �Z� 4izr" 4ze 8 --TCLYDE I . BUTTS • 9 Above substitution accepted. 10 DATED: :74 / ter/ 1 V""cnt 11 AMESJ. ELTZER � DATED: l 12 KENNETH G JOHNSON 13 14 15 16 17 18 19 20 21 22 r 23 24 25 26 -2- 1621C —ADM ISSION/OUTPATIENI P—ISTRATION FORM INPATIEV • ADMIT BY UNIT NO. PREADMIT BY CONTRA COSTA COUNTY HEALTH SERVICES PATIENT NUMBER ^OMIT OATE E WARD/ROOM/BED AM I SERVICE BJRI�"!�T!. AGE IGfON ADMIT JFC,, PT SEX rAR rEL ,'>11%..0 o'd, NO PATIENT NAME TEL NO. DRIVERS LIC.NO. ETH ANN,il 4151 006-0000% PLA PATIENT ADDRESS OWN/RENT HOWLONGOf DATEMMW i t' %3.t.',N 1.16160D CA i 41,106 EMPLOYER(NAME OF 004 W LONG? MP.TEL NO. OCCUPATION PA IE soc SEC.NJ). P P PA A R PATIENT T F I E i j 0 9 5' I EMPLOYER OYER ADDRESS STREET CITY STATE ZIP VETERAN? I INDUSTRIALINQUIRY? ry N ACCIOENv DOCTOR OCTOR NO. DOCTOR NAME REFERRED BY PATIENTS MAIDEN NAME MOTHER'S MAIDEN NAME 3 '3Er 3011. 76 _ ONE), '%I)- -,T -G'FZ A N T RESP.VARTY FIRST NAME PUT. LAST NAME RESP.PARTY SOC.SEFNO, IRESP.PARTY TEL NO.DAY/EVENING '4' GRAt4T 5541-90-5 4 1'7 RESP PARTY ADDRESS STREET CITY STATE Zip ONG? RELAT.TO PATIENT VALMABLES DE 'Ill G T 4*t0M-lSGTl)N 004 fl.ABL0 CA '94C.1.6 OWN/RENT RESP:PAM EMPLOYER(NAME OF C04 OCCUPATION HOW LONG? EMPLOYEE NO. DRIVERS LIC.NO. NONE ADDRESS STREET cm STATE ZIP BUS.TEL NO. REF.(I.E.CREDIT CARD INFO.ACCT.NOJ INSURANCE 00.NAME SUBSCRIBERS NAME CERT.NOJMEDICARE GROUP NO. MJCARE? INSURANCE COL NAME SUBSCRIBERS NAME CERT.NOJMEDICAL GROUP NO. M/CAL? ^OMITTINO DIAGNOSISPRIOR STAY(WITHIN 60 DAYU-NAME OF FACILITY ADMIT DATE DISCHARGE DATE EME m RGENCY CONTACT TEL NO.. HOW BROUGHT TO HOSP. PR AV SMOKER? V 00 E'D T.FIPD7 0"MR�.W,' 4 L.I M R Ll -Ii5 `Jf, AU N ICD-9,CM CODES DIAGNOSES PROCEDURES A� DISCHARGE WITH APPROVAL AMA DIED .OTHER HOSP. SKILLED NUBS.FAC. INTERMED.CARE FAC. HOMECARE STATUS TRANSFERRED: Z-=-- ID 11 1:1 ..0 . 0 IE] AUTOPYES NO WHOLE BLOOD PACKED RED CELLS SY: CORONER'S NUMBER OF •AOMT 0,(&184) 1-1 0 ICASE NUMBER CHART 7as flfl ElY,H B T • MF:rI(-AL!7'1IPG':::•S_ ;r... ., :" , :. ...... r;,, „•ty mt-ii.c•+l or psychiatric treatment including X-eiyexamination,Lb& tui t.•rct,. .rn cn. :.tr tie.,i?s..t u:•-�i era, ia:,•.:•t tran.l U. y c•x:ur.a. it•i•w t•..,- ions and psvchiatric testing et may be considered advisable or necessary p to" attvrtd.•:•t n+:y•..ci;... ..... .,, i,;;, •;. nr.iat• .•r«a••.S• ludinu rnco;cal student„i and physician residents,and persianne)assigned by2he_hosp, NURSING CARE: I unuer%i.mo that this husimal pro:.ri unly general duty nursing care unless the.physieiin orders more intensive hurling Bare t` i be provided for the patient or if the patient's condnro•i is such as to need the service of a special duty nurse-or attendant:-- TEACHING PROGRAM: I understand that this hospitel is a teaching institution and that unless the hospital is notified to the contrary in vvi'iting, may participate as.a patient in the medical education proutam of this institution. PERSONAL,VALUABLES: 1 understand that this husprtal maintains a safe for the safekeeping otmonay and-valuabl.esandlhat.theltasp6 she not be liable for the loss or damage to any money, jewelry,documents.furs;or other articles of unusual value or any other perlsanal°aropeftylt' i.. less deposited in the sate. NEWS RELEASE AND RESPONSE TO INQUIRIES. 1 understand it is the policy of Contra Costa County Health Services to release upon inquir t unless otherwise requested by the patient,parent or conservator,the following information:Patient's name,address,sex,age,reason for admissio 'general nature of injury and general condition. No iiiformation.is released for patianti biing iiaafed foi a'psychTatKE ionJitwn, w. •drup'cY.a }'},`,�7 'i alcohol abuse unless specifically authorized by the patient. 7-7 "1J7•:A:,: :.��, { "ii MAN,3i.) t}ItU j,tA�72AaV q•'vc i CONSENT TO PHOTOGRAPH:The Hospital is permitted to take pictures.of the medical or*Iuratealp►ogrtttss4 the Patient atW�* k < �" 7for seieritificraduiationa�or- It purposor es, �r ri !+i''lti'_'n fir... ' �1(: , `-'�-'4L. `.Nt" `•t .._ ____ —_. ." - __� r. S� iT@ c�4.r?•t.Y�"•.:.. 3') LEAVING HOSPITAL AGArNST ADVICE:1n the event the Patient elects to leave that Hospital against the edvjF*gf a physician and the Haepit _:;2hePatientreleasesatl hV*siciansand the Hospitil.tram all.responsibilityand any .ill effecicwF►icb Yeacu)Lf action:— ----- y u. .. ....Jt_ ."Y .. .. . •-.r-.. .. � t^„c.`�t .�i J=. _'.Vgvrty�Y:alY7`r.Far't.?:r9A 1r. DRUGS: It is imperative that the Hospital at all times be aware of the!Patient's intake.According1j' atientshall neithenilse not keep"any'drtW r• . -' drug-appliance*lpa►attts.I -P escribedby or'on."t4tf of the Attending'P_hysictet"rod-dispetf at! y11,16HolpiulliurMgPatitntl%WwUrr FINANCIAL AGf;jj=EMENT: {-promise-to reimburse the County-bf Contra Costa forapyftosgfjajsarfsndmedicalservfee'pr�}vtded not covered by Meaicarp;'•Medi-Cal, insurance or other health ease compensation carrier.Payment will at the rates astablisbad by t e Courit�';• Board of Supervisors. I will use any damages or indemnity due the•from the injury or illness which necesshated this care•to reimburse the Count ,. tlp.to the amount'bi{led;but tat to exceed the rates set by-the Board. 7 •'+1r+•�..••• " it.4}i•j . r_ :;;'" f _RELEASE OFJNFORMATION FOR.REIMBURSEMENT: I-give.permimion.to Contra Costs.Ceuaty..HaalihServieas a fur tish _informatio i, excerpts from my'patient record to the extent necessary to determine liability for payment and.to obtain reimbursement. thfoimation;may'srt?`r4 clude that related to drug)alcohol or psychiatric conditions,and may be given to any person or,'corporation'which is or may be liable_fol' o porxiorrot the,ho ital's.cha► e;,includia but not limited to insurance cum ani tteafth cats-service lant-arworkeritompe tiq ':� IP 9 9, P ei. P A RWr$ :. IL - AS "'Al1TF10R12AT10N TO.RELEE 1N FORMATION AND CONSENT TORELEASE -MMI-CAUUMEL5' _...... . . . _. _•_.I _.....EAS 1 e�1. ze£ ttp4;osta.De rtment of Soeier�lSertricRs to release.information concerning'�e status of my N1 gni off Pa edi Cal application;and..to send.my -Metti-tal labels-to Contm-Costs-Hearth Services Department. "{ ` r ` r #ISSIGNMENT..OF BENEFITS: 1 authoiiie any insurance company or carrier through wfiieh'•ttnay.have sotroroge to•tttake dyedt:Psymant of . ' -Ienefits to'Contra Costa County He`atthServiees,an amount not to exceed the Hospital's regular charges for thisperiod of service:A p4ot000py of .. �ahis`authorization shati:be considered as effective and valid is the original. 1 authorize the Attorney,Claim Adjustor,Insurance Company or any Person(s).Company or Corporation who may'effect a settlementbr payment of my claim foi damages or indemnity arising from the injury or illness which necessitated this hospital care and/or services to deduct the amount of the charges of these services from'sum due me and to pay that amount directly to Contra Costa County and I assign from that amount all or any `- portion of it which is necessary to pay those charges. I waive the statute of limitations on this matter for a period of 10 years.This agreement and waiver is binding on me,my heirs,assigns,administra• .. tors,and executors. . WHERE MINORS ARE INVOLVED, THE FOLLOWING PREVAILS: AGE OF CONSENT: t t:' The-consent of a arent or p legal guardian is required if the patient is unmarried and has not yet'attained his or her 18th birthday.. Z: If a patient under 18 years of age has contracted a.valid marriage, regardless of a subsequent divorce_ or annulment, then the consent t',; of a parent or legal guardian is not required. THE UNDERSIGNED CERTIFIES TO UNDERSTAND AND AGREE TO THE FOREGOING,.RECEIVING A COPY THEREOF,AND IS THE PATIENT, OR IS DULY AUTHORIZED BY AND ON BEHALF OF THE PATIENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS PERSONALLY AND UPON PATIENT'S BEHALF. f' G1 's' v� GSTORE OF PARENT OR PATIENT'S AGI.N1 ` / REL ATIONSHIP To PATIFN'r •S Time of signing - -— Date:- By - — - — -- — — CLAIM BOARD UPERVISORS OF CONTRA COSTA COUhvi. CA1 'R`A BOARD ACTION Claim Against the County. or District governed by) the Ward of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT July 7 , 1987 and Board.Action. All Section references are to ) The copy of this document ailed to You is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $1, 250, 000- 00 section 913 and 915.4. Please note all 'Warnings". CLAIMANT: ANNA''GRANT ' c/o Clyde I. Butts ATTORNEY: Law Offices of Marraccini & Butts 1225 Alpine Road, #204 Date received June 5 , 1987 hand del . ADDRESS: Walnut Creek, CA 94596 BY DELIVERY TO CLERK ON BY MAIL POSTMARKED: no envelope County Counse ' .J ur�_T 5-1981 1. FROM: Clerk .of the Board of Supervisors 70: County Counsel Attached is a copy of the above-noted claim. Martin,,, C,4 9,35^ DATED: June 12 , 1987 `�IL pUttiYLOR. clerk L. Hall ll. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies subsU ntially 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 IS days (Section 910.6). ( ) 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: /T1�(� BY: Deputy County Counsel 111. FROM: Clerk of the Board 70: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Sectione911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present I (X) This Claim is rejected in full. ( ) Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: J U L 7 1987 PHIL BATCHELOR. Clerk, By W- Z . Deputy Clerk WARNING (Gov. code section 913) _ Subject to ccrtsia r..+ay:suit,,, yvu heva only iie (6) monihs from the date this notice was personally served or deposited in the ail 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 al, etterrty, yov should do so iraediately. AFFIDAVIT OF iiAILING I declare under penalty of perjury that I an now, and at all times herein mentioned, have been a Citizen of the United States, over age 1B; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Bard Order and Notice to Claimant, addressed to the claimant as shown above. JUL 8 1981 Dated: - BY; PHIL MTCHEIOR by puty Clerk cc: County Counsel County Administrator y; •s'� ���. ray 7, i it• ��?�;.> t ! LO LO � ga ni ` a-► ski' .0 N N t0 O 34 m U ID Lr) t0 .,4 4-i O W 9 43 44 4J �+ 43 rl oar I O p+4-) Il1 CL 44 � 4J � O 44 >4 tU N O 0 O 43 ?t O e-4 ' U 4 :j N LO O w O ON O t0 wawa a3v pp w w � zoP4 Zu d0 � z ti 3 INPA�'ENT MEDT-DATA ENTRY FORM Last Name First dm4oeA� Medical Record No. Patcom No. Sex DOB �s3 Admit Date Discharge Date j:S'-'ff Race Attending M.D . Source of Admit Admit Type `' Readmit Discharge • .. Status Autopsy Coroner Transfusions WB PC Plasma Complications k1.) Transfusion' Rx (2) Infection (3). Stillborn " (4) Reoperate/OR Complication DIAGNOSES ICDQN (5)Adverse Rx Reaction r (6) Cardiac arrest resusitated J �• SURG PROCEDURES (7) Anesthesia / Code Unit Days issue PRIM. SERVICE arrI R SERVICE Tiss,,e OTfffR SERVICE,, Admitting Tissue =w Resident ~ Consultant Tissue Asst. Surg. Tissue Tissue . ,,y. Distribution: Initiat Original : Data Entry Arran ed Code Copy 1 : Chart .� EterFLed Lz Ana I -363 / CONTRA COSTA COUNTY HEALTH SERVICES MERRITHEW MEMORIAL HOSP: 'L AND CLINICS DEATH PROCEDURE • PHYSICIAN GUIDELINES, AUTOPSY CONSENT, AUTHORIZATION TO RELEASE REMAINS AND RECEIPT OF REMAINS PLEASE CHECK APPROPRIATE BOX: Q Inpatient Death Q Dead on Arrival Q Emergency Room or Fetal Death Patient ID s Outpatient Death [Record date and time of PATIENT PRONOUNCED: 3 S�S�� PM eath in Progress Notes Date Time ,�`.,.. DID PATIENT OR DOES NEXT OF KIN WISH TO MAKE AN ANATOMICAL GIFT? Q.YES Q NO If YES, see Merrithew Memorial Hospital and Clinics Policy No.554a & Form MR-361 fbr guidelines &-consent form. •• Coroner's case: Coroner must also consent to anatomical gift. Outlined on the reverse side DOES THIS CASE REQUIRE REPORTING TO THE CORONER? is a summary of the classes of deaths that are required to be reported to the Coroner p YES: 1. Call Coroner (x2406): • AM *Date called Time PM *Spoke with CORONER ACCEPTED CASE? YES p NO s Comments NOTE: If coroner refuses case, go to Item #1 in No" section below. 2. Notify Family: *Name of relative or friend called AM *Date called Time PM 'Time relative/friend will come in NO: 1. Notify Family: If unable to notify family, go to page 0• •Name of relative or friend called AM ,Date called Time PM -When relative/friend will come in 2. Meet with family and request auto s O •If an autopsy is refused, a state the cause of death on the typed death certificate and b sign the death certificate. 'If. family agrees to an autopsy, obtain appropriate signatures on "Consent for Autopsy"--see reverse s1de of .thi$ form. '•211I7 pa9 •} ^' e 1 (3/86) (PhysiciinAs Signature CHART CLASSES OF DEATHS REPORTABLE *0 CORONER (See also She -cf-Coroner Guide which is on ea ' ward. ) -1. ` All violent, sudden and unusual deaths. 11. Deaths known or suspected as. due to 2. Unattended deaths. contagious disease and constituting a 3. Deaths wherein the deceased has not public hazard. 3 been attended by a physician in the 20 12. Deaths from occupational diseases or days before death. occupational hazards. 4. Deaths related to or following known or 13. Deaths under such circumstances as to suspected self-induced or criminal afford a reasonable ground to suspect abortion. that the death was caused by the 5. Known or suspected homicide, suicide or criminal act of another. accidental poisoning. 14. Deaths reported by physicians or other 6. Deaths known or suspected as resulting persons having knowledge of death in whole or in part from or related to for inquiry by the Coroner. accident or injury either old or recent. 15. Sudden infant death syndrome. 7. Deaths due to drowning, fire, hanging, ` gunshot, stabbing, cutting, exposure, starvation, acute alcoholism, drug ** In addition to the above provision of addiction, strangulation or aspiration. the Government Code, the Health and 8. Death in whole or in part occasioned by Safety Code adds another category of criminal means. coroner's cases, namely, "If a phy- 9,.. Deaths associated with a known or sician is truly unable to state the alleged rape or crime against nature. cause of death, he/she may refer, the 10. Deaths in prison or while under sentence. case to the Coroner." . CONSENT FO. R AUTOPSY I authorize Merrithew Memorial Hospital and its medical representatives to perform an autopsy on the remains of 6.faAlLk to confirm the cause tient s name of death and nature of the disease process, and to remofe and retain any structure `s or organ, including eyes, for study and diagnosis and other scientific purposes. t Tv►c(c,�C.i v/ L�..-v�.o svw-e s�Acr sem.. �-,� -�• 0�,�C. d: ? The undersigned states that she/he is legally entitled to give authorization for such autopsy on the deceased named above, and hereby releases Contra Costa County, Merrithew Memorial Hospital and members. of its staff from any liability arising out of the performance of such autopsy. r AM 3 - Z:`4 O PM '�- Date Signature of person giving pg rmission Phone consent for autopsy & release VVA of remains to mortuary must be fol- Relationship .to deceased lowed by telegram sent to hospital COLLECT--to Nursing Administration (415) 372-4254 Signature of witness When telegraph office phones in the consent, message is to be heard by two 2 persons, documented on plain paper, dated and signed by both Person notifying pathology Parties and attached to Consent for Auto s . Tele ram will arrive later MR-211 Page 2 .(3/86) .x. PATHOLOGY REQUEST ^Y.i1j. u 4 • r 'CODE . 431 ds I? -a•- 3 —8 PATIENT I.D.Imprint Area must be readable on aUcooled ' �. -: CLINICAL SUMMARY "'.. PREOP:DIAG. POSTOP. DIAG. ` `:SPECIMEN QCe� rih4 ExCl OF. si 15I$�BIOPSY 'PREVIOUS PATH.NOS: SIGNED " 0.Sti 7Co' t Oti r 1 t GROSS.DESCRIPTION: Spec$men consists, of a small round placenta measilrir�g. � l6.an In diameter and 2.2 cm in thiclamess. It wieghs 496 grams Umb�:lical �;�•�s:i. _.cord is attached centrally and measures 23 cm in length a<nd:1,2 cm in .diameter; M. �4` Cut surface reveals .three.vessels. '7he amniotic membrane alcng..tine fetal surface appearssomewhat grayish tan opaque and slight yellovisht tan discolorticn Y` consistentwith mecc ii m staining is present.. Maternal surface is intact, shwoing pinksih red matted cotyledon. M=e is a small amount of retroplacental blood .clot weighing 30 grams approximately* . Fetal membrane is grayish tan and somewhat opaque. ' Representative section are submitted. _ .� D: .3/6 .T:.:'3/6/87 A =* MICROSCOPIC.MSC1W= Sections reseal team placenta.' ade up of small=tore ='''• and well'vascularized .cbbrionic. villi.. There is diffuse and quite extensive J s neutropb l ,c infiltration, associated With fibrin material deposition.:Wx the `.` :-= !•FIYSICIJW.- yati�'. '.,., AIJMM: 6 A. 8% GRANT, BABY BOY (4568937) FUM " M.D. DOB; 3 5/87 " X PROCEDURE � "' DAA;. 3f6187 AUTOPSY,GROSS ONLY AUTOPSY, INCL.CNS GROSS ONLY. AUTOPSY, EXCL.CNS GROSS AND MICROSCOPIC `1Y6r IATI■NT 1.0.ARRA MUGT 1t 06AOA9L9 ON ALL COIIii. AUTOPSY, INCL.CNS GROSS AND MICROSCOPIC PROSECTOR: AUTOPSY,SINGLE ORGAWSTUDY Hm=d.Gold M.D. E O. i�.I... m , GROSS EXAMIIJAT'TM SAND DES(RIP'I'IC�T{ ' •' , II TIItNAL:.Fx�� JCN: 7Iie body:3 'that..of a taell develoQed male'.tecta fetus. . . weighing.:2.15:kg.. . There is t 01ding of. rhe head and.facial.ecchymoses", 'P . ocularly:on the right side;: Ecchymoses are also tan-the tight_upper °"limbs andlateral aspect of the `lower .limbs; as vel � the: anterior - . :.:_ chest.•' ".E�es are unremarkable, as.are:-the ears; _there is no Potter's facies. �- �e bonynose and nares. are well developed ;--as"'are.the lips; there is no hares ,.r= 'lip. Opening.the mouth reveals ,normal.buccal mucosa and gingiva There. is.no cleft palate and the 'tongue is normally 16 med:. Five nozmally developed r".:.. .: digits axe present on both ids .and..botti feet, there .is:nto equinovarus-;or other lower limb deformity.,..: The external- genitalf a are normal, The: anus;. is perforate.: There is a nromally. developed vertebral column :�rithout` ti= evideaceof spina.bifida ox:.minigc elocele.. I -IlVMNAL:EKX4n�T X= lie`bbt.'is opened byy:.the:usual::Y•-0.baped:incision ; - :Zhe liver has: the usual `fetal: coafiguatia�n,.:a�►d:is 'otliezwse -u�ei>�kable. Zfe surall .,:and.-.large bowel.axe..normally.. 'loped--- there,:.is-;no'•malrotation. r.dissection there is no evidenceof re ri oneatl' testis and on al-, _ P patiAn, two testes are felt in :the scrotum.. The spleen has the `usual fetal Configuration and an cut section is unremarkable. The stomach"is unremark- ' 16*, as 'are the normal-appearing head,. body, and tail of pancreas. The �:- right,.and left ki&eys have the usual fetal configuration, with. typical fetal adrenal glands, Sectioning-them reveals normallydevel d.left and ri t : . .cortieo�medullary structures of.both kidneys and oth awls. ` Opening the rhes. t cage reveals a nor=!-appearing fetal thymus with sym- ' :metrical right and left lobes. The lungs are atelectatic. with. exythematous leiural:surfaces. Three normal right lobes and two normally developed left ,`lobes are"present. Opening the pericardial sac reveals a normally" developed "fotnr'"duabered heart with the usual" fetal great.vessels. On opening there is ;.:no-eVideneeof septal defect. 'Incising g the scalp reveals no noteworthy scalp hematoma. Opening the skull with parasagittal dissection reveals no evidenceof epidural, subdural or aracbaioid hemorrhages. Neither is there evidenceof hemorrhage inthe region `.` of the falx. The hemispheres have the usual fetal configuration with normal aPpearing sulci and gyri. There is no evidenceof microcephaly. Representa- tive tissue is fixed in the event of future need. CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY 0�1'I'Il`TUFD ON PAGE 2 : . .�. HYE-KYUNG KIM,M.D.,PATHOLOGIST IRCHG-403 (5/83) : HYSICIAH;:;::"„_s, AUTOPSY: 6 A 87 GRANT, BABY BOY (4568937) ' M.D. 'X PROCEDURE'S +` ` AUTOPSY,GROSS ONLY PAGE -2- . AUTOPSY, INCL.CNS GROSS ONLY AUTOPSY,EXCL.CNS GROSS AND MICROSCOPIC •Arts NT I.D.^Pt^MUST■f Pf AO^tLf ON ALL COrlf{. AUTOPSY, INCL.CNS GROSS AND MICROSCOPIC.' PROSECTOR: AUTOPSY,SINGLE,ORGAN STUDY f VORi 'DIAGW=: ANAIMICAILY NOM TER4 MALE-1-MUS (STIIZBIIZ'IfI) <f N •i i '. D../11 T: 3/]1/87 zr . Yf i t '' i ATHOLOG .D, CONTRA COSTA COUNTY HEALTH SERVICES-PATHOLOGY LABORATORY ` :' HYE-KYUNG KIM,M.O.,PATHOLOGIST Y AumpsY: 6 A 87 PHYSICIAW-': ,' GRAW, BABY BOY FY7ltrA N7 D. 4568937 DOB: .3!5/87 _X" -'PRC?CEDURF=- _., ': ' `,. ..-DOA: 3j6j$7 AUTOPSY,GROSS ONLY AUTOPSY, INCL.CNS GROSS ONLY AUTOPSY,EXCL.CNS GROSS AND MICROSCOPIC �. •ATIL'NT 1.0.AN<A MUST•t PMADAOLS ON ALL COVltf. AUTOPSY, INCL.CNS GROSS AND MICROSCOPIC PROSECTOR: AUTOPSY,SINGLE ORGAN STUDY Hlr =d Goldman, M;D , 4*•,.•.. AfimVDED ms of the 2.15 kg weight, this fetus is teCbnicallp.prematt2e A -TEMED MSS DIAGMSTS: ,ANAM41CAILY MI MAL PEtE"SA NE MKI.F FEMS CSI'II.LB .3/23 T: "3/23/87 i.: IU:sk W AM W1 W, M.D. 4� ' CONTRA COSTA COUNTY HEALTH SERVICES•PATHOLOGY LABORATORY HYE-KYUNG KIM,M.D.,PATHOLOGIST IRCHG-403 45/83! .CONTRA COSTA COUNTY HEALTH SERVICES Name: 4b BIRTH CERTIFICATE INFORMATION WCRKSHEE.T Baby's # Mother's BABY'S NAME: (Fir ) ( e) (Last) MOT, HER OF BABY (First) (Middle) (Maiderl,Name) ' ;_ Address• City: Zip Code: county: 60 State: c j w' !'State of Birth:. a�,Q.a•• Ager Usual Occupation: Kind of Business or Industry FATHER OF BABY A 4. . Name:_ first) (Middle) ( t) State of Birth• Ager Usuak Occupation: �- Kind of Business or Industry t . OTHER CHILDREN OF THIS MOTHER NtanUer born alive:_�� (Do not count this baby) Date of last live birth: Number of children,born alive, but now dead: C7 ;Date of last termination (miscarriage) Before 20 weeks: After 20 weeks; First day of last normal menstrual period: ing what month of pregnancy Was prenatal begun- IL SIGNATURE OF JJ �-�• Other informant DO NOT WRITE BELOW THIS LINE SEX: _ DATE OF BIRTH: - 77 DELIVERED BY: ' � V✓ TIME OF BIRTH: WEIGHT AT BIRTH• INTT ao11a77 f77-- ,, — StsoNof California—Health and Welfare Agency Department of Health Services SELF-IDENTIFICATI.ON WORKSHEET FOR THE CERTIFICATE OF LIVE BIRTH Name of Childais Name of Mother �• ,� (ITEM 18) IS THE FATHER (check ONE box): (ITEM 21) IS THE MOTHER (check ONE box): ❑ White ❑ Cambodian ❑ Guamanian ❑ ite ❑ Cambodian ❑ Guamanian Black or Negro 13American Indian ❑ Samoan Black or Negro ❑ American Indian E3Samoan Japanese (Specify Tribe) ❑ Eskimo ❑ Japanese (Specify Tribe) ❑ Eskimo ❑ Chinese ❑ Aleut ❑ Chinese ❑ Aleut ❑ Filipino ❑ Asian Indian ❑ Other (Specify) ❑ Filipino ❑ Asian Indian ❑ Other(Specify) ❑ Korean ❑ Thai ❑ Korean ❑ Thai ❑ Vietnamese ❑ Hawaiian ❑ Vietnamese ❑ Hawaiian >. (ITEM 19) IS THE FATHER OF SPANISH/HISPANIC (ITEM 22) IS THE MOTHER OF SPANISH/HISPANIC ORIGIN OR DESCENT (check ONE box): ORIGIN OR DESCENT (check ONE box): 4No— (Not Spanish/Hispanic) No—(Not Spanish/Hispanic) Yes— Mexican/Mexican-American/Chicano ❑ Yes—Mexican/Mexican-American/Chicano 13 Yea—Puerto Rican ❑ Yes—Puerto Rican ❑ Yes—Cuban ❑ Yes—CubAM Yes—Other Spanish/Hispanic(Specify) ❑ Yes—Othel Spanish/Hispanic(Specify) M: L .>These items may be left blank;however,this information is essential for determining the health problems of these groups within ..California. Enter This Information On The Certificate Of Live Birth (Form VS 10). VS 108 (1/82) CERTIFICATE OF FETAL DEATH STATE'PKE NUM6ER STATE OF CALIFORNIA LOCAL REGISTRATIOH DISTRICT ANO CERTIPICATE NUMBEII IA-NAME-FIRST 118.MIDDLE IIC.LAST THIS BABY BOY mmn GRANT FETUS 2-SEX 3A.THIS DELIVERY.SR+GLE.TWw 136.IP MULnnR.THIS FETUS 4A.DATE Of OEUVERY-MONTH.DAY.YEARI4B.HOUR(24 HOUR CLOCK T1ME1 Male ET` Single '1.T.2ND.ETA March 5 1987 0212 5A-PLACE OF DEUVERY-NAME OP HOSPITAL 158.STREET ADDRESS(STREET.NURSER.OR LOCATION) PLAGEMerrithew, Memorial Hosoital 1 2500 Alhambra Avenue OF SC.CITY OIG TOWN ISO.COUNTY DELIVERY ' Martinez Contra Costa GA.NAME OF FATHER-fIRlT Is& MIDDLE IQC.LAST !.STATE OF BIRTH a AGE OF FATHER :FATHERC1 de ' ' mmn ' Nealey CA 44 9A-NAME OF MOTHER-PIRRT ;98.MIOOLE IBC,LAST(BIRTNNAME) 10.STATE Of BIRTH 11.AGE OF MOTHE -> �oTHER Anna Ernestine Grant =TX 33 't'•GERTIFICA- 1 CERTwv THAT Twa FETUs wAs somw DEAD 12A PHYSICIAN OR BONER-DEGREE Dw TITLE AND TYPED NAME 1 128.DATE SIGNED AT TME HOUR.DATE AND PLACE STATED AND ON FROM THE CAUSES STATED. hLt-Vv. M.D. 's 13.DISPOSITION e a ne Qr wra11LOI/TH.D r.YEAR NAMI�2 yDAD Ess OFPZ ET RY OR GRE ATORY `�:`�', UNERAL errs VF4�emor�ai F�osoi to T RECTOR Scientific purposes 03/05/1987 Pgnn klhambra Aypnap. Martin 7- CA 94591 .AND 16.NAME OF PLONMAL DIRECTOR lOR PEIISCN ACTRIG As SUCN1 17.LOCAL REGISTRAR-SIGNATURE tfl.OAR ACCEPTED EY I="REGISTA �-:���LOGAL , .REGISTRAR Merri thew'Memori al Hospital 19. FETAL DEATH WAS CAUSED BY ENTER ONLY ONE CAUSE PER UNE FOR A.B AND C ' .z, PETAL OR MATERNAL"CONDI- IMMEDIATE CAUSE /�,_//1_�/i/y� O TION DIRECTLY CAUSING { At Ll� d( Wl JT PETAL DEATK UE TO.OR AS A CO11NSEOUENCE OF IP- �CLL>'iiT //�s " ` � ":.CAUSE FETAL ANOiow MATERNAL (� �..� ���'/U��'(/�� Ar + OF: CONornoNs, s ANY. AHK N -- 0 vP GAYE RISC TO THE a.MEDIATc DUE TO,OR AS A CON5EOUENCE OR p :; "DEATH CAUSESTATING THE u... UNDERLr.naG CAusa LAST. ICJ Z._ � 20.OTHER SITYEPICANT CONDITIONS OF FETUS OR MOTHER- N COTOtOUYION TO PETAL DEATH BUT NOT RELATED TO CAUSE GVEN IH 1 BA 21.AUTOPSY (SPECIFY YEs Ow NOI x5 VL 22-RACE/ETHNICITY 23.SPANISH/MISPAIVIC 24A.USUAL OCCUPAVMN 248.KEW OP BUSINESS OR INDUSTAY 'iil;f;;FATHER •► I 1�I NO none 21none i 5-RACE/ETHNIClTY `/11 20.SPANISH/HfSPANIG 27A. USUAL OCCUPATION �127B.KIND W BusINEslt OR wDUSTRY Black 0 ND Homemaker. Home OTHER 25A-REStOENGE(STREET.NUMBER OR I.00A710N) 1288.CITY OR TOWN I28C.STATE 1260.ZIP GODS 1280 COUNTY 1410 Mission Street #4 ,, San Pablo CA 94806 Contra Costa 29A.DATE LAST NORMAL MENSES BEGAN 1296.MONTH OF PREGNANCY PRENATAL 30•BIRTHWEIGHT 31.PREGNANCY HISTORY ICOMPLETE EACH SECTIO MONTH ( DAY 1 YEAR 1��BEGAN(1ST.$JNp ••�flTH.9711 2197 LIVE BIRTHS OTHER TERYINATKHJa June 04 1 1986 1 s L GRAMS too HOT COUNT TM1a CHILD EXCLUDE INDUCED ASORnc ENTER THE APPROPRIATE CODE OR CODES FOR EACH ITEM 32 THRU 36 32 CESAREAN SECTION NOW UVING NOW DEAD BE►ORE FROM 20 APTER 20 M TME VS 12A SUPPLEMENTAL WORKSHEET.IF NONE CHECK-NONE (NUMB J R awl wEs INuus[RI ARS INIRN : ,Wa EDICAL NO A e (J c O D DATAV33. PLICATION OP PREGNANCY AND CONCURRENT ILLNEaau 3A BIRTH INJLRY 70 cNED DATE OP LAST LrvE E/RTN DATE OF LAST TERMINAmn,/+Tc�eFect/sTUCE of /11r/�1B ' 11 JOB 173Aw MDNTN r YEARONE NONE E 1 F` 0' <,. OMFLICATKMIS O►LASOR ANp OeUYERY 36.CONGENITAL MALFORMATIONS OR ANOMAUES OF CHILD L1?gip NONE NONE `• ' FATE A. B. G. D. E. F. CENSUS TRACT SssGISTRAR v13:.12 (REv 2-84) PENALTY FOR UNAUTHORIZED RELEASE. 5500 FINE 'OR SIX MONTHS IMPRISONMENT. SETES-..Ba-s+zoMl O ow N f�. r �T U W N � • � � J �� J c , w Q o ars N ��'x G io .c s W, o J Wo ua 5. d W G u = u is • �:a O p N O O W O u L '" V; `kms gg a 0 U. _t O C7w � � l0 w z r O -0ul ` La r i• n, p �j p • p, Z L O OR co o u syroo n,, • 7 o g� is s-•. �. K YO , — O � W { 0-- L� w O Y w N Q �' > r 1• �.,�. < 'Tc V P Z m a • Q G i N N O 16 C V d Z * u. 0 W t Y • .ij Y'. Z Q .r q O us , N �k W d y 'itr•.. \ tfy it r�• i v t�tWx ' d w '� , ug led 40SO C) r W W 3 ,, E • a .c o g o 10, OR �±eZ•`.`�` �/r x 7 � _ °F u- O N W 'Q t � .� asp r- p s Uzi W T Z P �' �: •�•' W V Z Z W O Z W �'. �' O r Z �' .ac Z Wn;a r d to c a o Np 0 6 Z W W i Rte" W L7rP o 0 3n r'� x O ✓ N �p p W b Q 2 1 i 6 pv.ti.J iZiy O5 rd y o r r"Z �uW 0 tty�jQ `o4i� O i �• P 1 r r� � N W tiC Q �,,.. ir— t4 91 7 � N .� W �v. ydg N ,C 4 Y PATIENT NUMBER7NO. 7DUSTRIAL M D EMM F4GENCY Ii D MEDICAL RECORDS NUra6ER LQ- 0 60143053-2 MC� ER MC!� . . 75-93-13 r PATIENT NAME(LAST.FIRST.MI) DATE TIME IN SERVICE I PATIENT N g GRANT.ANNA E 03/0418 02138 E1k Y O Z ADDRESS CITY.STATE ZIP TELEPHONE SEX RACE MARITAL ST TUS = O 1410 MISSION STREET SAN PABLOU. CA94806 NONE F B RELIGION JBIRTHDATE ACE BIRTHPLACE $MOtIND(E MEVIWS DISC,, RGE LAST HOSPITAL DATE F.C.LLd GAVE GMT IN Q v N00 07/08/53 33 N P co EMPLOYED BY ADDRESS CITY.STATE ZIP OCCUPATION TELEPHONE NOW LONG R (/�) Y O NONE 49 YES ONO O, d GUARANTOR- ADDRESS CITY.STATE ZIP TELEPHONE RELATpNSHIP DOCTOR WILL CALL GRANT.ANNA E SAN PABLO CA 94806 NONE P.M.D.NOTIFIED EMPLOYED BY ADDRESS CITY,STATE.ZIP OCCUPATION TELEPHONE 04OW LOONG i� MALI RENDER TREATMENT NONE EMPLOO REFERRED TO ED - PANEL BY: - EMERGENCY CONTACT NAME ADDRESS CITY,STATE ZIP TELEPHONE RELAT05MP a r PERK I NS.CHARLES C ItLICE OFFICERS hAMEINO. NNS PLAN PRIMARY INSURANCE COMPANY ADDRESS CITY.STATE ZIP IOENTIFICATN)N/SS• GROUP 1/POLICY a/LOCAL UNION - INSURED PATIENT SS 553-90-5349 NO PLAN BECGNAR OY INCE SUPANCOMPAW1 CODE ADDRESS CITY,STATE 21P GUARANTOR SSS PENDING MEDICAL .553-90-5349 IDENTIFICATION/SS GROUP#/POLICY#/LOCAL UNION• INSURED S '.�mLiP, DATE TIME REPORTED TO ACCIDENT SITE jt•c PATIENTS COMPLAINT CLERKS NAME ;V LL TERM O.B. LN L � AUTHORIZATION: CONSENT TO ANY MEDICAL OR SURGICALTREATMENT OR HOSPITAL SERVICES RENDERED THE PATIENT UNDER THE GENERAL OR SPECIAL INSTRUCTIONS OF THE PHYSICIANS. AUTHORITY IS GRANTED TO FURNISH FROM THE PATIENTS RECORD REQUESTED INFORMATION OR L •_,; EXCERPT TO ANY HEALTH INSURER OF THE PATIENT. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO =i BROOKSIDE HOSPITAL. y CONDITIONS OF ADMISSION: THE UNDERSIGNED FURTHER AUTHORIZES THE RESPECTIVE COUNTY, STATE, AND/OR FEDERAL AGENCY TO RELEASE ANY AND ALL DOCUMENTATION AND INFORMATION 17 RELATED TO MEDICARE ELIGIBILITY ANO/OR BENEFITS, MEDI-CAL ELIGIBILITY, AND/OR BENEFITS :- AND PROOF OF ELIGIBILITY LABELS FOR BILLING PURPOSES, AND BASIC A�ULT CARE AND/OR CONTRA COSTA HEALTH PLAN MEMBER ELIGIBILITY AND/OR BENEFITS, TO BROOKSIDE HOSPITAL arytta�•. AND/OR ITS AUTHORIZED AGENTS. �I FINANPIAL AGREEMENT: THE UNDERSIGNED AGREES. WHETHER HE SIGNS AS AGENT OR AS PATIENT, cD ` a THAT IN CONSIDERATION OF THE SERVICES TO BE RENDERED TO THE PATIENT, HE HEREBY = LL O INDIVIDUALLY OBLIGATES HIMSELF TO PAY, THE ACCOUNT OF THE HOSPITAL IN ACCORDANCE W :i (] a WITH THE REGULAR R ESA TERMS O THE HOSPITAL. m+ SIGNATURE X O < O d RELATIONSHIP Z WITNESS x .r. Q - � CIYICIIVCIrV f IYICUIL.ML /lLVVn✓ I - J• PATIENT NUMBER PRIG... /INDUSTRIAL MD EMERGENCY MD MEDICAL RECORDS NUMBER QAM _ PATIENT NAME(LAST.FIRST.MI) DATEn'a TIME IN FC PATIENT TYPE a• PATIENTS COMPLAINT LAST HOSP.DATE •AGE SEX RACE MA rrAL STAT. W co B/P TET.TOX ALLERGIES: MEDS: PMH a R >10 yrs ❑ t'-f `+ t��v�- tJ� cwt- `GW N U lyo p IAREG Given:yrs ❑ /:,,.�.�■ Y d O+-c lr �: VW O CO NU HIS RY / O D a TIME O T t LNMP Qa m co) PHYSICIAITS HISTORY DICTATED TIME YES❑ NO❑ •PHYSICAL EXAM Elf NZ �- • PLAN: PHYSICIAN'S ORDERS/RX TIME LAB ORD BY TRE BY X-RAY TIME ORD BY vs ❑CBC C CHEST ,J O U/A ❑C-SPINE I0 LYTES NA_ K ?EXT CL CO, ❑LS SPINE 7 ❑GLUCOSE _—)SKULL O BUN/CREAT. r�"D.SERIES o r)ER PANEL EKG J < Q DIAGNOSIS co Z DISPOSIT IO �ii7 Y BY W ADMIT TR SFFR TO �((, STRU II)Nti IVLN / T II O DISCHARGE TME-DATE SIG M D SI DINT NUMbEr, DATE IME I PAIIEk-. SEr-vICE SEND RECORDS TO INDUSTRIAL MD MEDICAL RECORDS _ 7YPc CODE 5 EMR '• LAST-FlgsT,INITIAL BIRTHDATE AGE SEX RACE • SOCIAL SECURITY NO f.C, LAST TIME AT n.+�s BROOKSIDE w i '"IRATIONS MENTAL STATUS RESPONDS TO PUPILS SKIN �'•'IMAL ALERT VOICE EQUAL DRY NORMAL -'•-,LLOW CONFUSED ORIENTED x CONSTRICTED DIAPHORETIC FLUSH= =UREO UNCONSCIOUS PAIN DILATED r:I�.1R NORMAL COOL MOTTLED +''•�CZES SF Li C?a,`�`i.�._ AMMONIA UNEQUAL R L WARM PALE - UNRESPONSIVE FS RESPONSIVE NOT CYANOTIC CHI FIXED 11. • 1 it/pEL1 AEGnRgEGTym RESP. � � p —_^ TIME IIJIIINE 04or?Use) AmouKT I 011 gMIN(MASK,CANNULA) OR RHYTHM I 'row I NU)M ER SOLUTIONS 1Z MEDICATIONS RATE AMOUNT ABSORBED VIAE • • �1 BP P R MEDICATIONS ASSESSMENTS OBSERVATIONS 261 ' 33 u t") I A I T n T I A l- I— C 14S ,ADr&ndo m" r �.n w S y , T I t P " T,10 . 14T w _ z z w cn z i EMERGENCY PROTOCOL FOR PATIENT TRANSFERS DATE ' AT 1 ENT'S NAME: Grcyr _ yl y'lO� CHART NO. lrj q3 SEX: AGE-: DIAGNOSI-S: Tu00 ` PII^• 09 a.m. TIME OF ARRIVAL IN ER: CALO VITALS ON ARRIVAL: T�! BP ����� .m. TIME OF DISCHARGE ti a.m FROM ER: .m. VITALS ON DISCHARGE: T P� R �j".� BP l l$ Z YES _P IV: NO TYPE OF SOLUTION: AMOUNT REMAINING: AGNOSTIC WORK: EKG: CBC: URINALYSIS: X-RAYS: YES BLOOD TYPE s X MATCHED: 1S BLOOD BEING TRANSFERRED WITH PT.? NO MEDICINES GIVEN IN ER: PERSON ORDERING TRANSFER: M� M.D. *EASON FOR TRANSFER: (CONDITION AT TIME OF TRANSFER: FAIR GOOD 17 STABLE 17 YES 4S PATIENT AWARE OF REASON FOR TRANSFER? NOB 1F NOT, GIVE REASON: 0 YES 15 Q HAS NEXT OF KIN BEEN NOTIFIED? NO METHOD OF TRANSFER: AMBULANCE _' D TAXI U PRIVATE CAR �) IF TRANSFERRED BY PRIVATE CAR, ACCOMPANIED BY: Name Relationship HOSPITAL ACCEPTING PATIENT: NAME OF PERSON CONTACTED AT ACCEPTING HOSPITAL: �r M.D. PERSONAL EFFECTS: CLOTHES WATCH : WALLET OR PURSE : MI SC.: FILLED OUT BY: Name Title SIGNATURE OF PHYSICIAN: M.O. i MEDICAL RECORDS b PERSONAL EFFECTS SENT WITH: Signature of Responsible Party Title IgDICAL RECORDS 6 PERSONA! EFFECTS RECEIVED BY: Signature of Responsible Party Tit e fsrm 7230. 1 + (Rev. 9/80) CONTRA COSTA COUNTY HEALTH SERVICES _ r MERRITHF MEMORIAL HOSPITAL - INCOMING TRANSrER FORM - EMERGENCY DEPT • , E 1 . Date � �`/�/ ,� / Timej) AM M S _a 7 F 7 - ' S PO 2. Is call being recorded? qu, _ 4 SE) ' If not, why? 3. Patient name I Patient'-;, 3 _ 4. Patient age Sex M 5. Referring Referring facility ���- - .�. -�� physician 6. Is this call from one of our clinics? If yes, the one below: q Direct admit that will arrive before 5PM. Transfer call to appropriate resident or ward staff (Name ). Post form in ER. On arrival, send original to ward. Direct admit that will arrive after 5PM. Go to 10. Patient being referred for ER-evaluation. Go to 10. • T. Patient's ,permane 8. Insurance Medi-Cal P BAC address C > •� < Coverage Medicare None;:, 4C Veteran (How determined: ) Q Other (Ya oamat accept uninsured out-of-county residents from other acute care hospitals.) (Encourage transfer of yflnsured eligible veterans to Yl if they are inelligible for both Medi-Cal and !fedi-Care.) • 9. Is this an inhouse-to-inhouse transfer from another acute care hospital? If yes, transfer call to appropriate resident or ward staff (Name: That person will be responsible for workup of medically elective inpatient transfers that arrive after 5PM on weekdays, noon on weekends and _) holidayy.) Post form in ER. On arrival, send original to ward. 10. Nurse or Cler . . - - - - - - - - - - - -C - - - -�- - - - - - - - - - - - - - - - - - - History U, Q /� 47) O Reason for transfer Mode of transport _ ® Accompanying information _ Objections to transfer Distribution: White - Chart MR-144 (7/85). Yellow - ER Director Physician_ CONTh^s _':LISTA COUNTY PRE-HOSP.'TAL CARE FORM it COCAS oR Au W AIIROM1Ars TAPE / / -DATE }1 IME :_.L AGENCY AUTH. 0. NAME �-Y r J l^n B AGE a M tEJ ETA 2 _-&, iOSPITAL_fi45;,_l1I14.., �.�r..�►�ra LOt' IONIPOSITION i+ h 6 t ,i" � DISTRESS: nad rid mad severs CHIrF COMPLAINT A DURATION: H.P.I. COMMENTS: 4 P.M.H. kn '� �• MEDICATIONS: id ran e At. ALLERGIES a f i.o. 7777,--t INITIAL VITALS: BP I D P R FO CP !IT- -�f QUALITY OF VITALS N' t� ��. INITIAL RHYTHM: L.O.M: ALERT, �i"' RESPONDS TO: &4C , S1RY, C%'' DIAPHOREnt In 4:._ :COOL. 1-0' RM_,�HOT.t x l4a, COLOR:: NORMAL USHEDA&_PALE "7-7 CYANOTIC, HEAD - INJURY.' s Aiwrar: a�, -• '' b PUPILS: PERRL 7~" UNEOUAL.'RT: ✓"� LT.,, EARS: l`DRAINAGE �A+a NOW DRAINAGE '} a h° r ► �', NECK: TRACHEA /"ti' C/S—TE NDERNESS ''''i JVD n CHEST: EXPANSION-' i" ,L_TENDERNESS r LUN `_ ENTRY r' RALES /�''a EEZES a I' ABDOMEN TENDER `3 -*SOFTDISTENDED ► PELVIS: TENDER / a BACK: TENDER EXTREk: PULSE x4 EDEMA n*' INJURY ^a M/S G 7W ASS£S�SMENT �' EBL r MANAGEMENT'L, x,i, TIME DONE ". PATIENT RESPONSE...: r:.. . ,J ll ' s c . y � i vim" i , �• - '' ^•' - = ,,y�+s >, -" ,.a a- r. 2 -- � ray, ..i v G"k � i.>! �'ir.} s: t .�"si i �1; F:�d k.. !�,c k.,L•. .rr'��' :�+'. � k � ,. � ►, 3RfOR MOVEMENT/T'REATMENT CODE TO SCENE„„_ >CENE ASSISTANCE—n _,>v,6 INCIDENTLOCATION 74 -RANQ TO AMBULANCE � �-g✓���f" PT.Dt POSiTTON r �i CODE wST1RtED `� PT.PERSON a RAD/DRIVER ,1 �1 ;ASE SIGN: r BASE FIELD lr+filTE oopy to rsoalvxnQ hoepitat;YELLON copy retained by mnbuZowe ooWwW;. PIAX to Barrs Bospital EMS-2 (4/82) a ,enNam e as ,rs • , �e atcom Numoe. Patient'sMaiaen I CHART SOURCEVISIT RANT . ANNA E 5075304 GRANT 4568937-02-0001 Local Address(space/apt)City State Zip Telephone Arrival 1410 MISSION SAN PABLO•CA.94806 /05/87 T101120 AUow Permanent Address(It different from above)Space/apt City State Zip Telephone Pt.Type JOR Serv. — 410 MISSION STM4 SAN PABLO CA 94806 15 0000000 PO E ' Occupation Soc.Sec.Number Age Date of Birth M/S Sexau Rtllglon ONE 53-90-5349 033 107/08/53 4 F 3 NO Employer(Name of Co.) Employer Address Street City State ZIP How Emp•Tel.Number ONE.. : Long Presenting rob ems Mother's Maiden Namea ABOR ASKEW Rarty Name(Last,Flrst,M.I. Resp.Party Tel.No.Day/Evening Resp.Party Soc.Sec.No. Sex WT ANDA E 15 000-0000 553-90-5349 Resp.Party Address Street �• city. State Zip Own Relationship to Patient Occupation _ 41;0• .MISSION STOSAN PAHLO .GA *94806 O NONE. s� Resp. arty�EMPloy*U(NameofCol)'_ - — Address: Street City- ` -State �li`..Zip i ONE �. , , . , r. Pa er Source *1 Subscriber's Name Group No. Policy No. . Cov.Code Verified Payer Source *2 Subsvlber's Name Group No. Policy No. Coy.Code Verified Payer Source Subscriber's Name Group No, Policy No. Cov.Code Verified ubscribe►•s Relationship to Patient Namt and Address of Insurance Co. Nearest Relative(Not Living With Patientlirelationship elativa Address Relative Tel.Number -• R.•�MRS.WALKER AUN&UNCLE 6814 DELMONTE AVE.P'RICH 415 232-4830 j A F V a. 1 fY1 � '7f1 T ^i T�i �`,DISCHARGE SUMMARY AND ORDERS YMAA-t AA,I/-U�-- 1. ADMISSION DATE: $� DISCHARGE DATE: e. 3. INITIAL COMPLAINT: c. PATIENT I.O.Imprint Area must be readable on all copies 4• PRINCIPAL DISCHARGE DIAGNOSIS: (D SI i (Chief reason for patient's admission) Other Dx O� 3"-t -3 Co 5. P OCEDU RES PERFORMED/GENERAL TREATMENT MEASURES: DICTATED SUMMARY— YES ❑ NO 0' 'het: �( �W(.� {�s�►SC.t'�'s _(AM T I.� L tsiS 6. PERTINENT FINDINGS/HOSPITAL COURSE: G -t P c -L Z-✓+L2t.�`� •l `�d` _ '�'`'`'--�"'�"" d''-7�1'�-tv 1-,r.-t. � . . �y,,.t,f,LO wcrl� (,•e.,�2 law-+r� Cu�K-✓ -.0L, o-t..r r.%�-. ,... kk, UA-A 4UC.L U- t-- �t o-�. I�J+t'3. c.�.ah•T T-�-d —r)-zUvw>✓� - � A- S�4 1-10c>i+ a" AyS&-v L-> ro L,� Li-13Y2- k,*0 PS1j rc�llcsd� ► �_ . CONDITION ON DISCHARGE: Ef7l Le 8. INSTRUCTIONS TO PATIENT: (Activity,diet,etc. Include medications not being dispensed.) g I�1.0-rte; Imo•. V"-t 1--4- - �° s _ 3 e?c , Etr+�. w..r� v„�L^el— �. VLa.}yt_v� � � o•�..o w.;.r� hr+•-. � -fv.-�— s,�ac.t... .�. �}-:s s/-�.''� � 52��_l w- (2�t.�..�.•-�-t7—c�.:.�c �:.� l-2..t.�c�(L S e.r -}e 1=�.,..�:(.a.1 tars-Lfi`c-c �. APPOINTMENT REQUEST FOR OUTPATIENT FOLLOW UP: CLINIC ''""�L`'� Primary ,�^_ � - 1-ZS Dolcttor �: C't!>�-� yr WHEN?NEEyXT OPENING/OR SPECIFIC TIME PERIOD �y LOCATION: MARTINEZ V ICHMOND [ PITTSBURG ❑ BRENTW" 1 OTHER'LJ"'A C (SPECIFY) 10. ADDITIONAL APPOINTMENTS: .ti DISCHARGE MEDICATION ORDER r • a r*4'• >± (DISPENSED) J 1 PATIENT I.D. imprint Area must be readable on all copies Q V DEA NUMBER (SIGNATURE► (3F( Tk.ARo ,QOc'Cti2 CONDITIONS OF N $SJ N ZJA is: 10 \8\iU\C,0 dOS � .r110J8N;, Mia ADI C ;,,'iL,'SlJRGICAL TREATMENT PERMIT: 1 give permission for ariy'rriedical.or psychiatric treatment including X-ray examination,labors- j`��l res. Vt /?a dVl°n �' }Z4'a sting as may be c "d pO ilie•:•ttettditig physician and/or his associates.assistants.Including medical students and physician �residents,and personnel assigned by the hospital,•;: NLOANG CAGE: I uide,,10 E t1E.�.ikisSQsp«Provides only"A duty tTsil JQ)teTilf+aa�lhe physician orders more intensive nursin;,=k. be p•uolded for the pattetit or if the paiient's'condition is such as to-need the se►vjoe of-special duty nurse or attendant: TEACHING PROGRAM: I understand that this hospital is a teaching institution and that unless the hospital is notified to the contrary in vAI M. i may ParticjPate_af a patient in the medical sdueatioriprogram'of this institiltion. ' t -sot VALUABLES 1 understand that this ho;pita) maintajns a safe for the safekeeping of honey and valuables and that the hoIUtaTs�ha�l` : j sot be"liable for the loss or damage to any money; 'ewelr ,document •furp,or otter articles of unusual value or any other{sersone pro rty.utt Y � les:dedositPdAS"? ECZ� C�OU(�-000 L:A a ., AHMA fNAA�;y NEWS R AND RESPONSE TO INQOIRIE`Sti understand.it is the aat��rro r C ' ((�� ��.I� �rX{e r I {����pn}(�yy�r unless oth ..AND by the patient,parent or conservator,the follow Vk rk=la rhe,�AZhe 4Eit,.�idaadrrlilA'o " ariei i"nature of i tlr and `' '. ' tr j g .,,b rfj. Y general cbndiYiwi;No informatibh`itfeleaa�d for patients being treated'for 3 psychistric adition,:or,forttJrug �bohol abuse sinless specifically authorized b the patient. �i ft/+�,i � .... .r.1�:r " _L �:: �..:'.... a, r-.`i u4..�...' ��► ._.: .�.t�!��� ; ^ ;,. _•. .. t,CONSEN�Td liafiOGRAPH:The Hospital is permitted to takepictures o}the medical or surgical progress involvirtirtV Patient and to uae same ' 0 ertttfic gducational or researeh'puposa r . I _ _ ' r �,_ " VING HQSPITAL AGAINST ADVICE:)nJthe?event the Patient elects to leave the Hospital,agamst th4sdyice ofii physician and,tM Hospital;'r <" L't i•. a.' .g he Paj�p ltl�sasall physiciart;.and Lhe Hospital:frgm altresponsjbility and any-ill effects which may result from such action. .:�` f f n•a'i -_S...iA't i..- .., - i ... 1 _. _ ,V.�y... �.•_a•,t+iii '.�"�} � lz q� ��tt--� ,e�. `- "''..� •" y.., ' -, t_ 1 :' ,•...•.,.r9'.-�. ... � - .. I i?i 1 DRUGS IJs Imperative:that the Hospital stall tinter be awareof the Patients intake.Accordingly,Patient shall neither use nor keep onydlYg ofiy �S;y j t dresg spPllefteefapparatus net presrxiberl-by of on behalf oithe Attendirt�•Physician:ori f dispensed by th4 HosRitalslYring Patrent'i•cunrentstalbcr a } t ii 16. FINANCIAL AGREEMENT: I pwailsaao reimburse the County.of Coins a Costa for any hospital yaw and medical service psovlded.to the that to i . ve �¢t�ipre, Med' i r or. t e nt will be at the rat Qin t;. wed orvFAls!'1 will usi{t �r dlal�nef'r f:i4e4y'lfitilMdis�0111ich necessitated his fblhsdttts 'urrtathe'amount-billed,•but' not to exceed the rates—set by the Board: !� RELEASE OF INFORMATION FOR REIMBURSEMENT` I eve ermission to Contra.Costa Count _ 9 P•- Y Health.Services to furnish information from my.patient'.record to the extent necessary tar determine-liability for payment and to obtain reimbursement.'.lnfomation:may include shaf - + related to a.drug,alcohol or psychiatric conditions,and maybe.given.to any persan.or corporation which is or may be liable for all or any r.y.,. ti:. .. tion of the hospital's:charge,.including but not limited to insurance companies,health care service plans,.workers compensation or.peer treview'';r. <•'" _organizations: :z - :i J i AUTHbRIZATION TO RELEASE INFORMATION AND CONSENTO RELEASE MEDICAL LABELS t. I authorize Contra-Costa Department-of Social Services to rele'tise information concerning the status of my Medi-Cal applicatioand to send - = Medi-Cal labels to Ccntri Costa Health Seryiees Department .ASSIGAIMfiNT.OF BENEFITS: 1 authorize.any insurance company or carrier,through which I may have coverage to make direct payment of.'` . benefits to Contra Costa County Health Services,an amount not to exceed the Hospital's regular charges for this period of service.A photocopy of this authorization-shall be considered as effective and valid as the.original. 'i I authorize the Attorney.Claim Adjustor, Insurance Company or an Person(s),Company or Corporation who may effect a settlement or Y. I Y P Y P Y Payment of my claim for damages or indemnity arising from the injury dr illness which necessitated this hospital care and/or services to deduct the amount A of the charges,of these services from sum due me and to pay that amount directly to Contra Costa County and I assign from that amount all or any portion of it which is necessary to pay those charges. 4y, 1 waive the statute of limitations on this matter for a period of 10 years.This agreement and waiver is binding on me,my heirs,assigns,administra- '? tots,and executors. WHERE MINORS ARE INVOLVED,THE FOLLOWING PREVAILS: AGE OF,CONSENT: 1. Thi.consent of a parent or legal guardian is required if the patient is unmarried and has not yet attained his or her 18th birthday. 2. If a.'patient under 18 years of age has contracted a valid marriage, regardless of a subsequent divorce or annulment,then the consent +. of a parent or legal guardian is not required. THF UNDERSIGNED CERTIFIES TO UNDERSTAND AND AGREE TO THE FOREGOING, RECEIVING A COPY THEREOF,AND IS THE PATIENT, OR IS DULY AUTHORIZED BY AND ON BEHALF OF THE PATIENT TO EXECUTE THE ABOVE AND ACCEPT ITS TERMS i'ERSONALLY AND UPON PATIENT'S BEHALF. C� ' PA 1L%T'S +( tiP_T REL4T1 T PATIENT copy of this Do. ::n,:•:. ..r d+burred t t.Pat rpt' te:_ __ Patient undo', to :.tV:: FILASON. -. r Timebf signing:. CONTRA COSTA COUNTY HEALTH SERVICES,,EPT. EMERGENCY ROOM RECORD Patient Name(Last,First,Middle) Patcom Number Patient's Maiden Name CHART SOURCE VISIT GRANT ANNA E13075304 GRANT. 4568937-02-0001 Local Address(Space/apt) CityState Ip Telephone Arrival 1410 MISSION SAN PABLO.CA:94806 415 0000000 W/05/07 VIZO AU H.*4 Date of Birth Age Emergency Contact Name Telephone F.C. Pt,Type Med Serv. 7/08/53 33 R.&MRS. WALKER PO E `1E/R NURSE ASSESSMENT&PRELIMINARY TREATMENT CCHP YES r) Tylenol, Meds(Include BCPs,ASA, TyNnol,Vitamins) Authorized NO❑ y, Primary Physician Other Medical Problems Last Tetanus— > :•. - y ,C .� Nursing Contraeapllen- �,. Signature Time PHYSICIAN ASSESSMENT&PLAN . ORDERS B/P .. . Pulse Resp.-. Temp. r Time B/P w` Pulse. t w� - t }.. Resp. Temp. l F' I . ju Weight. * VISUAI ' A U1T� OS OD Corrected ❑ , . ?^« Uncorrected ❑ ` Allergiesentative Diagnosis Condition on Release PATIENT INSTRUCTIONS DISABILITY Will be able to return to work or school on: sm x `~ Restrictions Was visit an emergency by Medi-Cal standards? YES NO DATE- 1 have read and understand these instructions PHYSICIAN'S SIGNATURE MID TIME: PATIEN PM B T'S SIGNATURE 1'ONTRA COSTA COUNTY HEALTH SERVICE" DEPT. EMERGENCY ROOM RECORD • Patient Name(Last,First,Middle) Patcom Number Patent's Maiden Name CHART SOURCE VISIT Local Address(space/apt) City State Zip Telephone Arrival Date Time How Date of Birth Age I Emergency Contact Name Telephone F.C. Pt.Type Med Serv. NURSE ASSESSMENT&PRELIMINARY TREATMENT CCHP YE Current Meds(Include BCP s,ASA, �`----��� ❑ Tylenol,Vitamins) AUYM rIzW--ryt�❑ Primary Physician ri`t AN T• A►.N A � . Other Medical Problems - --- -------. ....-----.. . Last Tetanus- aR S t LMP- Nursing Contraception- Si9natu%, Time PHYSICIAN ASSESSMENT&PLAN ORDERS /P 3314 p, c M p IvAk 1!-j'3d:tYo t,Uj ION Pulse - f� V Resp. ��- T 3 1. � Temp. -- Qt.c -Time B/P 1A A.rl - Pulse --- a4 oay) t: Resp. --- Temp. L7 ' r Weight ' J ,l • Zv -- .., ., VI UITLL Y - Cis OD Corrected t Uncorrected Allergies entative Diagln_osiis_^ Co dition on Release —7 — .L° =.es PATIENT INSTRUCTIONS DISABILITY WIII be able to return to work or school on: - - - - - --- -- Restrictions Was visit an emergency by Medi—Cal standards? Y S NOU DATE: hl have read and understand these instructions M.D. TIME: / O PHYSICIAN'S SIGNATU PATIENT'S SIGNATURE Contra Costa Count)...ealth Services 0 I ; Merrithew Memorial Hospital EMERGENCY DEPARTMENT— NURSING RECORD ,T •+N )ATE ALLERGIES: 3 011 � TRIAGE STATUS AqA' L l 5 •,/ I' 1 ❑ IL ❑ 111 ` Patient ID � :,�•. RRENT MEDS PAST MEDICAL HX: LAST TETANUS: AVISUAL CUITY WEIGHT: ~ - �� " LMP � - OS ❑ CORRECTED r ? CONTAACE OD ❑ UNCORRECTED ..; Q' °❑W/C,`='' ❑CARRIED ❑POLICE ❑5150/5170 ❑OTHER k", 4 - , ': :•.:K'>NURSES'.NOTES..:::. TIME I� TYPE BP P R r TRIAGE `(CCiiPI) V r� T �s ��'ie 3 iy r, • rte, _ - O�� .. y: -- -- ADDITIONAL NOTES ❑ Itvz MEDICATIONS AND IV SOLUTIONS 'TME MEDICATION OR SOLUTION(IV solution bag#and rate) DOSE GIVEN/ ROUTE/ RESPONSE INT. AMT INFUSED SITE INTAKE pO IV DISPOSITION: ❑HOME ❑MHS ❑JAIL ADMIT—&-- ❑OTHER HOW DISCHARGED: ❑WALKING ❑W/C ❑GURNEK. ❑OTHER OUTPUT NOTIFICATION DISCHARGED BY: DISCHARGE TIME: URINE EMESIS/NGT OTHER ❑POLICE ❑CORONER A 4 ❑CPS ❑OTHER PM �IGNATURFC ..•i • CONTRA COSTA CuUNTY HEALTH SERVICES HISTORY AND PHYSICAL EXAMINATION Patient T.D. DATE S I p-pl 3 i c m Wa s Gni A-/ `go eZ- g4�' fv 2 i� 1 .711-4 7 t 1 4 % 7 d� J Af /ass f; PCc' lam' fft ��Lv1 1411-4 4/81 CONTRA COSTA COUN HEALTH SERVICES I HISTORY AND PHYSICAL EXAMINATION Patient I.D. DATE / iZu u CQ � ' £C� uf' uD�1'Z' �c,OG�JU>'B� -I .. ,Y •!/ G'�W w• lad', - i "f&21 rl�G` s MR-4 4/81 4M e*i cs •o > r' v vii O r c* x > m 70 to Z4 10 ri OD \ -� _-0 co x O r► Aat m VS 20 C> ^, Z •w INK >-� H VV\\ M ril } 1 K tv 1N'{ v s L � � '� ago QI �uatled t ` `n f � A V .1 ;o c G m _ GO► OR r Z tp g A P � Z N ` N � � O t \ -3 rl CA A v a G \ �e� rm { � � 64 rG O ! nX m cI D I r s Z I cn o! o �c-A4 G s 1 ^� o d !7 t 3 a m 1� • i ny X 1 a� i j nA d �• _ 10 -a l ( K s i rrs-••.2� i � \ 1 i r Lo, s • C � A 1 � Z � o y ` 4 Q'1 iN311<1d w m this x rn a r M r � r 1 , r � . . r r ►. . r r r r r - rr rte' ONE ' ' -- / % r � r � iI, Fill I I `J� /►, ►ram., j.i> `. . � /`.rr�.r i Merrithew Marc --it Hospital / I CONTRA COSTA COUNTY HEALTH SERVICES • 2500 ALHAMBRA AVENUE MARTINEZ, CALIFORNIA Patient I.D. FETAL MONITORING HISTORY SHEET REASON FOR MONITORING: 1) ✓ROUTINE SCREENING 3) FETAL FACTORS t(-Bradycardia 2) MATERNAL COMPLICATIONS Tachycardia Toxemia Irregularity Diabetes Meconium Passagey' , Heart Disease Fetal Activity Decreased Anemia Fetal Activity Increased RH Isoimmunization Breech Presentation . Prev. Perinatal Death Prematurity Elderly Primagravida Postmaturity Grandmultiparity Dx Fetal Viability Other 4) COMPLICATION OF PREGNANCY 5) UTERINE FACTORS Premature Rupture Membranes Poor Progreso: suspected CPD Abruptio Placenta Prev C-Section • Partial Placenta Previa Uterine Anomaly Prolapsed Cord Multiple Gest. Undet. 3rd Tri. Bleeding Oxytocin Augmentation Amnionitis OTocin Induct. . COMPLETE AFTER MONITORING: 1) METHOD USED 2) FHR OBSERVATIONS ultrasound Normal 4-'focotransducer LPeriodic Changes ciSpiral Electrode Head Compression Intrauterine Catheter L,,Cord Compression U.P.I Acceleration Baseline Changes Tachycardia Bradycardia PATIENT INFORMATION: Gravida I/ Para 3 Gestation ,7 Type of Delivery QSVe Sex APGAR Score 0 / 0 ' Birth Wt. 2, 1-7 1 . 1- 1 min / 5 min M.D. White - Mother's Chart MR-156 9/85 Canary - Newborn's Chart CONTRA CGSTA COUNTY HEALTH-JFRVICES Obstetrical/Delivery Reco MATERNAL A Age Gr. P 3--r Ab EDC T el • d ep 'r",('iEypepe Rh Rubella VDRL ' Significant prenatal factors: (^ G a,--16 MOTHER'S I.D. ILABOR DELIVERY a.m. Onset Labor �pd�m, Duration 1st. stage hrs. 0-set 2nd stage ,ZI3 p.m. Duration 2nd stage �/jAA w_ hrs. Membranes' L{ ✓+�uK57O� a.m. ruptured at _ i�;�,,�A i p.m.. ❑ spontaneous �] artificially Labor Analgesia: (agent/route) / • Delivery Analgesia: (agent/route) Fetal pos t on Clean Delivery at ,�- p,m. Date 3 E 7 at delivery Unclean Type of delivery spontaneous ❑ operative ❑ elective Indication for operative delivery T Forceps: ❑ mid ❑ low type •flacenta @ p.m. • Appearance Cord verse i Veins Z�rterii es ❑ Episiotomy type laceration ❑ , Cervix inspected cervical laceration(s) Describe any repairs Estimated blood loss ��O c� cause -if excessive It BA Sex N41J Weight 41;1 t Length Respirations: ❑ spontaneous ® delayed minutes Resuscitation (� endotracheal ❑ bulb ❑ gastric aspirate Apgar Resp / cry---L— color / tone / heart rate / Apgar @ 1 min n @ 5 min O `. ❑ Bilateral breath soundsabd-. ma�r/es_ n cord Rh C] coombs Other findings - comments: �tr,�G:�iY Ilotycin o nt. Identaban D Fetal Monitor: (� Internal. hrs. ( ] External hrs. M Medication Findings M.D. MR- (4/84) Dist: white - Mother's Chart Yellow - Baby's Chart Pink - .Clinic/Baby's Chart CONTRA COSTA COUNTY HEALTH SERVICES CARDIOPULMONARY RESUSCITATION + Date �1R__� f Location Patient I.D. EVENT TIME Cotof TS: m Unresponsive/CODE BLUE called f�� 3�{-�jrp W k °�Q5�4�1 y n14 Breathin : -Yes -No f qr (3 o/0 N° frq-Y1q`�� Cwi Mouth-to-mouth begun Ambui Ba 2 begun 11 r4 Endotracheal-tube placed. A 'c ' .•.. Pulse check k . - resent -absent . p 44 com ressions.begun, - K: .Monit6r EKGz Initial- rhythm 5 I. �- a'�'.: .y .V = �, -in. lace -started C O Solution' bJ Site.; - F L O W R E C O R D STATE MONITOR-RHYTHMDOSAGE TIM$m DOSAGE T DOSAGE TIME DEFIBRILLATION pm y MEDICATIONS (Z,V.) Soda Bicarb 3 0 5CC E rine hrine : ,, 11ee Lidocaine: Bolus' �C X. Dr i '4v .. Bretylium Procainamide 'Atropine FIQ Isuprel Do amine Calcium Spontaneous Pulse Blood Pressure S ont. Respirations Arterial Blood Gas cc :1 vy\ Z:.t8� ,Team Members: Physicians: DISPOSITION: ��Yj - �,-.11-t_. 1./?7 .�Lii.�t�j. Aj Time Recorder's SignaturdJ 3• J ; R. N. 's Signature UPLACE MONITOR/EKG STRIPS ON REVERSE SIDE (patient's name, date, time) M. D- 's Signature orl�inal - ghart Tall. — SurR•r7lforvard to Ed. t Tralnlnr tm_"1ni NEWBORN MATURITY RATING and CLASSIFICATION ESTIMATION OF GESTATIONAL AGE BY MATURITY RATING Side Symbols: X - 1st Exam 0 -2nd Exam NEUROMUSCULAR MATURITY o t 2 3 4 5 Gestation by Dates wl MUG je FL Birth Date Hour of �' : APGAR 1 roin _5 m M)kTURITY RATING • s ao r- 80� . OObt �[90� Wk: 26 T 10 26"O."d BO°" 15 30 r � yQr Q 20 32 C 25 3435 38 R7 40 40 45 42 PHYSICAL MATURITY 50 44 0 1 2 3 4 5 A • SCORING SECTION gil 1st Exam=X 2nd Exam=O •a Estimating Gest Age • by Maturity Rating y 3� Weeks Weeks �a � / �+ Time of Date 3 Date _? Exam 140 am xm Hour3f pm Hour pm �v M Age at D Exam Hours Hours Signature o' -� of W.D., M.D. 'o Examiner B c / 121y NUTRITIONAL DIVISION MERRITF; MEMORIAL HOSPITAL CONTRA COSTA COU,vfY HEALTH SERVICES PC PHYSICIAN'S ANTEPARTUM .ORDERS Date 3/ 6-717 Patient I .D. 1 Wei ht BP FHT TPR on admission. 2 Shower as needed. 3 Clean Voided urine to lab. Check for albumin and su ar on ward. CBC VDRL on entry. RH factor and blood t e ;j unknown 3 5. Fleet enema PRN. No enema if premature, If patient iS- bleeding or if patient is to be sectioned, unless ordered-.':. pecifically-by y doctor. No enema if membranes are ru tured k' 6. Liquids as tolerated if in labor - otYierwise"diet as tolerated. 7. Notify Resident on service (or call) when .patient first admitted to ward. - 8. I.V. Fluids 1000 cc Ringers ' Lactate 125 cc. per hour on all atients in active labor. 1\9 Fetal' Monitor Tracing'. r . ..; M.D. y " (Signature) MR-23a .9/85 U d •- 2 O ro a pauos m :. 1 AND SaEA�MEN OJOS ' i SAME � ►`'` '` j a '�`''�S W W s ' C W Ca 1r .y: r W h � .i''µ.0• o ; ' A^ SIGN. b O I W M.D. o s : Oft 01 TM NT o -t _;�. ✓ � a . .,,,max. :}jam W pot pEN us'��p�` S v StGNA.�VRE � 104' Du R PNYS � .CONS SH SOuvE*kGES OVNSY pYMs 0 5 tl sro) MEPTtITHkW ME�fORIAL HOSPITAL " }" 7 F pp POSTPARTUM PHYSICIAN'S ORDERS C D I 4 r_ ^ a Y } ow Date .. Patient ID 1. VITAL SIGNS: check fundus, pulse and vaginal bleeding q 15 minutes X 4; . then q 30 minutes X 4. Record blood pressure on arrival to ward; then cr 15 minutes X 3 or until stable; then blood RMssure and terripBID. l ' 2. AMBULATION: Ambulate with assistance PRN. May shower'PRN with assistance. If spinal block: Horizontal in bed X 8 hours,-.then ambulate PRN with assistance: 3. ' DIET: Reaularvith additional. nourishment. 4. CATHF=ZE: In 6 to 8 hours, if unable to void or if distended.\\ If necessary to re-catheterize insert a 416 Fol to straight drains e. .. .,•.r.' 5'. HDATLUCRTT: On postpertafi da 1. 6. . .SEDATTCN: .100 mg nembutal po q .hs .PRN,. may repeat X 1 if necessary. . ,. _7.: ANA=TA, I 2 Tylenol tabs q 2-4 hrs po PRN ./ 1-2 #3 Tylenol tabs 1& 2-4 hrs po PRN ` -1-2 Tylox tabs q 3-4 hrs po PRN 1-2 Percodan tabs q 3-4 hrs po PRN - >wc - IF NO RaSEE FROM THE ABOVE MAY GIVE. - Demerol .50 .mg and Vistaril .50 mg.3M q .3-4 hrs PRN X 2. M. 8. Bow=: 2 Doxidan HS until has bowel novenent 1 DSS tab po BID PRN Fleets enema .or .Dulcolax Suppository PRIG' - 9. " 'BREA=: Breast pump PRN ✓ Ice bag PRN Lanolin ointment PRP? - IF NC T NURSING: Deladumone OB 2 cc D1 STAT s 10. F.PISIdInMY: /Hot sitz bath TID or PRN Ice pack TM or PRN Dermaplast PRN 4th degree .laceration precautions t'- `= b side 1 (8/85) MMRI=v ME-MDRDL HOSPITAL s POSTPARTUM PHYSICIAN'S 'ORDERS - continued 11. IV's: Run present bottle in hours, thea: Follow with 20 units Pitocin in RL 1000cc for 5 hours; then DC. IF PATIENT IS HAVING EXCESSIVE EKING:.'.; Keep IV open with jRL� 1000'.0c with Pitocin ]A • { - Sen t, NCY=.PHYSICIAN. .,. Methergine 0.2 mg PO-q 4 hours X 6 doses if blood pressure iso, l not elevated. 12. Rubella .vaccine day of discJe.if patient has �iegative titer, 13.' ✓Ferrous sulfate' l::tab.dai.lv.. lRr r 14. ADDI'TICEML'ORDERS e 7r . RIiOGAM IF INIDICATED Kwl 2 17 ;ti--.- b' 15. ALLERGIES: M.D.. MR-23-b Side 2 (8/85) /r` SWnp; Patient Stamp CONTRA COSTA COUNTY HEALTH SERVICES MERRITHEW MEMORIAL HOSPITAL&CLINICS MARTINEZ X-RAY ULTRASOUND C.T.SCAN AND NUCLEAR MEDICINE REQUEST { /y DeftOf AegUlIIM ApRWntment Oat* Appointment Time 1 ou EXAMS C jol`,j i3l-;`;^ �.�x;..'..�i. �� :�4}• _ e .. .�RI`�`r`_ �:�e�:�''Q.l+y-;rim. :,.• CLINIC-NFORMATION•. ^ _~ ` • ,• *� `' :- ' y t,,,i.�...,a-.. a - .. _•y ,:rte.•• ._ � t.t, +v '�-.,,'"`>:,"1-r' !�•ul•�beM���A�;��,i.r � .. . �:f. F 3. 4 �i ARIERGIEW r PREGNANT? " . li O'-NO0''•YT30 moo WBGW s: NF3G;ITSIGNATURE gas a v PHONEREPORI?• ,t PIMJNENQ' OiABETtt.7: PATIENT a "IES O YES O NO O we 0,^_ UER%"eV 0- RADIOGRAPHIC RzPORT 'DATE taAl?ENT'S NAfrta -° `�;' tlNiTNliM -�--- " tx/5/87k. =GRANT,: BABY "$OY .. -.,. k "ztr lO4*3U�i . xL; NO ;PORTABLE CHEST, ABDOMEN r ", 'r. � - .w:' -: •- \ ,\ trT r .� s ane�dotrachea7 �ube<termnatin.g in:the- mid trachea..;. Btathlurigs.are . . Y. + pa uet-wth 7nb rideanceraf aeration and 'a nonvisible cardiac silhouette,-because , h'e dense Surround �-lungs: There; .�s gas 'in the stomach ,and in, the duodent m' :r 4 up" o` the ':ligament�of treitz. `°. Otherwise, ttie..intestnal tract' is air:lS :,Ii: ` , tas `iltipossible to exclude or- include ,abdominal masses..'. There are no cat pti,cat ions .. " lei i 'the abdo An umbalic:al arte><?i.al catheter terminates. at. thejower':border of �"'' ,y��w'?t�`ys ,� ,� "� r' yr f -ai v. - �•�' c W.._ Y .t" .�v.yK1' OHCL OH ` � r «rTota]ly unaerated lung f:ie:rds. Mi.nimal,; as "has "entered ' the' intestina tralct and thas is abnormal r norm � epending : a t `�t5`the age of.: e:patien x •,; ,. • r �� `fMFat FREDERICK LEY, { D&T .1/5/87 " . NZ Jt ki.r v�. tau•*-' -+t+ .. i:.. .. ... ... .. 4 RADIOLOGISTS: SOLOMON KUPERMAN,M.D. ROBERT B.SKOR,M.D. FREDERICK M.FOLEY.M.D. BRUCE LONDON,M.D. RAMT A] f5/A 61 GONI kA (:US]A COUNTY - MERRITHEW MEMORIAL HOSPITAL HEALTH SERVICES ' LABORATORY REPORT AND CLINICS = 43x1 8 c 1'. m' t; °2 3 S 1'7 A kARQ o p N rid = W L) OIL 7= cS IrH a a Z 4" W d j ' - S - ' F • ?'-.':�-53xF _�. ��€ t fo Lo IATfE i AREA IWUS EAOAttE ON Ali CO►IEt. N S,;► ' Q r r �: " .2, 0r URINALYSIS I"WWill mm CHART t�+►�1� 'it' X. PR�ORTiY t. QUESTEDBY> 'dPEC.C`0l1FCiflON r 77 .. a U1 ROUTINE :TECH .,r ' •'f'Sr•"t`t y�sY ¢ ...mss-- o A Y1P'r ' ASAP M.D. STAT DRAW 'r. : AI►!F S r U1T, t: z a R i STAT S C AFTER HOURS PM �o AT'_ A80 GROUP/RA TYPEt rDux F DIRECT ANTIGLOBULIN MOOMMTEST E_ ' rrt ;r te 'S• INDIRECT ANTIGLOBULIN/ANTIBODY SCREEN PATIENT Ul IMPRINT AREA MUST BE REAWU ON ALL COPIES r aS ' � g RhPROCEDI pi : �o k i Rh IMMUNE LOTS _ GLOBULIN PROTHROMBIN TIME 11-13 SEC SEC. �t,; "r. fF;::•.: $a PARTIAL THROMBOPLASTIN ANTIBODY LD. TIME 29-37 SEC s M ~ ASO SCREEN FIBRINOGEN.20OA00"19% MONO TEST FSP:L 10 UG/MI. p 01 RHEUMATOID FACTOR LBMT09 �►IMMUNOLOGY/COAG CHART I' t DATE OUT , y "wlftnvY CBC t O1FF REQ sy IEC.COLLI DATEOUT ROWINE C6C rY X PRIORITY IFF Y COLLECT. ASAP PLATELET = DATE ROUTINE CDC .Y�. v STAT RETIC .. 4-0 ASAP "TELET AFTER FMS, SE RATE MTE TECHNO PM STAT RE71C A SED.RATE �S RESULTS EXPE 4:0.2q/Ar, RETIC AFTER HMS, SED RATE : , PM b RANGam E d:p-9/hr. 0.5.1.596 SED.RATE RETIC' PATH NOTES: RESULTS EXPE 9:0.20/hr. p-51,596 ��I z i /�L 48•iD.$ CHART RANGE d:0.9/M. ` �yyp • a RBC M 4,74 EXPECT 1-7.737-7--7 �:++{µl 4.8•iD.B PATM NOTES:'.!r__ TEST nI'1 CHAR 11110 6/w1 F 42.5.4 RANGE :t.► RSC M 4.73 t TEST XPECT HGB M 1418 MPV• x 106!µL F 42-5.4 RANGE, I/dl F 12.16 fl 7.2.11,1 .upV. •• j NCT M42-52 HGB M i4 1$ 7.2.11,1 % F 3747 4/dl F 12-16 *-f HCT #1142-62 MCV M 80 84 u % f 3747.. 1:.; fL F 81.99 i4.5 H MCH..,.::.•. MCY 27-31 HS/pdW' 2 2-3.2 ILMcH ND1M•. I MCH 273T 23.3.2 9JdlG 3337 T LI* 1.9-3.0 S • E1dL c 4 t r po G• MCHC 33�7 t t`..,. 19-3.0 ROW 11.5.14.5 MPXI* f/dL P T R8C s t{ -•a. ...� RDW. 11.5.14.5 MPXI•.: •10.0 _ x ALL 130.400 FLAG 0000 +10.0 PkT•% 13p-400 R$G IXu� DIFFE T! L FAG BOOo x IOJaL FLAG WBt RESULT% T ST IXP£CT RESULT 103iy L EXPECT DIFFERENTIAL FLAG, 0000' RANGE RANGEg RESULT% TEST EXPECT RESULT 103/w L EXPECT RANGE A 0.0 T4A •1• "" ' 1.908.00 oa RANGE _ a» M« ••`� * t 1.90.8.00 'B:3 LYM 19.0.48.0 `" r D,90.5.20 =c NEUT +10..1-740 u« «u o x L. LYMP 19.048.0 4 0.90.520 —o MON 3.4.5.0 0.161.00 ; • a oc •4�•^ " .. $.4 _ t N _ EOS fl.0 70 0.00.80 MONO' i A EOS .0.0 7.0 0.004.80 u T. BASO 0.0.1.5 •`i 0.00-0.10 6 « . .. E 11 • Ilk 0.04.0 4 0.00-0.40 BASO:- :8.0-1,5 000420 ,,.. E u 4t • LUC O.OMAO .a 3" DATE TIME `'f I OATS: JJ TIME ID y ti t SEONO ; ID SEO NO PARAMETE SUS• ERI ; SYS NO 40 Z PECT FY SUS ERI _ PARAMETER SYS NO ANISO r sti',•ry��. .. PECT FY ANISO so 4-ft 40 m MICRO; . v MACRO 44 MICRO M +` c + !: MACRO a VAR ,- fly Nt o .. y HYPO VAR HYPER ^f HYPO _ ?t' LEFT HYPER ' SHIFT LEFT ATYP SHIFT 1 BLASTS ATYP _ MIMI BLASTS j OTHER OTHER T•c.,Noa.: 7, ti,/ ,a q� . T.c..Note F:. -_f j _ ItJ p [j •"^ �. t�J... ,.1�. _ I ?' • � L Y r/ j(7. CONTRA COSTA COU HEAL. MERRITHEW MEMORIA '(3 2500 ALHAMBRA AVE.,MT2:,94553 S_ CONTRA COSTA COUNTY HEALTH SERVICES Y MERRITHEW MEMORIAL HOSPITAL AND CLINICS ' 2SOO ALHAMBRA AVE.,MT2.94553 NYE-KYUNG KIM,M.D.,PATHOLOGIS AAl1.-" _ L A b U K A I URY REPORTS AND CLINICS a �m�•s"iY s f <�. - � 'L:.Cf' L.a -•''k s" a1`.,,. •,s.r ,t�i � 3 w a z N� �• >:O�LEGTED.:,; 'X: nROCEDURE"' ��'>'',' A.M. GRAM STAIN TE: E P.M. BLOOD.CULTURE /(�7Z46,0 CCI.tE�TEDAT% -REQUESTED BY THROAT/NOSECULT.' OTHER SOURCE CULT. ^ 3e' D. SCREEN:G.C. ✓& SCREEN:(STREP)THRT. /O qSa/ JJ F SCREEN:UA -� STOOL CULTURE ' - I �`- ANAEROBIC CULTURE Is V a'3 ' �. ROUTINE 4 ASAP KOH PREP PATIENT I.D.IMPRINT AREA MUST BE READABLE ON ALL COPIES "oiN �W� STAT DRAWL SALINE PREP Ea , o s B Z^ mc° STAT SENSIT Va i AFTER HRS SENSITIVI TY:DISK "�ICYL711RE NOS SENSITIVITY:DISK SENSITIVITY MIC asrT;ia(Vw) W MICROBIOLOGY CHART '1) i�:, nom .. .. Bij,v 'BPEC.700LLEC7i0N'' _ If 7 y, G ROUTINEXECH Yu ASAP M.D. 2 STAT DRAW INOLOO{ST �i1TE 7 ! �� o STAT AAL �p pro n T • AFTER HOU S �. R / ' (PROCEDURE CODE .� LI141TE� PATIENT I.D.IMPRINT AREA MUST BE READABLE ON ALL COPIES i3 RESULTS n �( S fF,uj 00 d� LBMT 10(7/84) MISCELLANEOUS LAB ' CHART MR-38(8-86) _ CONTRA COSTA COUNTY MERRITHEW MEMORIAL HOSPITAL HEALTH SERVICES LABO RATO R Y REPORT AND CLINICS Z N PR=DURE St. ja i1A P.MM. GRAM STAIN „BA.B.Y:.'r.-B.-OY ^N ♦ CULTUR LOOD 034005-9? P,Q03-OS-91 �F�► + oO< , '- THROAT/NOSE B OTHER SOURCE CULT. n �. D T Sl. «� SCREEN:G.C. 10 T 5 3 O 1 tier.. isE! SCREEN:(STREP). kT 5 T Z Y F �'f S N P « -: I ow SCREEN:UA ?r.. i Q STOOL CULTURE �1Q Xr... •} ,m. S ANAEROBIC CULTURE <i a, NE V� �/ o a s ASAP�:,,'. KOH PREP � PATIENT I.D.IMPRINT AREA MUST BE READABLE ON ALL COPIES <... SALINE PREP STAT DRAW «�z STAT URINE ID. s :, SENSITIVITY:DISK ` ;(}5,,,' i^ AFTER HRS. M � SENSITIVITY:DISK SENSITIVITY MIC . .. `: Jeno L r;•arn�1 MICROBIOLOGYCHART V. .X c,osat. 4a SEND TO. .i..' si 7? l r a i ; flEGUESTEA.6Y +ti= :•"x PRIORrry. t':`T I f M.D. 4. -,•. TERIIACtME COLLECTED PREMARITAL AGE =; BLOOD PRENATAL GRANT* F E. a Sa I ,J. RA E r t < ❑ SPINAL FLUID DATE / TREATED CASE F I- 5 81 f c 7-08 p= IS ROUTINE S W �? 1 �w5210 - �SbRq� TIME: Q- OTHER SEND TC►. X PROCEDURE:':: -- z_ A lMAENT LO.AREA MUST BE READABLE 1 AfrEAs o SEROLOGIC TEST FOR SYPHILIS QUALITATIVE R WR 3 VDRL V D R L SLIDE SEROLOGY,OUANT.VDRL MHA TP z MHA-TP FTA 1° OUANTITATTVE>t 0 2 4 8 i s 32 64 t 28 t �o TREPONEMA ANTIBODIES ^� w (FTA-ABS) VDRL Z, _ j¢ comments MCI MEDT-SCREEN VDRL PHW-02(5/86) W SEROLOGY—(PHD) S � CHART it t. SEND To: tg I f r..R.cot ? ) i. one c GP AaT y • f mM M.D. PREMARITAL E I �3«O S•8 T •, ���a-�� 5 $PEC.-COLLECT: PRENATAL f J T C a =. BLOOD 'S 't' C IMMIIINITY L, _ DATE J EXPOSURE DATE EX 104S210 . 1 t'/�4 7c 2! 0 • W g :rte:= ."• �t J r,C1 � , (�� I;.: TI1L D.W ME (J�. ' PATIENT LPRINJ AREA MUST BE READABLE ON ALL kPIES• �, aZc'g SEND T X PROCEDURE INTERPRETATION C =; RUBELLA IMMUNITY LEVEL SPEC �<plOS ❑NEG z O SEROLOGIC EVIDENCE OF RUBELLA VIRUS 2�d Z INFECTION PRIOR 10 RECENT EXPOSURE ❑POS O NEG SEROLOGIC EVIDENCE OF RUBELLA VIRUS SPEC. ..� w 'DATE D• •: I ECTION AT UNDETERMINED TIME v ❑NO SEROLOGIC EVIDENCE OF IMMUNITY DATE OUT.- Q TO RUBELLA VIRUS INFECTION PHMT07(8/80) `►:: 'W RUBELLA '► W CHART M_ .,ME 1ITHEW MEMOFAA! -- 40SPITAL PROGRESS NOTES - Inpatient Service s - Drob . Date No . Patient ID - e . �r/ ��_2�5:��s�./`�Jaz�- /f�o�-�• .���u�.� r i --PROGRESS NOTES - Inpatient Service Prob. o . Patient ID l'-/76rV / L ' Alsa.51 f L r7 ALI L-1 :LA ��— ?'c> r hz4k Tri � b•-wL� _ ./ klov I .-C— MERRITHEW MEMORIAL 105PITAL PROGRESS NOTES - Inpatient Service I'rob. Date No . . Patient ID 3Z-5-Aea cA,, 30 17 3 a.rh. A•++� . e L -� -T C-f, K -► _�.,I —C fi' ' L � 1a 1S 2S ,^o, v ��� AU C> v 140 Co LA4-J 74z -25 �vl , 3 � -�- : ; s MERRITHEW MEMORIAL HG... ITAL PROGRESS NOTES - Inpatient Service Prob. No Patient ID 2 . r7 ,- E" --- 2 P, z S-t -- �`c- �c Kw -77 1 r MERRITHE6: IVIORIAL HU.,PITAI PROGRESS NOTES - Inpatient Service , F Prob. 1 Date N o . I Patient ID r YAG rv� "' yo c-0 f' } —tv C) • MR-25 (P/"5) CONTRA COSTA COUNTY HEALTH SERVICES 0 '33 SOCIAL PROGRESS NOTES 6 EVALUATION L / • DC7 INCLUDE REPORTS OF CONFERENCES WITH `fy-c Q ATTENDING PHYSICIAN AND CLINICAL STAFF . CONFERENCES PRIOR TO ADMISSION, DURING STAY AND PRIOR TO DISCHARGE , TRANSFERS, PATIENT I .D. INFORMATION REVISED PLANS, FINAL DISPOSITION. ETC. DATE .uJ Gi 33 0 •3 a44;- a;& all.G� .�- 40 1011,e — 3 / 8 n WHEREINM I 11111111111 limiligilliguiligivinl �e9i1e�n � MINIMUM �i Hme om n�iiin'em�nn�niGGnne n 111 Ii11111lIA I1� gnu o o �mm�m�ue neneote �nMUSEUM C11 11111 1111111i iii 11111i i=iineu� Hill ellI1 MINIMUM i III i � ii11 11111111111111gillNmil� �iilgiit � IN ini111111111111C111111111i�= nol II � ° loll gill gill III i losilligill ui� � � � 111111111� � Iloilo�monn � CONTRA COSTA COUNTY.HEALTH SERVICES IV ADMINISTRATION RECORD COOEf FOR fV SITE CM;MEf'`�r �:a> f.RF Right Foraerta LF , Litt Fowane 1 RA - RightAntao anal LA'-'-" La11 AnMcubltai i^ cr..s RW RigMWrist;' ;LW-;'LsMYVrkt:._ .�,.•,�}'�-�t ;,�.'. - RW• RWM Upper Aier LUA"•`Left Upper Ami - RN RWM tlart0 �� x J LIQ left Hand .: ��», � �""tt ` �, = }' "y Patfent•I.D; . 9 A �j: I` r 'l ; r' ':a :^r �' v CODES SON IV SITE CHECK .. �, t 'a: y1 -} ♦t k R Redness I Infihrated .Yaw-: .-♦ Medication-Solution' �! %,ifw OUR n xM a; ..14OUR_:. HOUR HOUR '_ ,•f .}, 4:F is r r_V~° ':[ - .,•• .•. .�, . .� � ar � y _ V�-ty-+ �aj "�k'ti.-- a:v ,.�Y' vl.�" • r�; Cf' t•:r.c-� ' r t T'} s .- W'��'i �.r� y,.' `" .-L..`�'r'4y .�li?r�y� S. y��..ct•L .�y�i� ,i7!� ty r-_ _ �. .. � .r' - E� � t � J ''iia�: W �� �3�} d�C"`�`ic. k� r-. c•.,.. - � [_.i, _r • r d♦• '�,TIF .� •�' �s'}.'.-T� �.)l'�-�'. •►:_.' ♦. _ . f, r may,;.+- t 1' • Y •}({� �`J"I f' 1r�iF �•"7-C S"+-� � �` :'♦i.l-a��i z�'— 'a � .y y " Fr nYe 1 e. v • - K • 1 t L�s''� 3'': �°^ .r -�.A -C t -•va- .c _`c. li;.f i s-t _ ''' - i' - y�,, •„�+.>7 \:y jp.r - •iyr. }. Y;,,'ta= 7• ���*�''�' 2_' t•' - v-s�. .v .• .`� .ti r r Stte Cheek 8 Mrs �-'11-7 - iTirrte 8t Codes t' 7 ...3-1a } dV Site Chenpet::72'�:ir iTirrie,Code 8&Gauge) Primary Tubing Change-A8' Secondary Tubing Change-480 Signatures: 11.7 7.3 4 3-11 .PYMCHARTT 07 (4/83) ' r NURSE'S MEDICATION RECORD CONTRA COSTA COUNTY HEALTH SERVICES :1 z, USE SINGLE LETTER CODE FROM BELOW WHEN INDICATING AN INJECTION SITE AND/OR RELIEF. -DATE' - 76' •- :`:'MEDICATION ';; `... TIME Relief TIME Relief TIME Relief TIME Relief ;� top �i •�._.•�n•. x# a'•'-'d w.�5 .3 ate. '..'ID •r. r � 41 so Y •�9 S y I ' i y Au IT RELIEF CODES ' S 11 -7 A-RUDD R:Relief. I NURSE B-LUOQ S=Some ,G C_RAT O-None' N D-LAT A 7- 3 � vAw_ E-LLT T NURSE F LLT J -LVG U G -RD K-ABD. R H-LD X-Otner E 3-.11 I -RVG S NURSE PYMT08 (7/86) CHART 'r r r MEDICATION -111�111�111�111 LD X-Other RVG X111 X111 X111 X111 : SII/�III�IIIs/11 ;_ X111®IIISIIIaIie , ®eee®eeeeeo eee ,. ®111111®111®111 `` �111�111�111®111 �eee�eeee�eee®eee r ®111®111®1111®111 { 01ee®111®Iei�i®e ®111111®111®111 ®eeeeee eee eee ®eee®eee®eee eee ®111®111®111®111 ®Iei®111®111®111 X111®111111®111 ®eee®e,e eee®eee ®Iii®111 111 111 ®111®11�®111®111 ®11e®e11®i11®111 - eee®eee®eee�eee �Ie1�1ie■�ee1®eee �IeI�e11�e11®111 �Iee�eee�eel�sell _r. .s y �SI�� �■� e - CONTRA COSTA COUN'T'Y HEALTH SERVICES _ MERRITHEW MEMORIAL HOSPITAL NURSE'S NEONATAL ADMISSION RECORD Patient I.D. 1. ADMITTED AT PM DATEe 2. MODEi NURSE'S ARMS: DR'S ARMS: WARMER 3. FROMs DELIVERY ROOMr SURGERY: OTHER 4. ID BAND NUMBER /u/Q S. MEDICATIONS GIVEN AND SITEs • 6. WEIGHTs4-- 4&3-ls LBS. , . , GRAMS LENGTH. ' INCHES= CM. : Headm. 7. MODE OF FEEDING: BOTTLE .BREAST a. APGARs 1 MIN., = 5 MIN. AM 9. MOTHER'S BOW RUPTURED AT PM ON: 'S 7 (DATE) 10. MOTHER'S BLOOD TYPE INFANT'S BLOOD TYPE COOMBS ii. LABORATORY SPECIMENSi Newborn Screening—Serial A` CORD BLOOD CULTURES � iGASTRIC ASPIRATE OTHER 12. PERINATAL RISK FACTORS: CHECK APPROPRIATE CONDITIONS: MECONIUM STAINED AMNIOTIC- FLUID MATERNAL FEVER �-•'� IRREGULAR FETAL HEART RATE CAESAREAN SECTION TOXEMIA ADDICT (TYPE DIABETES PREMATURE RUPTURE OF MEMBRANES ABRUPTIO PLACENTA MORE THAN 24 HOURS PLACENTA PREVIA RH NEG MOTHER`MITH INC. TITERS ELDERLY PRIMIGRAVIDA DYSTOCIA WITH DIFFICULT EXTRACTION TEEN—AGE PRIMIGRAVIDA PREMATURITY POST—TERM 13. INFNT'S PHYSICAL PEARANCEs ® 14. EXAMINED BY, TIMES DATE r � 15. ADMITTING NURSES EL� C,� RN (SIGNATURE) MR-2—B-1 (8/85) ---- C CONTRA COSTA COUNTY HEALTH SERVICES - OBSTETRICAL SERVICE _ - _ t i -� - - S , FO NURSE'S ADMISSION NOTE 4 Admitted: To Ward Room/Bed DateTf d',7 Time 3 - pm 1. Mode of Admission: Ambulatory Wheelchair G u e r n e y -- 2. Admitted From: Emerqency Room 4/Elinic MH Screening Screening Nurse T Other Facility Home 3. :Valuables with patients: 4. Patient Orientation Completed -,.n_,, +._c.,. .:...:._ .:......._. ." _ No/Yes Disposition. L¢,rIle Y esNo Aenures A. Dentures tG A. Call System II B. Glasses B. Bathrooms )L C. Prothesis C. Visiting Hours _ =k '- D.. Money D. Smoking Regulations �- ;'' E. Other E. Meals _ Identification band secured'.YesNo If not, why? =' ------------------------------------- --------------------------------------==- ---------- _ '_`NURSING HISTORY L _ n/('� — IJt�-fc s 3•s -3 7 - s 1._:: Admitting diagnosis - .,,,� I /dc� ► 2: 'Allergies (and reactions) (Medicine/Food/Other) 3., Medicine taken at .home '4.._; Meds brought .from, home?. Yes' No -- If Yes, sent"to pharmacy?. Yes No r: 5 :Languages spoken Translator. required -.6 Quality of:. Vision ,. Speech Hearing 7.. Hem°ts: Bowel Dietary E. Use of:AlcoholeNo Yes Drugs: NoLzfYes. amount � amount Tobacco:No Yes. u �- t amoust. /►�it�o rw. (fy�{- 1nv1r3-G %�/`c�►�-5...�P.c 9. Sept care level: Independenteda Help with 10. H stor of Medical/Emotional Problems: Y RN ADMISSION- ASSESSMENT 1 GENITOURINARY - REPRODUCTIVE c n �ubelle VDRL Blood Type ,(a Due Date ? Gravida Para TA SA BOW: Intact Rupturedy Time ' ColorZZe--µ+'."Fetal Heart RatWy7-X0Ga ----------------------------------------------- --------------------------------------- N/A Vaginal Bleeding: Amount��� Color �tF Time Noticed /�A N/A Initial Vaginal Exam.:: Dilation: S Presenting Part t,/x Effacement Station _ N/A Contractions: Time Began Frequency Nowt Duration Now,.?-2 "i �- T NSA Genitalia: Swelling _L) Rash SL Discharge fJ . If Yes, Color �_ . : Coaments Amount,,, Last Menstrual Period NEUROLOGICAL LOC: Alert ✓_ Restless Lethargic . Unresponsive _ Orientation: Yea NO t..•` . • N/A Headache Dizziness Blurred Vision Double Vision Comments ' RESPIRATORY. - - .f Respiration Ratey Y 2 Breath/Lunq• Sounda C1eaongeated Moffat N/A Cough: Frequenc i Productive: Yes No • Comments CARDIOVASCULAR 3d Temperature :tiBlood'.'Prasaure �� Pulsee':Rate Strong. Weak Regular./ 'Irregular :. Skinf Warm`. �Cool Dry�oist ' ------------- ----------- --------------------------------------- N/A (/ .. .Peripheral 'Citculation: Edema_.(describe) ss . Calf Tetiderne � T Comments . .GAS TRO INTESTIONAL� Nausea/Vomiting No Yea = Lf 'Yes, �oi�' long? .,. Comments.: ; ti. MUSCULOSKELETAL !!77 -.Height ` "3 Weight - Skin: Condition:' Clear dc .Intact -Yes No Parasitic .Infeatation•: Aea. Na Indicate locatfon` of skin ,. condition by marking on„chart ' \ x Abrasion - = A - 3 ` t •., ,;' , Amputations AMP • ' ,�. Bruise:---- --- B Cast- ----------- Dressing ----- - Dressing ------- .D. �. Laceration ----- _�Open Wound Pressure Sore -<P Rash Scar ---------- S Comments `• EMOTIONAL - SOCIAL y>. � s:•}�?4N n.: Grooming/Hygiene: Clean ✓ Malodorus Unkempt t Manner of Relating to: Interviewer: Cooperative / Uncooperative _ Agressive Withdrawn Agitated Demanding Anxious Indifferent _ Frightened � - Support Systems: No Yes If Yes, Who? Comments R.N. '4R-2£32 (?/$4) Side 2 '•' L t 1, i G t --i - Y1 ren " Z T A = J1 to n 33 -1 -a m z o 0 rn x 0 Z { to a D in Oto rn y rn [� 1 n LJ n a 1 V m 3 to A .Gt s M 0 g7S 0 s m 7 0 3 f c c o m D » m Or co A .` « a m a o = ca 106 < ,y c m O n ca a Sao IN � 2 K z g a 1 v s y am O in m p IC m NJ a ` � o4rzom w Ir A orz w +� O ., O c " V �► o o ,a» °' is _< n Lra .. ' A y G Z m m $ „ co a s o c N -qf ! —a z m i � z m » Z i ❑ 0 � C7 a 0 a ° M m » w M r a m Z K M M 1+ r .+..... y v y+ d s cz r .: fi w m N LA F ry a SERVICES CONTRA COSTA COUNTY �ALTH MERRITHEW MEMORIAL HOSPITAL AND CLINICS ;nor.•=_::. . OBSTETRICAL SERVICE 24 HOUR NURSING PROGRESS NOTES % E... ' DATE NN = See Nursing Notes Patient SYSTEMS REVIEW 11-7 7-3 3-11ith FUNDUS e LOCI A BRFA.STSor ✓ : "EPISIOTOMY onDTR UJ /�� atheLOC w..-.r- _ /1 /1, Up . ORIRMTION Affbulatory y MO�IOR �,— v Y- , ') Bedrest Bedsid SKIN ..✓ IN e Sleep UPULSE .v ct EMA D Vi it v - •� PR S EYZ ABDOMIEIQ G,,, X-ray 46 H BOWEL S NM Urine to Lab 6 BM Blood to Lab Fetal Monitor Ultra Sound URINE COLOR a FOLEY CATH. Na US VOIDING 0 ae, Visitors Foley Care Mn4 Breast Feeding $/S EbrmuLa Feedin TCI3ING s, DIET: �� t R� INOISION 14>- Appetite n Meal Eaten v Fluids Taken �.KA-283 Side 1 10/85 / SOAP NOTES SOAP-NOTES mmwAudl�� - - ... r �■ %� _/� /�'. /.. ' Ili. L._✓��� , W, -,-%- 1 XPOWN. W,Fm pR= ® _ - _ � I■� � ' til - ��,- - , - � / A.0 E ME /Emmm _. -,wtt W-2�m/ W-..J M W AIA'M!1 0 IN Em- ME 1 SEEM INEWE 0.W EWA ■. � .i . ,. � �:��/ � /iii t I■.I%LCL/ --`ii/ ' � � I No ■�.�,� � ,. , _ ,.. --� - I�.� ' Ali, • , . � _ ..,��. ■tom' .�� �:� , ._ � _- I�� .,�.-_�.-_ ' �, ■. S_Ili` � � / ' I■. •,fir/.lL�1l ' TRA COSTA COUNTY HEALTH SERI _E meatal Intensive Care Record ` Iso- 0 ! Nte Time Temp. Pulse Resp. lette CoAc. Intake output Nurses Notes ' 11'emp. o 4 1�0-2A-1 (side 2) 12/R11 CONTRA COSTA COUr.TI HEALTH SERVICES DEPARTMENT MERRITHEW MEMORIAL HOSPITAL > . : t t'0 DISCHARGE INSTRUCTIONS • i r Patient ID HOME MEDICATIONS DOSE/ROUTE/SPECIAL INSTRUCTIONS (FREQUENCY) t r: DIET INSTRUCTIONS: t: ACTIVITY: 3 INSTRUCTIONS/TREATMENT/LITERATURE/SUPPLIES• dw APPOINTMENT/FOLLOW UP• �— VALUABLES RECEIVED PREADMIT MED. RECEIVED Yes No N/A Yes No N/A CLOTHING SHEET SIGNED I -1 11 DISCHARGED BY GALLINOT E] Q Yes No N/A Yes No N/A MISC. I UNDERSTAND THE ABOVE INSTRUCTIONS: V.�.�. Patient's Signature D to Time 's Si n ture g Parent/Guardian/Conservator e u Original - Chart