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Home My WebLink AboutMINUTES - 12071993 - H.5B " TO: Board of Supervisors FROM: Perfecto Villarreal, Director Social Service Department DATE: December 7, 1993 SUBJECT: APPEAL OF GENERAL ASSISTANCE EVIDENTIARY HEARING DECISION BY WARREN JACKSON SPECIFIC REQUEST(S) OR RECOMMENDATIONS AND BACKGROUND AND JUSTIFICATION RECOMMENDATION: That the Board deny Warren Jackson's appeal of the General Assistance Hearing decision. BACKGROUND: Claimant filed request for Hearing onSeptember 14, 1993. The Hearing was scheduled for October 6, 1993. The claim was denied. Signature: ACTION OF BOARD ON necember 7 , 1993 APPROVED AS RECOMMENDED x OTHER This the time heretofore noticed by the Clerk of the Board of Supervisors for hearing on the appeal by Warren Jackson from the General Assistance Evidentiary Hearing decision. Barbara Weidenfeld, Social Service Department, presented the staff report on the appeal . Warren Jackson, appellant, presented testimony in support of his appeal . The hearing was closed. On recommendation of Supervisor Powers , ITIS BY THE BOARD ORDERED that the appeal by Warren Jackson from the General Assistance Evidentiary Hearing decision is DENIED. VOTE OF SUPERVISORS UNANIMOUS (ABSENT ) AYES: 3 , 5 , 1NOES - ABSENT 4 ABSTAIN 2 Contact: Jewel Mansapit, 313-1601 Original: I HEREBY CERTIFY THAT THIS IS A TRUE AND CORRECT COPY OF AN ACTION TAKEN AND ENTERED ON THE MINUTES. OF THE BOARD OF SUPERVISORS cc: Social Service Department ON THE DATE SHOWN. Program Analyst'-- Appeals nalyst:Appeals Unit ATTESTED December 7 , 1993 County Counsel County Administrator PHIL BATCHELOR, CLERK OF THE Warren Jackson BOARD OF SUPERVISORS AND COUNTY ADMINISTRATOR BY ° , DEPUTY DATE: �7A � REQUEST TO SPEAK FORM (THREE (3) MINUTE LIMIT Complete this form and place it in the box near the speakers' rostrum before addressing the Board. NAME: �d2 ,� J A-Cl(S'o,n PHONE: ADDRESS: L� 0$�1-1 r9�� '� CITY: I am speaking formyself OR organization: (NAME OF ORGANIZ-NTIO:N-) Check one: I wish to speak on Agenda Item # My comments will be: general for X against X , I wish to speak on the subject of C,,19 , Ca/f A 7— _' I do-r wish to speak but leave these comments for the Board to consider. on1 or+ l i Go 5 7t-1 Cc7UNT�11 60An-0 btu ✓�vj��nVtS'r�ZS I?_ CK57o'-J/ ;z0 J/ Oo S?.! 5A 7' 7'0 S 7,-Vh E IAF l�' : 1 _ _q _.. Fl6o EC - 2 L ARD OF SUPERVISORS l?1;1�12- �c�ac21J ar' S'�PE�-1,�15 �S ; CONTRA COSTA ca. 12LC�1 % f-� L l 4 6 Tiles n A 5" A To 717 4, r ,t o v, Ti mf Llr 114 7L1C coljP!57 t' lo196CE7 4 f' G1�flCE ft 5Gd l! G - Li? ?,cam �♦ ,Jr�y - < t !V r:^yj"�y PrkyvrX71=1� � CjJ!'1L�17c) l' c A F� `tt , 'ov 1�r� a jZ ,9fJ o v.�'tZ .911 F',�t� roll fz fi= t 1��'"3 4C- 7''. 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Sys 51�0� l �oc% c rC/IC11 �6153 UN,j.vA.V>LwC7 U'/I�r •�y �'/�1= �.�4 • ort=!c� ,q E•J%��'r -`� tc loo Lv/►I y us�o i f�T� -s �, ,r�r r'n>VFCaj✓(.:_ 70 411 A I.L S oirtF PAP��S :� CRa%acid, aFI�'rCE� t�1='t1. �vv ��C. .� �I�1 ruo� 111�Ur' lQ b9jZ4& Pr�j��nS I N V s t AJ6 �vT r7.C'�ll!-l7 S.R1lJ Y6 Lin CNV FLOPOdE Doi=S'"�T A LRJ,-Zy Ati-47 lz�?af7- l!.-V I,OF, 17`tAlz f ticlqrr,v--- ( ► a - ; - 9 3) �r sc A 40 7x Cl 15 r4 lel~ jz E cc�h 11 7"110 L c>G GUA ;i Ti p1=F Gv 11 � �n 3�actcta.,�` WA 2' �p e�IZ c 4,9 l,4-t AA-140 C- P 7W,,? 6cwv". iT IS k.�41,C i'pV A, eG ��iL .L Lvy 5' fir,► a•Ys�2 7' J 1.1.11ve: f14 1 r Q0'-t7Z 40 AZ e >1 1 1= n 1 C�ntra Co a County RRECEIPT FOR OCUM NTS sDclal E C E D S vice Department County received the following informatiRECEIVE ICOVNTYNAME I D for SEP 141993 CLIENT 5 NAME IOR G NAME F DIFFERENT) SERVICE MARTINEZ,CA GSE IDENTIFIER ISSN DOB OR ADDRESS) SOCIAL ❑ CA 7 for ❑ Pay Stub(s) ❑ MC 176 SAO ,Mo►nN, ❑ Dependent Care Receipt ❑ MC 177 S-M F-1 Birth Certificate: ❑ Pregnancy Verification ❑ MC 210 ❑ Rent Receipt ❑ MC 211 ❑ Social Security Card ❑ Utility Bills ❑ MC 220 ❑ Medical Bills ❑ MC 223 Other: __�/ 3 / 1 Received by: Date Received — 9� Title: iL G 31(1/WI*F COMMENDED FORM Copy 1: Client, Copy 2: IM Case file fastener 4v6. Copy 3: Control PT F Cont Costa County RECEI OR DOCUMENTS S Ial Service Department ��— ( County received the following information ICOVNTY NAME I for RECEIVED CLIEIIT"S NAMOO GSE NAME R DIFFERENT) IF vy OCT 081993 GSE IDENTIFIER ISSN DOB OR ADMESSI 40 MUIR ROAD SOCIAL SERVICE MART) CA E3IMDN'i MI CA 7 for ❑ Pay Stub(s) u MC 176 SAO . El Birth Certificate: ❑ Dependent Care Receipt ❑ MC 177 S-M ❑ Pregnancy Verification ❑ MC 210 El Receipt ❑ MC 211 D Social Security Card: ❑ Utility Bills ❑ MC 220 ❑ Medical Bills ❑ MC 223 Other: � . 9 3 9 Received by: Date Received Title: CA 3111/98,RECOMMENDED FORM Copy i: Client, Copy 2: IM Case file fastener *6, Copy 3: Control RECEIPT FOR DOCUWiENTS :.� Contra Costa uDep r- Soal Service Department County received the following informati4yECEIVED KOVNTY NAME) for �' CLIENT 5 NAME IOR CASE NAME F DIFFERENT, SEP 2 71993 CASE IDENTIFIER DSSN OOB OR ADDRIESS1 40 MUIR ROAD SOCIAL SERVICE MARTINEZ,CA ❑ CA 7 for ❑ Pay Stub(s) ❑ MC 176 SAC! IMONT N 1 13 Dependent Care Receipt ❑ MC 177 SW ❑ Birth Certificate: ❑ Pregnancy Verification ❑ MC 210 ❑ Rent Receipt ❑ MC 211 ❑ Social Security Card: ❑ Utility Bills ❑ MC 220 ❑ Medical Bills ❑ MC 223 ❑ Other: q c Received Date Received Title: - S 1_0 , CA 31 I1/981 RECOMMENDED FORM Copy t Client, Copy 2: IM Case fete fastener a6; Copy 3: Control Irk Contra w Contra Costa C unty RECEIPT FOR DOCUMENTS Social Service Department County received the folloinformation KOLNTY NAME I wRCEIVE D for CLIENT'S NAME IOR USE NAME F DIFFERENT) SEP 2 71993 USE IDENTIFIER ISSN DOS OR ADDRESSI 40 MUIR ROAD SOCIAL SERVICE MARTINEZ,CA ❑ CA 7 for IMONTNI ❑ Pay Stubs) ❑ MC 176 SAO ❑ Dependent Care Receipt ❑ MC 177 S-M C1 Birth Certificate: ❑ Pregnancy Verification ❑ MC 210 ❑ Rent Receipt ❑ MC 211 ID Security Card ❑ Utility Bills ❑ MC 220 ❑ Medical Bills ❑ MC 223 ❑ OthZer: / r Received by: Date Received Title: G 3t 0i981 RECOMMENDED FORM Copy 1: Client, Copy 2: IM Case file fastener *6; Copy 3: Control Contra Costa County Social Service Department MEDICAL AOSF ESSMENT I�1 L,c)Z A& DATE OF REFERRAL EMPLOYABILITY STATUS PATIENT'S NAME COON"MEDICAL SERVICES USE ONLY 1 a.ti SOCIAL SECURITY# BIRTHDATE ❑ NEW APPLICATION RECEIVED _ — ,c y V—/,/- —1 r CASE NAME ❑ REEVALUATION UG 2 31993 -'sf(lye ❑ SSI PENDING SOCI SL,.e.,,'.",.w A ELIGIBILITY WORKE TELEPHONE NO. Y +f PATIENTS AUTHORIZATION I authorize the release of all information for the purpose of tinuity of l� ' t ca and verification of disability for Public Assistance to Contra Costs County Social Service De rtment,includin enation which may be related to drug, alcohol or psychiatric conditions. This authorization Isit dr undl: or one year from signing. PATIENT'S SI2TU E V. PATIENTS STATED COMPLAINT/REASON FOR FERRAL.— i DATE LAST WORKED: USUAL CC ATION: TO BE CO P TED BY PHYSICIAN / 1. DEGREE OF EMPLOYABILITY ❑ EMPLOYABLE WITH NO LIMITATIONS ❑ UN LE TO WORK UNTIL date ❑ EMPLOYABLE WITH THE FOLLOWING LIMITATIONS: ❑ RMANENTLY DISABLED (Please specify) f/ DESK MARY 2. DIAGNOSIS AUG i 6 1993 f . J emorial Hospitr. Medical ReCCdrLnEtpartm(j,,r 2500 Alhambra Avenue Martinez,CA 94553 3. PROGNOSIS Cv 4. Does this patient have alcohol/other substance abuse problems? ❑ YES ❑ NO ❑ UNKNO If'YES',is patient receiving treatment? ❑ YES ❑ NO S. Does this patient require a special diet? ❑ YES ❑ NO If'YES', Type otdiet Duration i ✓ nT/�. A,— This is to certify that this patient was last seen on . Next scheduled appointment is date date Doctor's Namerritle Hospital/Clinic Location date form Completed By date Copy 1: IM Case art 2 Copy 2: Physician GA 341 (Rev.9/86) Ref: DM 49-220 Copy 3: Control CONTRA COSTA COUNTY HEALTH SERVICES emwial MARTINEZ 1iARRE 4461 �OgPO4l�1d . J A C K S O N URGENT CARE CLINIC -_3 4 / 11 /1947 510 256 AO MART DATE TIME5„ IT R • J . "D Patient I.D. SPECIFIC INSTRUCTIONS(If Checked) E] HEAD INJURY: The patient should be observed closely during VOMITING AND DIARRHEA: These problems can usually be the next 24 hours. Check every hour or two to make sure treated by discontinuing all solid foods and cloudy liquids. For patient can be aroused.Any of the following should be reported the first 24 hours give clear fluids like flat 7-Up or ginger ale, immediately: Persistent severe headache, nausea, repeated Kool-Aid, clear fruit juices, Gator Aide, diluted bouillon or vomiting,excessive sleepiness,difficulty arousing patient,slurred consomme, etc. Frequent small feedings such as 1 tbs. (1 tsp. speech,unusual irritability or other abnormal behavior,weakness, for infants) every 10 minutes are best. Popsicles and jello are partial paralysis,numbness,unequal pupils,leakage of fluids from usually welcome. Once these are well tolerated, advance the nose or ears,convulsions or any other symptom of concern. diet to easily digested foods such as applesauce, bananas, �] TETANUS: You were given a tetanus booster shot today. it is crackers, rice, rice cereal, dry toast, boiled or broiled white to help prevent tetanus("kxkjaw").If it was your first shot, you chicken meat. Carefully reintroduce infants to diluted formula. should see your doctor about completing immunizations.In any Gradually resume a normal diet, but avoid fatty foods, leafy case, we recommend you write today's date on the back of vegetables, fried foods, prunes, peas and plums for a while. your driver's license,or someplace else where it will be available Repeated or severe vomiting,especially in children, or vomiting for future reference. This injection also boosts your immunity blood deserve early medical attention. to diphtheria. COLDS/FLU: Colds and flu are usually caused by viruses and CASTS: Allow a plaster cast 24-36 hours to harden. Keep limb are therefore resistant to antibiotics such as penicillin. Your elevated and dry.If parts of your limb become cold,blue,numb symptoms may include sore throat, headache, muscle aches, or unexpectedly painful, you should return right away. Do not stomach cramps, nausea, vomiting and diarrhea. Usually such put sharp instruments inside the cast,even if it itches.You must illnesses get better by themselves in a few days. If you are not be checked in 24 hours. better in that time, if you develop fever or swollen glands, or if you become unexpectedly worse, contact your doctor or return WOUNDS: Keep your wound as clean and dry as possible. here. The most important things g you can do are to take in Change your bandage when and if your doctor recommends it. plenty of liquids and to get plenty of rest.Discomfort from sore Watch for signs of infection (pus, unusual redness, increased throat may be reduced by gargling with diluted salt water (1h pain or warmth, red streaks, swelling of lymph nodes or fever). tsp per 8 oz.glass)or by using various lozenges,mouth washes Return in case of infection, bleeding, numbness or decreased or sprays. Fever, swollen nodes, and pus on the tonsils can be ability to move the affected part of your body. Keep your caused by bacterial infections. If the doctor suspects such an appointment. infection,a culture may be taken. ❑ MIDDLE EAR INFECTIONS: Otitis media is an infection of the BRONCHITIS: Inflammation of the tubes in your lungs can be middle ear. It can be painful and can cause fever. It should not caused by infection or other irritation. Get adequate rest. 8 cause serious complications as long as it is treated adequately. ounces of fluid per hour(for an adult) will help keep secretions Be sure to give or take medicine as directed and for as long loose so that you can cough them up. A vaporizer or sitting in as directed. Return if symptoms do not improve after 36-48 a steamy bathroom may also help. If you smoke, stop it.Follow hours or if they get worse at any time. Be rechecked in clinic any other instructions from your doctor. Return, if you have at end of treatment even if well. blood in your sputum, fever, chest pain, shortness of breath or other symptoms of concern. The care you have received has been rendered on an urgent basis only. You may be released from the Urgent Care Clinic before all your medical problems are known or treated. Be sure you understand all instructions given to you.Do not hesitate to ask questions. IF YOU FEEL THAT YOUR RECOVERY IS NOT PROCEEDING AS EXPECTED, OR IF YOUR CONDITION WORSENS UNEXPECTEDLY, YOU SHOULD RETURN HERE OR CONTACT YOUR REGULAR PHYSICIAN. APPOINTMENTS — We have clinics in Richmond, Pittsburg, Brentwood, Martinez and Concord. Appointment desks are open weekdays between 7:00 a.m. and 7:00 p.m. (except Brentwood: 8:00 a.m. to 5:00 p.m.). Be sure to tell the clerk that you were referred by the Urgent Care Clinic. RICHMOND 374-3021 MARTINEZ 646-4715 -$RENTWOOD 634-1102 PITTSBURG 757-5496 CONCORD 646-4715 ADVICE NURSE—The Advice Nurse is available Monday-Friday from 8 AM to 4 PM—Telephone 370-5277;CCHP members call 1-800-524-2247 (24 hours a day) TEST RESULTS — Tests may have been ordered to assist in your care. X-rays and EKG's interpreted by the Urgent Care Physician will be reviewed later for a more definite interpretation.You will be notified about any abnormal results not known at the time of your visit. PATIENT INSTRUCTIONS - REVIEW INSTRUCTIONS ABOVE REGARDING: V f'j ❑ iar Head INury ❑ VDrhea 1 ` ! ❑ Tetanus ❑Colds/Flu ii ` • \ r} r �y' ❑Casts Wounds ❑Bronchitis ✓!` �f, ❑. ji; ❑Middle Ear Infections I HAVE READ.YC UNDERSTAND THESE INSTRUCTIONS M.D. = PHYSICIAN'S SIGNATURE PATIENTS SIGNATURE MR441-0(4/92) White-Clinic Copy Canary-Patient Copy Pink-Chart MARTINEZ URGENT CARE CLINIC Contra Costa County0_ - Social Service Department MEDICAL ASSESSMENT. ILII Lt_rt � OF -DATE OF REFERRAL ' EMPLOYABILITY STATUS PATIENT'S NAME COUNTY MEDICAL SERVICES USE ONLY LQ A AQ f-0 C fa X17 SOCIAL SECURITY# -BIRTHDATE . O + ❑ NEW APPLICATION " CASE NAME ❑ REEVALUATION ' p ❑ SSI PENDING ELIGIBILITY WORKE TELEPHONE NO. PATIENT'S AUTHORIZATION I authorize the release of all information for the purpose of continuity of patient care and verification of disability Public Assistance to Contra Costa County Social Service Department,including information which may rub, alcohol or psychiatric conditions. This authorization Is valid until: or year from signing.�. PATIENT'S SIGN TU DATE PATIENT'S STATED COMPLAINT/REASON FOR REFERRAL t _.DATE LAST WORKED: USUAL OCCUPATION: TO BE COMPLETED BY PHYSICIAN-; 1. DEGREE OF EMPLOYABILITY EMPLOYABLE WITH NO LIMITATIONS UNABLE TO WORK U(tY ❑ EMPLOYABLE WITH THE FOLLOWING LIMITATIONS: PERMANENTLY DISA (Please specify) Sciatica exacerbation 2. DIAGNOSIS r 3. PROGNOSISzT ' 4. Does this patient have alcohol/other substance abuse problems? ❑ YES Ej No. .0 UNK WNL '\ If'YES',is patient receiving treatment? ❑ YES P No \ i S. Does this patient require a special diet? ❑ YES Rb If'YES', Type of diet Duration This is to certify that this pati nt was last seen on 8/23/93 . Next scheduled appointment is atilt -' date date civ l,t�G 2500 Alhanbra Ave., Martinez 8/2SA3nw Doctor's Name/title Hospital/Clinic Location date 3 F m Co eted By ! d#te Copy 1: IM Case 2 Copy 2: Physician GA 341 (Rev.9/86) Ref: DM 49-220 Copy 3: Control �A« of - 0 P A,oT.oc,6� G,f -vro9 - 39 51� x fAl C) S-`13 v,,,q U • je Alp1 5'cr-v:CZ � .� r��1..;741c,:�W- s 1 r° wj7tA1 R N ��-7 7-uC S'H'PT- 2� q - 3 T� /71zzE c2gT X02 iPI�o�Nrz��r�; A�«PT� I >> ya v 4a,4 42r--- `i 5 t e 1 e->.,,> (, _ C /, l� 1l. S-s 35 M��.,a! F��n,,n-� (�j' -Z 3 --93 � tritJ •:�'�.�2�.wz� �� .. c.Q¢ Cll..�t clfo , ("l-Z3-931 — Jlool wl7?l Cc_?-�5� ` 3 . r'�" a �*�.rWr t �.� z ;!.e - x� _ , _ � r � f ,��„. „� k �s, .•a ,,/ t fid";; . - .ecy s Sel' XS Lv rfi r c �Eg'' iCSA - -�� x �y S �M I,...'»SXi"' toly yam . Ly• 'X" rot R vl'�. f.� 'Y Y"}yid ,n22L k� 1:,r' 1 ,� .r� � ..T ,�7 'S'w� 'Tf4i.�.�-r3'Y S3Rs.•IF ��. �3f .y Y � 3.}} 1 � Jeol - ♦t��. - r'E y. 'h- �'!!� .�, r+� � ,N .� .. �'`.e.. i' � Y.• `A s�.>?f'��...r � - ..� +a� i F aL �tCF•,�.`a4�a-,��s. sy4.Yir Z ti '<� x�g:y_.r. j..h. =x �,�v r *, ,x£ •�t�"-1T"t• aK�"" -iar.4#,'A.. � +?. ,a�TTT�, ,��b�Jr...`fit '.`� -ay. 'r Y � S r {.,r_s ,�e� r `� �.$`��8 F•-.r' �•✓' 7v '.E�' �•�,'ti �.� -tsa'r.,r" .f'. 4 e .i.. s�'- �i;1C y4 w+ _.. s �"r ��"•>+'T� {v �-L,�a' -�• a3�. � t .yam++ '� b `it +.a..J�'at'' 'r! ��p -i ` .. 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IN .? #.3 �J+' F'$�Y�•y vi_' �'¢�,[•r liY'-4.1 '"�'}-_'!4`�+�Hs�� f.. ' l .t a y � IMP �^�72sa.i4'3�� +` ��T'. � 4 - -.- 9• � - � 'S! it ;. • �� f?3. +i ..Ta--ae xy'! 1 �•w,,��.,r~ •r�w^�y�h,4r,�, ,�r.z� y 4't t.�l :•- %rte 'RC.-F. a i�3 ,r�"� '!a=' 3 2 "'�".��a.y + '.Ye:-•r+i u �'r y �}• D Hyl lo Mt t r +' . 4 1 G ,Contra Costa County \� Social Service Departm,• EMPLOYMENT SERVICES APPOINTMENT SLIP ' 4545 Delta Fair Blvd. ❑ 1305 Macdonald Ave. Antioch,CA 94509 Richmond,CA 94805 ate- 374-3791 q7c o T G� YOUR NEXT EMPLOYMENT SERVICES APPOINTMENT WILL BE: I VAS " S�t• .2g at { ' 3O AT THE OFFICE CHECKED ABOVE. day/date time Failure to appear for this appointment may result in your aid being discontinued and a period of ineligibility. Your must call in advance if you are unable to keep this appointment. Lack of transportation and being out of town are NOT valid excuses. Please arrive at least 10 minutes before your scheduled appointment. Your appointment is for a: ❑ GROUP MEETING ❑ INDIVIDUAL MEETING / SPECIAL ASSIGNMENT/COMMENTS: ej& jg�.�Alt /IG."` �e1 � - � P-a- 6 a' Iho to-- Q 6ppe - Q"-"` C. ❑ I acknowledge receipt of this app intment/assign ent. I understand that failure to appear without good cause may result in my aid being stopped. Q �,,t o� ;�(,"'f' ' 4,�.�. , ,c Ir NAME (Print) SIGNATURE DATE Work APPOINTMENT MAILED ON: BY r UA1l I14111AIS keA;Ct W I Copy 1: Applicant/Reclplt: WP 30(Rev.1/92) Copy 2: WP Case Copy 3: IM Case 'A COUNTY Contra -��..~ • -E DEPARTMEh CostaVii ' �! Boulevard s Ttia 94509-3950 wu"`7 w l r�1 CONTRA COSTA COUNTY HEALTH SERVICES 49 13 93 FP: �7 �. RETURN APPOINTMENT' `` ^.- �e►r 0 o OUTPATIENT CLINIC AND CLINICS CITA.DE REGRESO �� JACKSON WARREN PARA LA CUNICA �. M 4 / 11 /1947 510 256-4461 Instructions: Your provider would like you to have a follow-up appointment i.t in the clinic(s) identified below. You are instructed to: S 13—4 AO Instructions: Su Medico quiere que usted haga una c'ita de regreso a la(s) c " ' `� • J . HO M A R T clinica(s) identificada(s) abajo. Sus ordenes son: I ❑ Present this slip at the appointment deskCall the appointment unit (see reverse) Entregue este papel al escrhori a cites ❑ Llame a la unidad de cites (vee detras) Weeks/Semanas Double Appt/cita doble Family Practice/Practice General Months/Meses Next Available/el qua sigue Weeks/Semanas Double Appt./cite doble Specialty/Especialidad Months/Meses Next Available/el qua sigue n Weeks/Semanas �drer/Qtra Months/Meses RETURN APPOINTMENT DATE AND t• Clinic/Provider Clinica/Medico Date/Fecha Time/Nora TIME SHOULD BE WRITTEN HERE APUNTE LA CRA DA Y HORA AQUI 2. Clinic/Provider Clinica/Medico Date/Fecha Time/Hors 3. Clinic/Provider Clinica/Medico Date/Rcha Time/Horn *****SEE REVERSE SIDE FOR INSTRUCTIONS AND IMPORTANT TELEPHONE NUMBERS***** " —VOLTIE LA OJA PARA INSTRUCCIONES Y NUMEROS IMPORTANTES DE TELEFONOS••"' AMB2-6(6/92)We 1 09 23 93 CONTRA COSTA COUNTY HEALTH SERVICES T errithm (?c�4 emorial MARTINEZ N A IN �PO4I^ld JACKSON O N W A R R E CLINICS URGENT CARE CLINIC QAC H 4 / 11 / 1947 510 256-4461 DATE TIME nn4 bSS-13-4 AtJ MART SMITH . 3 . t1D Patient I.D.# SPECIFIC INSTRUCTIONS(If Checked) 1 HEAD INJURY: The patient should be observed closely during VOMITING AND DIARRHEA: These problems can usually be the next 24 hours. Check every hour or two to make sure treated by discontinuing all solid foods and cloudy liquids. For patient can be aroused. Any of the following should be reported the first 24 hours give clear fluids like flat 7-Up or ginger ale, immediately: Persistent severe headache, nausea, repeated Kool-Aid, clear fruit juices, Gator Aide, diluted bouillon or vomiting,excessive sleepiness,difficulty arousing patient,slurred consomme, etc. Frequent small feedings such as 1 tbs. (1 tsp. speech,unusual irritability or other abnormal behavior,weakness, for infants) every 10 minutes are best. Popsicles and jello are partial paralysis,numbness,unequal pupils,leakage of fluids from usually welcome. Once these are well tolerated, advance the nose or ears,convulsions or any other symptom of concern. diet to easily digested foods such as applesauce, bananas, TETANUS: You were given a tetanus booster shot today. It is crackers, rice, rice cereal, dry toast, boiled or broiled white to,help prevent tetanus ("lockjaw"). If it was your first shot, you chicken meat. Carefully reintroduce infants to diluted formula. should see your doctor about completing immunizations. In any Gradually resume a normal diet, but avoid fatty foods, leafy case, we recommend you write today's date on the back of vegetables, fried foods, prunes, peas and plums for a while. your driver's license,or someplace else where it will be available Repeated or severe vomiting, especially in children, or vomiting for future reference. This injection also boosts your immunity blood deserve early medical attention. to diphtheria. COLDS/FLU: Colds and flu are usually caused by viruses and CASTS: Allow a plaster cast 24-36 hours to harden. Keep limb are therefore resistant to antibiotics such as penicillin. Your elevated and dry. If parts of your limb become cold, blue,numb symptoms may include sore throat, headache, muscle aches, or unexpectedly painful, you should return right away. Do not stomach cramps, nausea, vomiting and diarrhea. Usually such put sharp instruments inside the cast, even if it itches. You must illnesses get better by themselves in a few days. If you are not be checked in 24 hours. better in that time, if you develop fever or swollen glands, or if O you become unexpectedly worse, contact your doctor or return WOUNDS: Keep your wound as clean and dry as possible. here. The most important things you can do are to take in Change your bandage when and if your doctor recommends it. plenty of liquids and to get plenty of rest.Discomfort from sore Watch for signs of infection (pus, unusual redness, increased throat may be reduced by gargling with diluted salt water (16 pain or warmth, red streaks, swelling of lymph nodes or fever). tsp per 8 oz.glass)or by using various lozenges,mouth washes Return in case of infection, bleeding, numbness or decreased or sprays. Fever, swollen nodes, and pus on the tonsils can be ability to move the affected part of your body. Keep your caused by bacterial infections. If the doctor suspects such an appointment. infection,a culture may be taken. MIDDLE EAR INFECTIONS: Otitis media is an infection of the BRONCHITIS: Inflammation of the tubes in your lungs can be middle ear. It can be painful and can cause fever. It should not caused by infection or other irritation. Get adequate rest. 8 cause serious complications as long as it is treated adequately. ounces of fluid per hour (for an adult) will help keep secretions Be sure to give or take medicine as directed and for as long loose so that you can cough them up. A vaporizer or sitting in as directed. Return if symptoms do not improve after 36-48 a steamy bathroom may also help. If you smoke, stop,it. Follow hours or if they get worse at any time. Be rechecked in clinic any other instructions from your doctor. Return, if you have at end of treatment even if well. blood in your sputum, fever, chest pain, Shortness of breath or other symptoms of concern. The care you have received has been rendered on an urgent basis only. You may be released from the Urgent Care Clinic before all your medical problems are known or treated. Be sure you understand all instructions given to you. Do not hesitate to ask questions. IF YOU FEEL THAT YOUR RECOVERY IS NOT PROCEEDING AS EXPECTED, OR IF YOUR CONDITION WORSENS UNEXPECTEDLY, YOU SHOULD RETURN HERE OR CONTACT YOUR REGULAR PHYSICIAN. APPOINTMENTS — We have clinics in Richmond, Pittsburg, Brentwood, Martinez and Concord. Appointment desks are open weekdays between 7:00 a.m. and 7:00 p.m. (except Brentwood: 8:00 a.m. to 5:00 p.m.). Be sure to tell the clerk that you were referred by the Urgent Care Clinic. RICHMOND 374-3021 MARTINEZ 646-4715 BRENTWOOD 634-1102 PITTSBURG 757-5496 CONCORD 646-4715 ADVICE NURSE—The Advice Nurse is available Monday-Friday from 8 AM to 4 PM—Telephone 370-5277;CCHP members Call 1-800-524-2247 (24 hours a day) TEST RESULTS — Tests may have been ordered to assist in your care. X-rays and EKG's interpreted by the Urgent Care Physician will be reviewed later for a more definite interpretation.You will be notified about any abnormal results not known at the time of your visit. _ PATIENT INSTRUCTIONS REVIEW INSTRUCTIONS ABOVE REGARDING: J �I Head Injury Vomiting Diarrhea Tetanus Colds/Flu�1 %, :� ,-i r ••/ ; ;�'� i.a r :•> ❑casts � Wounds Bronchitis y �' �l ' ❑ l� � e- f); tr O Middle Ear Infections I HAVE READ A D THESE INSTRUCTIONS r r/. A? M.D. r � V/��?"- l. �.. •i� '`." �� -- PHYSICIAN'S SIGNATURE PATIENTS SIGNATURE MR"1-0(4 192) White-Clinic Copy Canary-Patient Copy Pink-Chart MARTINEZ URGENT CARE CLINIC Contra Costa County Social S' MEDICAL ASSESSMENT DATE OF REFERRAL OF EMPLOYABILITY STATUS _ PATIENT'S NAME COUNT"MSDrcAL SERt7CaS USS 01. r SOCIAL SECURITY* ( BIRTHDATE ! y J� _ ❑ NEW APPLICATION . 7 CASE NAME REEVALUATION 6'/�' k ❑ SSI PENDING ELIGIBILITY WORKER TELEPHONE NO. ;, - 4 �. yn AAelj 3 13 PAT1EO 'S ALIHORIZATION I authorize the release of all information for the purpose of continuity of patient care and verification ofdisat Public Assistance to Contra Costa County Social Service Department,including information which may be vela, alcohol or psychiatric conditions. This authorization Is valid until: or one year fror. P TIENT'S SIGNATURE DATE q J NnISTATED COMPLAINT/REASON FOR REFERRAL DATE LAST WORKED: USUAL COPA O : TO BE CONAETRYA Y PHYSICIAN C1--)DEGREE OF EMPLOYABILITY ,t /7 ❑ EMPLOYABLE WITH NO LIMITATIONS/ �, i /{V /y,-� ❑ UNABLE TO WORK UNTIL 1 II 11 JI l dot ❑ EMPLOYABLE WITH THE FOLLOWING lJ1IV4 ATI 4':1 (}� •� ❑ PERMANENTLY DISABLED (Please.specify) r 11ri 1/( & DIAGNOSIS 63) PROGNOSIS C4) Does this patient have alcohol/other substance abuse problems? ❑ YES NO UNKNOWN If'YES',is patient receiving treatment? ❑ YES ❑ NO 6S1 Does this patient require a special diet? ❑ YES ❑ NO If'YES'. Type of diet Duration This is to certify that this patient was last seen on Next scheduled appointment is date t Doctor's Name/Title Hospital/Clinic Location dal Form Completed By date Copy I Copy 2 ` A GA 341 (Rev.9/86) ;of: DM 49.220 COPY 3 Y ✓ y - Atj`aYK'fi' '4•'"yTFf_S y Y'.. y ,i, . F •15 � j ` Sx.' y�•'v. EMERGENCY DEPARTMENT FAST TRACK RECORD JACKSON WARREN AND C ° C INICS N MAPT 510 256-4461 AO L . 104 bSS -1 -1 -4 010gQ.2P 1 q- DATE3 4 / 1.1 / 19471 SMITH . J MD E 11 / 12 /93 FAST . J 02 Patient I.D. SPECIFIC INSTRUCTIONS(If Checked) ❑ HEAD INJURY: The patient should be observed Josey during VOMITING AND DIARRHEA: These problems can usually be the next 24 hours. Check every hour or two to make sure treated by discontinuing all solid foods and cloudy liquids. For _ patient can be amused.Any of the following should be reported the first 24 hours give dear fluids like flat 7-Up or ginger ale, immediately. Persistent severe headache, nausea, repeated Kool-Aid, dear fruit juices, Gator Aide, diluted bouillon or vomiting,excessive sleepiness,difficulty arousing patient,slurred consomme, etc.Frequent small feedings such as 1 tbs. (1 tsp. speech,unusual irritability or other abnormal behavior,weakness, for infants) every 10 minutes are best. Popsicles and jello are partial paralysis,numbness,unequal"is,leakage of fluids from usually welcome. Once these are well tolerated, advance the nose or ears,convulsions or any other symptom of concern. diet to easily digested foods such as applesauce, bananas, ❑ TETANUS: You were given a tetanus booster shot today. It is crackers, rice, rice cereal, dry toast, boiled or broiled white to help prevent tetanus ("lockjaw').If it was your first shot,you chicken meat Carefully reintroduce infants to diluted formula- should ormulashould see your doctor about completing immunizations.In any Gradually resume a normal diet, but avoid fatty foods, leafy case, we recommend you write today's date on the back of stables, fried foods, prunes, peas and plums for a while. your driver's license,or someplace else where it will be available Repeated or severe vomiting, especially in children, or vomiting t for future reference. This injection also boosts your immunity blood deserve early medical attention. to diphtheria ❑ COLDS/FLU: Colds and flu are usually caused by viruses and ❑ CASTS: Allow a plaster cast 24-36 hours to harden.Keep limb are therefore resistant to antibiotics such as penicillin. Your elevated and dry.If parts of your limb become cold,blue,numb symptoms may include sore throat, headache, muscle aches, or unexpectedly painful, you should return right away. Do riot stomach cramps, nausea, vomiting and diarrhea Usually such put sharp instruments inside the cast,even if it itches.You must illnesses get better by themselves in a few days.If you are not be checked in 24 hours. better in that time, if you develop fever or swollen glands,or if you become unexpectedly worse,contact your doctor or return WOUNDS: Keep your wound as clean and dry as possible. here. The most important things you can do are to take in Change your bandage when and if your doctor recommends it. plenty of liquids and to get plenty of rest.Discomfort from sore Watch for signs.of infection (pus, unusual redness, increased throat may be reduced by gargling with diluted salt water (Ih pain or warmth,red streaks, swelling of lymph nodes or fever). tsp per 8 oz glass)or by using various lozenges,mouth washes Return in case of infection, bleeding, numbness or decreased or sprays.Fever, swollen nodes, and pus on the tonsils can be ability to move the affected part of your body. Keep your caused by bacterial infections. If the doctor suspects such an appointment. infection,a culture may be taken. ❑ MIDDLE EAR INFECTIONS: Otitis media is an infection of the ❑ BRONCHITIS: Inflammation of the tubes in your lungs can be middle ear.It can be painful and can cause fever. It should not caused by infection or other irritation. Get adequate rest. 8 cause serious complications as long as it is treated adequately. ounces of fluid per hour(for an adult)will help keep secretions .Be sure to give or take medicine as directed and for as long loose so that you can cough them up. A vaporizer or sitting in as directed. Return if symptoms do not improve after 36-48 a steamy bathroom may also help. If you smoke, stop it. Follow hours or if they get worse at any time. Be rechecked in clinic any other instructions from your doctor. Return, if you have at end of treatment even if well. blood in your sputum, fever, chest pain, shortness of breath or other symptoms of concern. r The care you have received has been rendered on an urgent basis only. You may be released from the Fast Track Department before all your medical problems are known or treated. Be sure you understand all instructions given to you. Do not hesitate to ask questions. IF YOU FEEL THAT YOUR RECOVERY IS NOT PROCEEDING AS EXPECTED,OR IF YOUR CONDITION WORSENS UNEXPECTEDLY, YOU SHOULD RETURN HERE OR CONTACT YOUR REGULAR PHYSICIAN. APPOINTMENTS — We have clinics in Richmond, Pittsburg, Brentwood, Martinez and Concord. Appointment desks are open weekdays between 7:00 a.m. and 7:00 p.m. (except Brentwood: 8:00 am. to 5:00 p.m.). Be sure to tell the clerk that you were referred by the Emergency Department. RICHMOND 374-3021 MARTINEZ 646-4715 BRENTWOOD 634-1102 PITTSBURG 757-5496 CONCORD 646-4715 MEDICINES — We can only prescribe enough of most medicines to last you until you are to be checked in clinic. Refills of your medicines (especially ones you take regularly) should come from your clinic doctor. Unused medicines should be discarded.Pharmacy hours are from 8 AM to 10 PM on weekdays and from 8 AM to 4:30 PM on weekends'and holidays. When the Pharmacy is closed, we can dispense small amounts of some medicines.The balance of your prescription can be picked up from our pharmacy the next time it open. ADVICE NURSE—The Advice Nurse is available most days from 8 AM to 4 PM—Telephone 370-5277 TEST RESULTS — Tests may have been ordered to assist in your care. X-rays and EKG's interpreted by the Emergency Room Physician will be reviewed later for a more definite interpretation.You will be notified about any abnormal results rot known at the time of your visit. PATIENT INSTRUCTIONS REVIEW INSTRUCTIONS ABOVE REGARDING: ❑Head In fury ElVomiting Diarrhea ❑Tetanus ❑Cads/Flu ❑Casts ❑Bronchitis v'v ❑ Wounds LlI ❑Middle Ear Infections nn 1 HAVER 7D UNDMUND TH INSTRUcnoNs M.D. _4�? ' / PHYSICIAN'S SIGNATUW PATIENTS SIGNATURE MR-6o3-0(4/92) White-Chart Canary-Patient Copy Pink-Clinic EMERGENCY DEPT.FAST TRACK RECORD I,VIV 1 MM UUOIM IiVUIV I T r1CALI rl OF-nVIVCO anrvitr MARTINEZ - P041�1d JACKSON WARREN AND CLINICS URGENT CARE CLINIC JAc s o 256-4461 M 4 / 11/1947 51 ' DATE TIME �3-`� AO�f14b55 HAAT � SMITH . J . MD Pant I.D.# SPECIFIC INSTRUCTIONS(If Checked) HEAD INJURY: The patient should be observed closely during E] VOMITING AND DIARRHEA: These problems can usually be the next 24 hours. Check every hour or two to make sure treated by discontinuing all solid foods and cloudy liquids. For patient can be aroused. Any of the following should be reported the first 24 hours give clear fluids like flat 7-Up or ginger ale, immediately: Persistent severe headache, nausea, repeated Kool-Aid, clear fruit juices, Gator Aide, diluted bouillon or vomiting,excessive sleepiness,difficulty arousing patient,slurred consomme, etc. Frequent small feedings such as 1 tbs. (1 tsp. speech,unusual irritability or other abnormal behavior,weakness, for infants) every 10 minutes are best. Popsicles and jello are partial paralysis,numbness,unequal pupils,leakage of fluids from usually welcome. Once these are well tolerated, advance the nose or ears,convulsions or any other symptom of concern, diet to easily digested foods such as applesauce, bananas, TETANUS: You were given a tetanus booster shot today. It is crackers, rice, rice cereal, dry toast, boiled or broiled white to help prevent tetanus ("lockjaw").If it was your first shot,you chicken meat. Carefully reintroduce infants to diluted formula. should see your doctor about completing immunizations. In any Gradually resume a normal diet, but avoid fatty foods, leafy case, we recommend you write today's date on the back of vegetables, fried foods, prunes, peas and plums for a while. your driver's license,or someplace else where it will be available Repeated or severe vomiting, especially in children,or vomiting for future reference. This injection also boosts your immunity blood deserve early medical attention. to diphtheria. COLDS/FLU: Colds and flu are usually caused by viruses and CASTS: Allow a plaster cast 24-36 hours to harden. Keep limb are therefore resistant to antibiotics such as penicillin. Your elevated and dry.If parts of your limb become cold,blue,numb symptoms may include sore throat, headache, muscle aches, or unexpectedly painful, you should return right away. Do not stomach cramps, nausea, vomiting and diarrhea. Usually such put sharp instruments inside the cast,even if it itches. You must illnesses get better by themselves in a few days. If you are not be checked in 24 hours. better in that time, if you develop fever or swollen glands, or if you become unexpectedly worse, contact your doctor or return WOUNDS: Keep your wound as clean and dry as possible. here. The most important things you can do are to take in Change your bandage when and if your doctor recommends it. plenty of liquids and to get plenty of rest.Discomfort from sore Watch for signs of infection (pus, unusual redness, increased throat may be reduced by gargling with diluted salt water ('h pain or warmth,red streaks, swelling of lymph nodes or fever). tsp per 8 oz.glass)or by using various lozenges,mouth washes Return in case of infection, bleeding, numbness or decreased or sprays. Fever, swollen nodes, and pus on the tonsils can be ability to move the affected part of your body. Keep your caused by bacterial infections. If the doctor suspects such an appointment. infection,a culture may be taken. MIDDLE EAR INFECTIONS: Otitis media is an infection of the ❑ BRONCHITIS: Inflammation of the tubes in your lungs can be middle ear. It can be painful and can cause fever. It should not caused by infection or other irritation. Get adequate rest. 8 cause serious complications as long as it is treated adequately. ounces of fluid per hour (for an adult) will help keep secretions Be sure to give or take medicine as directed and for as long loose so that you can cough them up. A vaporizer or sitting in as directed. Return if symptoms do not improve after 36-48 a steamy bathroom may also help.If you smoke, stop it. Follow hours or if they get worse at any time. Be rechecked in clinic any other instructions from your doctor. Return, if you have at end of treatment even if well. blood in your sputum, fever, chest pain, shortness of breath or other symptoms of concern. The care you have received has been rendered on an urgent basis only. You may be released from the Urgent Care Clinic before all your medical problems are known or treated. Be sure you understand all instructions given to you. Do not hesitate to ask questions. IF YOU FEEL THAT YOUR RECOVERY IS NOT PROCEEDING AS EXPECTED, OR IF YOUR CONDITION WORSENS UNEXPECTEDLY, YOU SHOULD RETURN HERE OR ff AV CONTACT YOUR REGULAR PHYSICIAN. APPOINTMENTS — We have clinics in Richmond, Pittsburg, Brentwood, Martinez and Concord. Appointment desks are open weekdays between 7:00 a.m. and 7:00 p.m. (except Brentwood: 8:00 a.m. to 5:00 p.m.). Be sure to tell the clerk that you were referred by the Urgent Care Clinic. RICHMOND 374-3021 MARTINEZ 646-4715 BRENTWOOD 634-1102 PITTSBURG 757-5496 CONCORD 646-4715 ADVICE NURSE—The Advice Nurse is available Monday-Friday from 8 AM to 4 PM—Telephone 370-5277;CCHP members call 1-800-524-2247 (24 hours a day) TEST RESULTS — Tests may have been ordered to assist in your care. X-rays and EKG's interpreted by the Urgent Care Physician will be reviewed later for a more definiteter interpretation.You will be notified about any abnormal results not known at the time of your visit.of _ PATIENT INSTRUCTIONS REVIEW INSTRUCTIONS ABOVE REGARDING: ❑Head Injury ❑ Vomiting i ❑Tel ❑ ColdDiars/Flu Z1�� AJC J C/j 117.�'t= t c.4, ; h 0 C ❑ Bronchitis Wounds ✓ ��/W H ❑Middle Ear Infections 1 HAVE READ A THESE INSTRUCTIONS '"— M.D. 2 ZZ PHYSICIAN'S SIGNATURE 1 4 PATIENTS SIGNATURE MR441-0(4/92) White-Clinic Copy Canary-Patient Copy Pink-Chart MARTINEZ URGENT CARE CLINIC Contra Costa County �—' -� Social Servic, MEDICAL ASSESSMENT OF DATE OF REFERRAL EMPLOYABILITY STATUS PATIENT'S NAME COVNtT MEDICAL SERJrICES USE ONLY - SOCIAL SECURITY# BIRTHDATE • ��_ _ _� � , ,f _ � ❑ NEW APPLICATION CASE NAME REEVALUATION 401"7 r.--e._- ❑ SSI PENDING ELIGIBILITY WORKER TELEPHONE NO. 7 ,L /. �n&A,-4 3 13 - PATIEO S AU HORIZATION I authorize the release of all information for the purpose of continuity of patient care and verification of disability Public Assistance to Contra Costa County Social Service Department,including information which may be related I alcohol or psychiatric conditions. This authorization is valid until. or one year from sic P TIENT'S SIGNATURE DATE xpf q NTS'STATED COMPLAINT/REASON FOR REFERRAL DATE LAST WORKED: USUAL CUPA O TO Bt CONKETAVA Y PHYSICIAN (1. )DEGREE OF EMPLOYABILITY /7, `J ❑ EMPLOYABLE WITH NO LIMITATIONS `'/ ❑ UNABLE TO WORK UNTIL date ❑ EMPLOYABLE WITH THE FOLLOWING ATI ln� •� ❑ PERMANENTLY DISABLED (please specify) "1 r � 2.J DIAGNOSIS 03. PROGNOSIS 64-1 Doesthis patient have alcohol/other substarce abuse problems? ❑ YES [] NO ❑ UNKNOWN If'YES',is patient receiving treatment? ❑ YES ❑ NO S., Does this patient require a special diet? ❑ YES [] NO If'YES', Type of diet Duration This is to certify that this patient was last seen on . Next scheduled appointment is date date Doctor's Name/Title Hospital/Clinic Location date filly r Form Completed By date i; - Copy 1: It Copy 2: P GA 341 (Rev.9/86) ;Pf: DM 49-220 Copy 3: C gad roty.4 .�� kr any ��." y,, r� ��k`-+� �-�r. �` �E. � ��'r,� „ � a ,� ��`•z��a �`s�,�� ,:;�P t>�:�._-. +'4' c�.✓af `�, ,-.� P.. ♦ :a.• ice' ';°z t r. �Y✓ ,-. 4 �t J i FROM: Perfecto Villarreal, Director Social Service Department DATE: December 7, 1993 SUBJECT: APPEAL OF GENERAL ASSISTANCE EVIDENTIARY HEARING DECISION BY WARREN JACKSON - - - - - - - - - - - - -- - - -- - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - SPECIFIC REQUEST(S) OR RECOMMENDATIONS AND BACKGROUND AND JUSTIFICATION RECOMMENDATION: That the Board deny Warren Jackson's appeal of the General Assistance Hearing decision. BACKGROUND: Claimant filed request for Hearing on October 13, 1993. The Hearing was scheduled for November 4, 1993. Claimant did not appear for the hearing, and the claim was dismissed. Signature: 1/ ACTION OF BOARD ON APPROVED AS RECOMMENDED OTHER i i CLERK OF THE BOARD Inter-Office Memo TO: Social Services Department DATE: November 4, 1993 Appeals and Complaints Division and Program Analyst FROM: Jeanne Maglio, Chief Clerk Jeanne Bosarge, Deputy Clerk SUBJECT: New hearing on Appeal from Administrative Decision Rendered on General Assistance Benefits Filed By Warren Jackson Please furnish us with a board order with your recommendations and a copy of all material filed by both the appellant and the Social Service Department at the time of the Appeals and Complaints Division evidentiary hearing,' plus any information which your department may wish to file for the Board appeal which is set for 2: 15 p.m. on Tuesday, December 7, 1993. Attachment cc: Board Members County Administrator County Counsel 76 1 1°t = r1 RECEIVED CLERK BOARD OF SUPERViSORB CONTRA COSTA CO. uoo uU,7 L 1 f?5:A /9 !? 1 110 G c-4 - 1 r7 The Board of SupervisorsContra Phil Batchelor Clerk of the Board County Administration Building 6,51 and County Administrator 651 Pine St., Room 1p6 (510)fid6-2371 Martinez, California_ 94.553_ _ - - - - —��CQ u nt y ` f 9to ✓ (V ' L CD Z. ' November 4, 1993 0 r 1 o� ® o i _. ' Board of Supervisors (�. lAssistance Benefits quest and pursuant to Section f zance Code, this is to advise that a LID C3 -o o .the administrative decision u.' + ZUW f) -feral Assistance benefits will be n+� ,�ervisors in the Board Chambers, ;`ion Building, 651 Pine Street, p.m. on Tuesday, December 7, 1993. vJ �= 3 of Supervisor Resolution No. ,ation and all relevant material --~ \J� v ;t be filed with the Clerk of the ',nistration Building, 651 Pine Street, Q 'before the date of the hearing. Your the other provisions of said Pich set forth the General Assistance rrl, i truly yours, BATCHELOR, Clerk of the Board r».tiervisors and County ..:. > .. istrator `By Jea a Bosarge, Deputy Clerk Enclosure cc: Board Members Social Service Department Attn: Appeals and Complaints Program Analyst County Counsel County Administrator Social Service Department Contra Please reply to: Perfecto Villarreal 40 Dougias Drive O,rector Costa Martinez.California 2-552--Co3 County Evidentiary Hearing Decision IN THE MATTER OF: County #07-90-0358304 Warren Jackson Date of County Notice: 9-9-93 204 Poshard St. , #B Effective Date of Action: 9-30-93 Pleasant Hill CA 94523 Filing Date: 9-14-93 Hearing Date: 10-6-93 Aid Paid Pending: Yes Appeals officer Scott G. Clayton Ii,c:ome Maintenance Representative: Carl Dudley EH Representative Place of Hearing: Martinez ISSUE Whether the county was correct in its determination that claimant failed without good cause to provide form GA 341 Employability Assessment. The county also proposed a one month period of ineligibility. STATEMENT OF FACTS COUNTY ACTION AND POSITION: Claimant was notified in Aril, 1993 at his first job club that he must provide the county with verification of his medical limita- tions. Claimant has never provided verification that outlines his limitations. Between April and August, claimant was given multiple postponements to enable him to provide the necessary verification. An Evidentiary Hearing was held on August 9, 1993 , at that time claimant stated he would have the verification by his job club on Alugust 11, 1993 . When the form was not provided at that time, the county determined that he was not going to cooperate and proposed to stop assistance. CLAIMANT'S POSITION: At Hearing the Claimant stated that he has been trying to cooper- ate. He stated that he sees Dr. Smith at Evening appointments once per month that these have been continuous for some time. Claimant stated that he gave the forms to his doctor's nurse by mistake EVIDENTIARY HEARING Warren Jackson, Claimant Page 2 about a month prior to August 16, 1993 . He then stated he gave it to her three months prior to the August date. The form was misplaced by them or someone at the county hospital . He states he is trying to cooperate and to provide the information needed. REASON FOR DECISION t Department Manual Section II. POLICY A. General Assistance applicants and recipients who demon- strate noncooperation or noncompliance with Social Service Department program requirements by failing to meet any one of their enumerated responsibilities without good cause shall be denied aid or shall be discontinued. A period of ineligibility may be imposed on recipients in instances involving noncooperation and noncompliance in accordance with guidelines which follow. F. Recipients 2. A recipient who fails to cooperate with the Social Service Department by failing to meet any one of his or her enumerated responsibilities without good cause, shall be discontinued aid, and sanctions will be imposed as follows: a. first failure: one month b. second failure: three months C. third failure: six months 4. Examples of recipient responsibilities include, but are not limited to: a. appearing for Work Programs Assignment Group or monthly Job Club meetings h. providing requested information or verifica- tion, including verification of unemployabili- ty, by the due date G. Good Cause 1. The reasons,which establish good cause for a fail- ure to cooperate or comply are subject to verifica- tion and include, but are not limited to, the following: a. the failure has occurred by reason of a dis- ability under the Americans with Disabilities Act 1 ) The burden of proof to establish that the failure occurred because of a disability is on the applicant or recipient. 2) The applicant/recipient's showing may be rebutted by the Department. b. •employment has been obtained C. scheduled job interview or testing d. mandatory court appearance e. incarceration f . illness EVIDENTIARY HEARING Warren Jackson, Claimant Page 3 g. death in the family h. Other substantial reason. (These must be reviewed and approved by the Unit Supervisor. ) H. Willfulness 1 . A willful act is one that is intentional or without reasonable excuse or cause. It need not be done with a specific purpose to violate program require- ments. a. The burden of proof to establish good cause, which may include proof that the failure was not willful is on the applicant/recipient. b. The Department may rebut a showing of good cause by proving that the failure to comply was willful, in which case the Department has the burden of proof. C. In all case is presumed, subject to rebuttal, that the ordinary consequences of an appli- cant/recipient's voluntary acts are intention- al, and thus willful. 2. Willfulness cannot be found where the person is mentally disabled to the extent that s/he does not understand his/her responsibilities or is incapable of fulfilling them. 4. Conduct which involves negligence, inadvertence, physical disability or lesser mental disability may or may not be willful. a. Three or more acts of negligent failure of the recipient to follow program requirements, which may include acts for which the recipient previously has been discontinued from aid or sanctioned, evidence willfulness. FINDINGS OF FACT It is found that claimant has not cooperated with the county in providing the necessary verification. Claimant states that everything got originally confused as he gave the papers to his doctor or his nurse to complete and submit. He only later learned that he had to work though medical records and has been doing so since August. This is all very credible, except that in December his aid was stopped for a similar reason. At that time he stated he had given the form to his doctor and who stated he would return it and again the form was never returned. If the claimant truly intended to cooperate, he would have made sure to take the necessary steps to provide the needed verification to his worker. It is also found that this failure is willful as no reasonable excuse has been provided for claimant not providing the verifica- tion. EVIDENTIARY HEARING / Warren Jackson, Claimant Page 4 CONCLUSION As claimant failed to meet General Assistance program requirements he renders himself ineligible for assistance. The action to discontinue General Assistance and impose a one month period of ineligibility is, therefore, sustained. ORDER The claim is denied. Scott G. Clayton Date Social Services A e is Officer Program Manage Appeals Date If you are dissatisfied with this Decision, you may appeal the matter directly to the Contra Costa County Board of Supervisors. Appeals must be filed in writing with the Clerk of the Board, 651 Pine Street, Room 106, Martinez, CA 94553 within 14 days of the date of the Evidentiary Hearing Decision. No further aid is paid pending a Board of Supervisors appeal. The Board of Supervisors Contra Clerkoe��,Board and County Administration Building Costa County Administrator 651 Pine St, Room 106 (510)W-2371 Martinez, California 94553 County Tom Powers,1st District Jeff Smith,2nd District Gayle Bishop,3rd District " `�! Sunne Wright McPeak 4th District � .• Tom Torlakson,5th District F. n�q fOUN'� Ct November 18, 1993 Warren Jackson 204 Poshard Street, #B Pleasant Hill, CA 94523 Dear Mr. Jackson: This is to advise you that your hearing on your appeal relative to General Assistance benefits has been rescheduled to 3 : 00 p.m. on Tuesday, December 7, 1993 before the Board of Supervisors at 651 Pine Street, Room 107, Martinez. Very truly yours, PHIL BATCHELOR, Clerk of the Board of Supervisors and County Administrator By ° Q'In-CerVelli, Deputy cc: Board Members Social Service Department Attn: Appeals and Complaints Program Analyst County Counsel County Administrator I p� CLERK OF THE BOARD Inter-Office Memo TO: Social Services Department DATE: November 4, 1993 Appeals and Complaints Division and Program Analyst FROM: Jeanne Maglio, Chief Clerk Jeanne Bosarge, Deputy Cler470 SUBJECT: New hearing on Appeal from Administrative Decision Rendered on General Assistance Benefits Filed By Warren Jackson Please furnish us with a board order with your recommendations and a copy of all material filed by both the appellant and the Social Service Department at the time of the Appeals and Complaints Division evidentiary hearing, plus any information which your department may wish to file for the Board appeal which is set for 2:15 p.m. on Tuesday, December 7, 1993. Attachment cc: Board Members County Administrator County Counsel The...$oard of Supervisors Contra CPhrkofttthe�e aid and County Administration BuildingCOSta County Administrator 651 Pine St., Room 106 (510)646-2371 Martinez, California 94553 County Tom Powers,1st District Jeff Smith,2nd District 6E aE. O Gayle Bishop,3rd District Sunne Wright McPeak 4th District G Tom Torlakson,5th District �; S Y.4e sT'9 CU11N'� November 18, 1993 Warren Jackson 204 Poshard Street, #B Pleasant Hill, CA 94523 Dear Mr. Jackson: This is to advise you that your hearing on your appeal relative to General Assistance benefits has been rescheduled to 3 : 00 p.m. on Tuesday, December 7, 1993 before the Board of Supervisors at 651 Pine Street, Room 107, Martinez . Very truly yours, PHIL BATCHELOR, Clerk of the Board of Supervisors and County Administrator By o 4nanCerve li, Deputy cc : Board Members Social Service Department Attn: Appeals and Complaints Program Analyst County Counsel County Administrator 'Socia-1 Service Department Contra Please reply to: Perfecto Villarreal 40 Doug;as Drive Dlrec;pr Costa Martinez.California 94553 - +. County 1 Evidentiary Hearing Decision IN THE MATTER OF: County #07-90-0358304 Warren Jackson Date of County Notice: 9-9-93 204 Poshard St. , #B Effective Date of Action: 9-30-93 Pleasant Hill CA 94523 Filing Date: 9-14-93 Hearing Date: 10-6-93 Aid Paid Pending: Yes Appeals officer Scott G. Clayton Ixiuome Maintenance Representative: Carl Dudley EH Representative Place of Hearing: Martinez ISSUE Whether -the county was correct in its determination that claimant failed without good cause to provide form GA 341 Employability Assessment. The county also proposed a one month period of ineligibility. STATEMENT OF FACTS COUNTY ACTION AND POSITION: - Claimant was .notified in Aril, 1993 at his first job club that he must provide the county with verification of his medical limita- tions. Claimant has never provided verification that outlines his limitations. Between April and August, claimant was given multiple postponements to enable him.to provide the necessary verification. An Evidentiary Hearing was held on August 9, 1993, at that time claimant stated he would have the verification by his job club on August 11, 1993. When the form was not provided at that time, the county determined that he was not going to cooperate and proposed to stop assistance. CLAIMANT'S POSITION: At Hearing the Claimant stated that he has been trying to cooper- ate. He stated that he sees Dr. Smith at Evening appointments once per month that these have been continuous for some time. Claimant stated that he gave the forms to his doctor's nurse by mistake EVIDENTIARY HEARING Warren Jackson, Claimant Page 2 about a month prior to August 16, 1993. He then stated he gave it to her three months .prior to the August date. The form was misplaced by them or someone at the county hospital. He states he is trying to cooperate and to provide the information needed. REASON FOR DECISION 1 . Department Manual Section II. POLICY A. General Assistance applicants and recipients who demon- strate noncooperation or noncompliance with Social Service Department program requirements by failing to meet any one of their enumerated responsibilities without good cause shall be denied aid or shall be discontinued. A period of ineligibility may be imposed on recipients in instances involving noncooperation and noncompliance in accordance with guidelines which follow. F. Recipients 2. A recipient who fails to cooperate with the Social Service Department by failing to meet any one of his or her enumerated responsibilities without good cause, shall be discontinued aid, and sanctions will be imposed as follows: a. first failure: one month b. second failure: three months C. third failure: six months 4. Examples of recipient responsibilities include, but are not limited to: a. appearing for Work Programs Assignment Group or monthly Job Club meetings h. providing requested information or verifica- tion, including verification of unemployabili- ty, by the due date G. Good Cause 1. The reasons which establish good cause for a fail- ure to cooperate or comply are subject to verifica- tion and include, but are not limited to, the following: a. the failure has occurred by reason of a dis- ability under the Americans with Disabilities Act 1) The burden of proof to establish that the failure occurred because of a disability is on the applicant or recipient. 2) The applicant/recipient's showing may be rebutted by the Department. b. employment has been obtained C. scheduled job interview or testing d. mandatory court appearance e. incarceration f. illness EVIDENTIARY HEARING Warren Jackson, Claimant Page 3 g. death in the family h. Other substantial reason. (These must be reviewed and approved by the Unit Supervisor. ) H. Willfulness 1. A willful act is one that is intentional or without reasonable excuse or cause. It need not be done] with a specific purpose to violate program require- ments. a. The burden of proof to establish good cause, which may include proof that the failure was not willful is on the applicant/recipient. b. The Department may rebut a showing of good cause by proving that the failure to comply . was willful, in which case the Department has the burden of proof. C. In all case is presumed, subject to rebuttal,. that the ordinary consequences of an appli- cant/recipient's voluntary acts are intention- al, and thus willful. 2. Willfulness cannot be found where the person is mentally disabled to the extent that s/he does not understand his/her responsibilities or is incapable of fulfilling them. 4. Conduct which involves negligence, inadvertence, physical disability or lesser mental disability may or may not be willful. a. Three or more acts of negligent failure of the recipient to follow program requirements, which may include acts for which the recipient previously has been discontinued from aid or sanctioned, evidence willfulness. FINDINGS OF FACT It is found that claimant has not cooperated with the county in providing the necessary verification. Claimant states that everything got originally confused as he gave the papers to his doctor or his nurse to complete and submit. He only later learned that he had to work though medical records and has been doing so since August. This is all very credible, except that in December his aid was stopped for a similar reason. At that time he stated he had given the form to his doctor and who stated he would return it and again the form was never returned. If the claimant truly intended to cooperate, he would have , made sure to take the necessary steps to provide the needed verification to his worker. It is also found that this failure is willful as no reasonable excuse has been provided for claimant not providing the verifica- tion. EVIDENTIARY HEARING Warren Jackson, Claimant Page 4 CONCLUSION As claimant failed to meet General Assistance program requirements he renders himself ineligible for assistance. The action to discontinue General Assistance and impose a one month period of ineligibility is, therefore, sustained. ORDER The claim is denied. Scott G. Clayton Date Social Services Ajeis Officer Program Manage Appeals Date If you are dissatisfied with this Decision, you may appeal the matter directly to the Contra Costa County Board of Supervisors. Appeals must be filed in writing with the Clerk of the Board, 651 Pine Street, Room 106, Martinez, CA 94553 within 14 days of the date of the Evidentiary Hearing Decision. No further aid is paid pending a Board of Supervisors appeal. 0,3Itq ca 5 71 Cc'u"L> Tev .c 4 7067CA L 7-o 6iFXjn-?,,qC Af70)-5'74-,oc47 �0 )57COAJ T1 "Z RECEIV� D DEC - 2 m CLERK BOARD OF SUPERVISORS I CONTRA COSTA CO. :Fa A S' VEIL Y 6al InX 6t:,1q1 7"o U, le 0,57,7 47 t7.171 7 6.4 0 /V /vt k4LIC A eovl. - IF41 -7-0 In r 1 c-f L 41/5 a i 7'tl z r L c---A -c- eij)c t o S7 4--Q /11 �47 yr C L lvr-v1.w ykn,411 —IiA�7-54 4L c 464, vC 47 nf c g K A/ INA, AC - F�•v� 7fi�� 5`vGL9 L S�l�Cc�= {±D�d�% jZ�c�'ll�! �'oct.. �c � ^ 1 77 c ti2!_=as l C1l`ee-zo lt—v 'c5iw�-� � �,�' 7-,;VE f r f2 ?tel" �l�ll� C1t' �l C j,�rf� i4 f ,1it�y tica�sttfc�.•tt..` �"��'¢.1.r11'�h �?� rg��rCh' G�� i ti x pt��'F U.a��'tl�.�•�Q .� �'�ST W9�Z' Gt7 U,4771 C 7ky�s' �9 L t►'t /`I s1<inJG j= V r 1 i t� rl,�t�t3G p n� /Lti� /tC`,gs'%. /`dj/fJs �e�'�n� �a7•f!t �6 �"l H,,�L4 Kuck M all� � 7ECC �ov 97 i7�� 1�t=•4cu� �No� P S• �b f�tZ l/y` �Z�l�b ccs 1/vt l�c I�rQtztl�c1 sscO !/�� C��v�.v��c.�47 2�i jt r �y T/��.= �,,9 • pr='r-t c� ,� ��..��-v9-�.> rn>VFGo�✓f.:� `Ta MR 1 L $onF 1°AE'�-��S Tv /alt. l,�lcocc> 1 j o z� cl l ht� O"Q+ c l �gtL 7 /�,•.: n � .-•.r.� �.. c. �� !/� "1/OZ�R 'y�T:� TL�� ` Pip 5, V 4OErJT•1Alz ll Clq RlrVG 10 - 6 - q3). 57co 7T G < p�`�'l��tt..f Cry I�< 17 v r„�1,��,r� �� J2�..t��s��z-•9 7!L-� �"�� t.AJ< f,,�'tZ /-11✓�^ TA P46 &,c- c � 1 Ar, p� Al 454 111/L.AC 7-L, l/ Gcl�!! (��n�E,•U �,nctcfa�`� �A�•7. 17' �� u.,�,a� f � 1� l,�'N 1'x'0 72) 77S 1,e—"r rni O 5 L W V,11�141j. !1 Lvof �r .'fes l�h'8c 47141 15 a wl--'v 1.119 Q Pl'7',c 1 i !/tJ l�goiLJZ� 4� rzZ FI , 7LrQL '>1 ' ------ t L'1 rs P 2J CCC' - c 17 l 4 Contra Co a County .RECEIPT FOR DOCUM "NTS Social Se vice Department Ce,( . County received the following informatit r�ECEI l/ED • � ICOVNTY NAME) for U R CLENT'S KAME IOR NAME DIFFERENT) SEP 141993 CASE IDENTIFIER (SSN DOB OR ADORESSI 40 MUIR ROAD SOCIAL SERVICE MARTINEZ,CA ❑ CA 7 for (MONTMI 13Pay Stub(s) ❑ MC 176 SAC) ❑ Dependent Care Receipt ❑ MC 177 S-M ❑ Birth Certificate: ❑ Pregnancy Verification ❑ MC 210 ❑ Rent Receipt ❑ MC 211 DSocial Security Card. ❑ utility Bills ❑ MC 220 ❑ Medical Bills ❑ MC 223 Other: �/ -PL 3 Received by: Date Received Title: OL iL CA 31 It/Ul RECOMifENDE0 FORM Copy 1: Client, Copy 2: IM Case file fastener I►6. Copy 3: Control F Cont Costa County RECEIPTOR DOCUMIENTS S lal Service Department County received the following information (COVNTY NAAIEI for RECEIVED CLIENT S NAM CASE NAME IF DIFFERENT) 3 F y OCT 0 81993 CASE IDENTIFIER dsh DOB OR ADDRESSi 40 MUIR ROAD SOCIAL SERVICE MART( CA ❑ CA 7 for ❑ Pay Stub(s) u I MC 176 SAO IMONTNI [:1 Birth Certificate: ❑ Dependent Care Receipt ❑ MC 177 S-M ❑ Pregnancy Verification ❑ MC 210 ❑ Rent Receipt ❑ MC 211 ❑ Social Security Card: ❑ Utility Bills ❑ MC 220 ❑ Medical Bills ❑ MC 223 Other: 3 Received by: Date Received Title: S '4— 01 CA 31 0/881 RECOW>MENDED FORM Copy 1: Client, Copy 2: IM Case file fastener *6; Copy 3: Control t � i Contra Costa County RECEIPT FOR DOCUKENTS Social Service Department County received the following informati�ECEIVED KOUNTY NAME) for CIENT'S NAME(OR CASE NAME F DIFFERENT) SEP 2 71993 CASE IDENTIFIER ISSN DOB OR ADDRESSI 40 MUIR ROAD SOCIAL SERVICE MARTINEZ,CA ❑ CA 7 for ❑ Pay Stub(s) ❑ MC 176 SAO AAONTMI ❑ Dependent Care Receipt ❑ MC 177 S-M ;❑ Birth Certificate: ❑ Pregnancy Verification ❑ MC 210 ❑ Rent Receipt ❑ MC 211 DSocial Security Card: ❑ Utility Bills ❑ MC 220 C e .c,e ❑ Medical Bills ❑ MC 223 ❑ Other: njAo AnA64 1,63 ' qq Received4y Date Received `_ -7� Title: CA 3141/W RECOMMENDED FORM Copy 1: Client, Copy 2: IM Case file fastener p 6; Copy 3: Control w_ p Contra Costa C unty RECEIPT FOR DOCUMENTS Social service Department f-,ti9wt County received the folioMCEIVED information ICOVNTY NAME I for CLIENT'5 NAME IOR USE NAME 6 DIFFERENT) - SEP 2 71993 CASE IDENTIFIER ISSN WE1 OR ADDRESSI 40 MUIR ROAD SOCIAL SERVICE MARTINEZ,CA ❑ CA 7 for ❑ Pay Stub(s) ❑ MC 176 SAO EMONTMI ❑ Dependent Care Receipt [3MC 177 S-M ❑ Birth Certificate: ❑ Pregnancy Verification ❑ MC 210 ❑ Rent Receipt ❑ MC 211 ❑ Social Security Card: ❑ Utility Bills ❑ MC 220 ❑ Medical Bills ❑ MC 223 D ot3:`fee 19 � f Received by: Date Received Title: G 31 11iM1 RE COMMENDED FORM Copy 1: Client, Copy 2: N Case file fastener,r6; Copy 3: Control �� i I i i I i I i i I I �1uG • �7 `?3 GHQ ,� J�� M12- «`v � -9 rc 9 - 3 4 5-'m 5 � � X J b1r LV cc ^s Sq Z- ( � -; -c2 3)�:1 1zz---`x-) o a p 1�}•r� �r 5'c 0 v;mss, r1�G 1� Lvl Tt4l R iv Vf-76 l 7-i nIZ 7- . sFP7. /3 L c otv r-- D /vl& --1�7E 72—,7 1z I�la'o�,,�rz�.•Z; J001 a v o��.Y rt �2 m..>� A6 _71Y 4.1 v Al--GE--. i _73 ). 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IN • ' rw s,«a � �,Ft-$,T...y S'z�`^`r-9 t;,'r,'�•t+ 'fir`p `r M'w x:rte � .� r�t�-� s_� art r � ��1 ,i,�iy.�-..f 3•'r"�7� �,`�,�¢�i�c_�"�� ,� � �,�4'y�'��t$.!4 .P .i��4 .r�`��,�1.y ''�-a`��`�� 1 w t'a�7�Q f� ��4� r �T .-• .'�}�- .�`- '" ?t�J,i-. r..�,"yfi'�''r�'i,�l.��"r!��+� �,k ,�'r •.,7,. +!`'r �:. .,+� :.: ,i ':`4r' t''',€*Y Ra a«� V^4= �ar�# e �,.7�''s,�`a.��•rtk'''o-� .►yn ,yT.�yy,�•�a�, FL , . 4.ON >w �"d.�.�t+ 4+ SY�r��. 1"3..'x" � 1i.2-th �,�,ait •x y«'�A "�y�':'rr�•�"S .� r�•�. s+ ` .i7t �{'k ,y��„"" `A ��'sy,�,-��.*�y i•�'�,�- as�� s� r_ V F: ,yyyy- 4..t�N_'rit Y�F,11>"�^ •�� tat wi� .s4Y�.. �t'IS„�A: 4 4 Cont'a Costa County `� Social Service Departrn, EMPLOYMENT SERVICES APPOINTMENT SLIP 4545 Delta Fair Blvd. ❑ 1305 Macdonald Ave. Antioch,CA 94509 Richmond,CA 94805 374-3791 4(?c o er YOUR NEXT EMPLOYMENT SERVICES APPOINTMENT WILL BE: I VAS - S> j t• -2g at • 30 AT THE OFFICE CHECKED ABOVE. day/date time Failure to appear for this appointment may result in your aid being discontinued and a period of ineligibility. Your must call in advance if you are unable to keep this appointment. Lack of transportation and being out of town are NOT valid excuses. Please arrive at least 10 minutes before your scheduled appointment. Your appointment is for a: ❑ GROUP MEETING ❑ INDIVIDUAL MEETING SPECIAL ASSIGNMENT/COMMENTS: AS 4)&c—aA�C Q4I ❑ I acknowledge receipt of this app intment/assigngent.`I understand that failure to appear without good cause may result in my aid being stopped. kk Jq,Z-4 a� �� S w, h`t..t c.Ce — ka.. �Q,etZ e A- `j(r 3 13 NAME (Print) SIGNATURE DATE APPOINTMENT MAILED ON: V&7_41 �J UA11 INIIIAI S a `f Pos ko -.4- Sf -t V ?o Copy 1: Applicant/Reclplt: WP 30(Rev.1/92) Copy 2: WP Case Copy 3: IM Case Contra A COUNTY CE DEPARTMEN Boulevard Costa , ' t rnia 94509-3950County _ ' i� CONTRA COSTA COUNTY HEALTH SERVICES 89 13 93 r RETURN APPOINTMENT '' .R: ten►`. o U OUTPATIENT CONIC AND CLINICS CITA DE REGRESO �� JACKSON WARREN PARA LA CUNICA i. n 4 / 11 /1947 510 256-4461 Instructions: Your provider would like you to have a follow-up appointment in the clinic(s) identified below. You are instructed to: n n''i ~ ' S 13—4 A 0 Instrucciones: Su Medico quiere que usted haga una cita de regreso a la(s) c " 1 7" • J • H D n A R T ciinica(s) idents icada(s) abajo. Sus ordenes son: ❑ Present this slip at the appointment desk Call the appointment unit (see reverse) Entregue este papel al escritori It ciitas ❑ Mame a It unidad de cites(vea detras) �(} weeks/Semanas Double Appt/cite doble Family Practice/Practea General Vv __Months/Meses Next Available/el que sigue weeks/Semanas Double Appt/cite doble Specialty/Especiaridad Months/Meses Next Available/el que sigue n W weeks/Semanas _9 ther/Otra Months/Meses RETURN APPOINTMENT DATE AND t, Clinic/Provider Clinica/Medico Date/Fecha Time/Nora TIME SHOULD BE WRITTEN HERE APUNTE LA CITA DA Y HORA AQUI 2. Clinic/Provider Clinica/Medico Date/Fecha Time/Hors 3. Clinic/Provider Clinica/Medico Date/Fecha Time/Hora "'SEE REVERSE SIDE FOR INSTRUCTIONS AND IMPORTANT TELEPHONE NUMBERS""' "'VOLTIE LA OJA PARA INSTRUCCIONES Y NUMEROS IMPORTANTES DE TEL.EFONOS""' AM82-5(6/92)Side 1 CONTRA COSTA COUNTY HEALTH SERVICES 09 23 3 : errithew Oemoriai MARTINEZ 4�rUUgPO4l° JACKSON W A R R E N AND CLINICS URGENT CARE CLINIC to 4 / 111947 510 256-4461 DATE TIME nn4 ►,5513- • AOMART SMITH . J . NO Patient I.D. # SPECIFIC INSTRUCTIONS(If Checked) HEAD INJURY: The patient should be observed closely during VOMITING AND DIARRHEA: These problems can usually be the next 24 hours. Check every'hour or two to make sure treated by discontinuing all solid foods and cloudy liquids. For patient can be aroused. Any of the following should be reported the first 24 hours give clear fluids like flat 7-Up or ginger ale, immediately: Persistent severe headache, nausea, repeated Kool-Aid, clear fruit juices, Gator Aide, diluted bouillon or vomiting,excessive sleepiness,difficulty arousing patient,slurred consomme, etc. Frequent small feedings such as 1 tbs. (1 tsp. speech,unusual irritability or other abnormal behavior,weakness, for infants) every 10 minutes are best. Popsicles and jello are partial paralysis,numbness,unequal pupils,leakage of fluids from usually welcome. Once these are well tolerated, advance the nose or ears,convulsions or any other symptom of concern. diet to easily digested foods such as applesauce, bananas, TETANUS: You were given a tetanus booster shot today. It is crackers, rice, rice cereal, dry toast, boiled or broiled white to.help prevent tetanus ("lockjaw"). If it was your first shot, you chicken meat. Carefully reintroduce infants to diluted formula. should see your doctor about completing immunizations. In any Gradually resume a normal diet, but avoid fatty foods, leafy case, we recommend you write today's date on the back of vegetables, fried foods, prunes, peas and plums for a while. your driver's license,or someplace else where it will be available Repeated or severe vomiting, especially in children, or vomiting for future reference. This injection also boosts your immunity blood deserve early medical attention. to diphtheria. COLDS/FLU: Colds and flu are usually caused by viruses and CASTS: Allow a plaster cast.24-36 hours to harden. Keep limb are therefore resistant to antibiotics such as penicillin. Your elevated and dry.If parts of your limb become cold,blue, numb symptoms may include sore throat, headache, muscle aches, or unexpectedly painful, you should return right away. Do not stomach Cramps, nausea, vomiting and diarrhea. Usually such put sharp instruments inside the cast,even if it itches. You must illnesses get better by themselves in a few days.If you are not be checked in 24 hours. better in that time, if you develop fever or swollen glands, or if you become unexpectedly worse, contact your doctor or return WOUNDS: Keep your wound as clean and dry as possible. here. The most important things you can do are to take in Change your bandage when and if your doctor recommends it. plenty of liquids and to get plenty of rest.Discomfort from sore Watch for signs of infection (pus, unusual redness, increased throat may be reduced by gargling with diluted salt water (1k pain or warmth,red streaks, swelling of lymph nodes or fever). tsp per 8 oz.glass) or by using various lozenges,mouth washes Return in case of infection, bleeding, numbness or decreased or sprays. Fever, swollen nodes, and pus on the tonsils can be ability to move the affected part of your body. Keep your caused by bacterial infections. If the doctor suspects such an appointment. infection,a culture may be taken. MIDDLE EAR INFECTIONS: Otitis media is an infection of the BRONCHITIS: Inflammation of the tubes in your lungs can be middle ear. It can be painful and can cause fever. It should not caused by infection or other irritation. Get adequate rest. 8 cause serious complications as long as it is treated adequately. ounces of fluid per hour (for an adult) will help keep secretions Be sure to give or take medicine as directed and for as long loose so that you can cough them up. A vaporizer or sitting in as directed. Return it symptoms do not improve after 36-48 a steamy bathroom may also help.If you smoke, stop.it.Follow hours or if they get worse at any time. Be rechecked in clinic any other instructions from your doctor. Return, if you have at end of treatment even if well. blood in your sputum, fever, chest pain, shortness of breath or other symptoms of concern. The care you have received has been rendered on an urgent basis only. You may be released from the Urgent Care Clinic before all your medical problems are known or treated. Be sure you understand all instructions given to you. Do not hesitate to ask questions. IF YOU FEEL THAT YOUR RECOVERY IS NOT PROCEEDING AS EXPECTED, OR IF YOUR CONDITION WORSENS UNEXPECTEDLY, YOU SHOULD RETURN HERE OR CONTACT YOUR REGULAR PHYSICIAN. APPOINTMENTS — We have clinics in Richmond. Pittsburg, Brentwood, Martinez and Concord. Appointment desks are open weekdgys between 7:00 a.m. and 7:00 p.m. (except Brentwood: 8:00 a.m. to 5:00 p.m.). Be sure to tell the clerk that you were referred by the Urgent Care Clinic. RICHMOND 374-3021 MARTINEZ 646-4715 BRENTWOOD 634-1102 PITTSBURG 757-5496 CONCORD 646-4715 ADVICE NURSE—The Advice Nurse is available Monday -Friday from 8 AM to 4 PM—Telephone 370-5277;CCHP members call 1-800-524-2247 (24 hours a day) TEST RESULTS — Tests may have been ordered to assist in your care. X-rays and EKG's interpreted by the Urgent Care Physician will be reviewed later for a more definite interpretation.You will be notified about any abnormal results not known at the time of your visit. . PATIENT INSTRUCTIONS REVIEW INSTRUCTIONS ABOVE _ REGARDING: / Head Injury Vomiting_�//. : `Z�%./,.:,: f u-�i ..•j �'i._.s'.7 Diarrhea Tetanus Colds/Flu :�� ./, - :i.; • / J ;E" ;� ; , ;.� p casts l7 Bronchitis / p wands Middle Ear Infections ' 1 HAVE READ A "'�..,�L1cTe""'D THESE INSTRUCTIONS -* r / C ��• Z M.D. ;"d% PHYSICIAN'S SIGNATURE ' PATIENT'S SIGNATURE MR441-0(4/92) White-Clinic Copy Canary-Patient Copy Pink-Chart MARTINEZ URGENT CARE CLINIC Social SP ' MEDICAL ASSESSMENT DATE OF REFERRAL OF EMPLOYABILITY STATUS PATIENT'S NAME COUNTY MlDICAL SERVICaS usa o,� SOCIAL SECURITY# / BIRTHDATE ❑ NEW APPLICATION -1._ _ _ 7 CASE NAME -REEVALUATION 4/' A>._c ❑ SSI PENDING ELIGIBILITY WORKER TELEPHONE NO. 3 13 PATIENIrS AU HORIZATION I authorize the release of all information for the purpose of continuity of patient care and verification of disat Public Assistance to Contra Costa County Social Service Department,including information which may be rela, alcohol or psychiatric conditions. This authorization is valid until: or one year fror. P TIENT'S SIGNATURE DATE �� / q HT'S TATED COMPLAINT/REASON FOR REFERRAL DATE LAST WORKED: USUAL OmCCUPAilO TO B COY PHYSICIAN (1. DEGREE OF EMPLOYABILITY I (� `J ❑ EMPLOYABLE WITH NO LIMITATIONS/`,' �� /L, 1 C] UNABLE TO WORK UNTIL 6 �� 2 dot ❑ EMPLOYABLE WITH THE FOLLOWING JI�,`'I ATI �:: 1l�L '� ❑ PERMANENTLY DISABLED (Piesse.specify) n 02. DIAGNOSIS (3) PROGNOSIS C4) Does this patient have alcohol/other substarce abuse problems? ❑ YES ❑ NO ❑ UNKNOWN 1f'YES',is patient receiving treatment? ❑ YES [] NO S. 1 Does this patient require a special diet? '❑ YES ❑ NO If'YES', Type of diet Duration This is to certify that this patient was last seen on . Next scheduled appointment is date t t = Doctor's Name/title Hospital/Clinic Location dot Form Completed By date tk _ Copy 1. v Copy 2 GA 341 (Rev.9/86) ;ef: DM a9-220 Copy 3 7 y��^ +�A2yx - is �; EMERGENCY DEPARTMENT FAST TRACK RECORD JACKSON WARREN AND CLINICS M MAF' 1 510 256 -4461 AO IIS b,__93 '4 9 sn 010Pg2no9DATEI # E 11 / 12 /93 FAST . J 02 Patient I.D. ` SPECIFIC INSTRUCTIONS(If Checked) ❑ HEAD INJURY: The patient should be observed closely during ❑ VOMITING AND DIARRHEA: These problems can usually be ; the next 24 hours. Check every hour or two to make sure treated by discontinuing all solid foods and cloudy liquids. For _ patient can be aroused.Any of the following should be reported the first 24 hours give dear fluids like flat 7-Up or ginger ale, immediately. Persistent severe headache, nausea, repeated -Kool-Aid, dear fruit juices, Gator Aide, diluted bouillon or vomiting,excessive sleepiness,difficulty arousing patient,slurred wrisomme, etc.Frequent small feedings such as 1 tbs. (1 tsp. speech,unusual irritability or other abnormal behavior,weakness, for infants) every 10 minutes are best. Popsicles and jello are partial paralysis,numbness,unequal pupils,leakage of fluids from usually welcome. Once these are well tolerated, advance the rase or ears,convulsions or any other symptom of concern. diet to easily digested foods such as applesauce, bananas, ❑ TETANUS: You were given a tetanus booster shot today. It is crackers, rice, rice cereal, dry toast, boiled or broiled white to help prevent tetanus ("lockjaw").If it was your first shot,you chicken meat Carefully reintroduce infants to diluted formula. should see your doctor about completing immunizations. In any Gradually resume a normal diet, but avoid fatty foods, leafy case, we recommend you write today's date on the back of vegetables, fried foods, prunes, peas and plums for a while. your driver's license,or someplace else where it will be available Repeated or severe vomiting, especially in children, or vomiting for future reference. This injection also boosts your immunity blood deserve early medical attention. to diphtheria.- Ph E] COLDS/FLU: Colds and flu are usually caused by viruses and : ❑ CASTS: Allow a plaster cast 24-36 hours to harden.Keep limb are therefore resistant to antibiotics such as penicillin. Your elevated and dry.If parts of your limb become cold,blue,numb symptoms may include sore throat, headache, muscle aches, or unexpectedly painful, you should return right away. Do not stomach cramps, nausea, vomiting and diarrhea Usually such put sharp instruments inside the cast,even f it itches. You must illnesses get better by themselves in a few days.If you are not be checked in 24 hours. better in that time, if you develop fever or swollen glands, or if you become unexpectedly worse,contact your doctor or return ❑ WOUNDS: Keep your wound as clean and dry as possible. here. The most important things you can do are to take in Charge your bandage when and if your doctor recommends it. plenty of liquids and to get plenty of rest.Discomfort from sore Watch for signs.of infection (pus, unusual redness, increased throat may be reduced by gargling with diluted salt water (1k pain or warmth, red streaks, swelling of lymph nodes or fever). tsp per 8 oz.glass)or by using various lozenges,mouth washes Return in case of infection, bleeding, numbness or decreased or sprays. Fever, swollen nodes, and pus on the tonsils can be • ability to move the affected part of your body. Keep your caused by bacterial infections. If the doctor suspects such an appointment. infection,a culture may be taken. MIDDLE EAR INFECTIONS: Otitis media is an infection of the ❑ BRONCHITIS: Inflammation of the tubes in your lungs can be middle ear.It can be painful and can cause fever. It should not caused by infection or other irritation. Get adequate rest. 8 cause serious complications as long as it is treated adequately. ounces of fluid per hour (for an adult)will help keep secretions -Be sure to give or take medicine as directed and for as long loose so that you can cough them up. A vaporizer or sitting in as directed. Return if symptoms do not improve after 36-48 a steamy bathroom may also help.If you smoke, stop it. Follow hours or if they get worse at arty time. Be rechecked in clinic any other instructions from your doctor. Return, if you have at end of treatment even if well. blood in your sputum, fever, chest pain, shortness of breath or - other symptoms of concern. The care you have received has been rendered on an urgent basis only. You may be released from the Fast Track Department before all your medical problems are known or treated. Be sure you understand all instructions given to you. Do not hesitate to ask questions. IF YOU FEEL THAT YOUR RECOVERY IS NOT PROCEEDING AS EXPECTED,OR IF YOUR CONDITION WORSENS UNEXPECTEDLY, YOU SHOULD RETURN HERE OR CONTACT YOUR REGULAR PHYSICIAN. APPOINTMENTS — We have clinics in Richmond, Pittsburg, Brentwood, Martinez and Concord. Appointment desks are open weekdays between 7:00 a.m. and 7:00 p.m. (except Brentwood: 8:00 am. to 5:00 p.m.). Be sure to tell the clerk that you were referred by the Emergency Department. RICHMOND 374-3021 MARTINEZ 646-4715 BRENTWOOD 634-1102 PITTSBURG 757-5496 CONCORD 646-4715 MEDICINES — We can only prescribe enough of most medicines to last you until you are to be checked in clinic. Refills of your medicines (especially ones you take regularly) should come from your clinic doctor. Unused medicines should be discarded.Pharmacy hours are from 8 AM to 10 PM on weekdays and from 8 AM to 4:30 PM on weekends"and holidays. When the Pharmacy is closed, we can dispense small amounts of some medicines.The balance of your prescription can be picked up from our pharmacy the next time it is open. ADVICE NURSE—The Advice Nurse is available most days from 8 AM to 4 PM—Telephone 370-5277 TEST RESULTS— Tests may have been ordered to assist in your care. X-rays and EKG's interpreted by the Emergency Room Physician will be reviewed later for a more definite interpretation.You will be notified about any abnormal results not known at the time of your visit. PATIENT INSTRUCTIONS REVIEW INSTRUCTIONS ABOVE REGARDING: 92 OCI ❑Head Iryury ❑ Vbmitirg Diarrhea ❑Tangy ❑Colds/Flu (JtJ�{ UL ❑casts ❑Wonchft ❑ Wounds I ❑Middle Ear Infections 1 WAVER D UNDIPISTAND THEXE INSTRUCTaNS ooi �7 M.D. PHVSICIMI'S SIGNATUFW az FATIENrs SIGNATURE MR-609-0(4/92) White-Chart Canary-Patient Copy Pink-Clinic EMERGENCY DEPT.FAST TRACK RECORD %.AaIN 1 rlr% VVJ IA VVuIY I I C)L-P%L-1 1 1 k.7LII V 0floe hew � dall MARTINEZ ' � 3pQ4Qd K SON WARREN AND CLINICS URGENT CARE CLINIC JACKSON o 256-4461 M 4 / 11 /1947 51 + DATE > TIME on4 b55-13-4 AO MART .} SMITH . J . MC Pat I.D.# SPECIFIC INSTRUCTIONS(If Checked) HEAD INJURY: The patient should be observed closely during VOMITING AND DIARRHEA: These problems can usually be the next 24 hours. Check every hour or two to make sure treated by discontinuing all solid foods and cloudy liquids. For patient can be aroused. Any of the following should be reported the first 24 hours give clear fluids like flat 7-Up or ginger ale, immediately: Persistent severe headache, nausea, repeated Kool-Aid, clear fruit juices, Gator Aide, diluted bouillon or vomiting,excessive sleepiness,difficulty arousing patient,slurred consomme, etc. Frequent small feedings such as 1 tbs. (1 tsp. speech,unusual irritability or other abnormal behavior,weakness, for infants) every 10 minutes are best. Popsicles and jello are partial paralysis,numbness,unequal pupils,leakage of fluids from usually welcome. Once these are well tolerated, advance the nose or ears,convulsions or any other symptom of concern. diet to easily digested foods such as applesauce, bananas, TETANUS: You were given a tetanus booster shot today. it is crackers, rice, rice cereal, dry toast, boiled or broiled white to help prevent tetanus ("lockjaw").If it was your first shot, you chicken meat. Carefully reintroduce infants to diluted formula. should see your doctor about completing immunizations.In any Gradually resume a normal diet, but avoid fatty foods, leafy case, we recommend you write today's date on the back of vegetables, fried foods, prunes, peas and plums for a while. your driver's license,or someplace else where it will be available Repeated or severe vomiting,especially in children, or vomiting for future reference. This injection also boosts your immunity blood deserve early medical attention. to diphtheria. COLDS/FLU: Colds and flu are usually caused by viruses and CASTS: Allow a plaster cast 24-36 hours to harden. Keep limb are therefore resistant to antibiotics such as penicillin. Your elevated and dry.If parts of your limb become cold,blue, numb symptoms may include sore throat, headache, muscle aches, or unexpectedly painful, you should return right away. Do not stomach cramps, nausea, vomiting and diarrhea. Usually such put sharp instruments inside the cast,even if it itches. You must illnesses get better by themselves in a few days.If you are not be checked in 24 hours. better in that time, if you develop fever or swollen glands, or if you become unexpectedly worse, contact your doctor or return WOUNDS: Keep your wound as clean and dry as possible. here. The most important things you can do are to take in Change your bandage when and if your doctor recommends it. plenty of liquids and to get plenty of rest. Discomfort from sore Watch for signs of infection (pus, unusual redness, increased throat may be reduced by gargling with diluted salt water ('k pain or warmth, red streaks, swelling of lymph nodes or fever). tsp per 8 oz.glass)or by using various lozenges,mouth washes Return in case of infection, bleeding, numbness or decreased or sprays.Fever, swollen nodes, and pus on the tonsils can be ability to move the affected part of your body. Keep your caused by bacterial infections. If the doctor suspects such an appointment. infection,a culture may be taken. MIDDLE EAR INFECTIONS: Otitis media is an infection of the BRONCHITIS: Inflammation of the tubes in your lungs can be middle ear. It can be painful and can cause fever. It should not caused by infection or other irritation. Get adequate rest. 8 cause serious complications as long as it is treated adequately. ounces of fluid per hour (for an adult) will help keep secretions Be sure to give or take medicine as directed and for as long loose so that you can cough them up. A vaporizer or sitting in as directed. Return if symptoms do not improve after 36-48 a steamy bathroom may also help. If you smoke, stop it. Follow hours or if they get worse at any time. Be rechecked in clinic any other instructions from your doctor. Return, if you have at end of treatment even if well. blood in your sputum, fever, chest pain, shortness of breath or other symptoms of concern. The care you have received has been rendered on an urgent basis only. You may be released from the Urgent Care Clinic before all your medical problems are known or treated. Be sure you understand all instructions given to you. Do not hesitate to ask questions. IF YOU FEEL THAT YOUR RECOVERY IS NOT PROCEEDING AS EXPECTED, OR IF YOUR CONDITION WORSENS UNEXPECTEDLY, YOU SHOULD RETURN HERE OR MAP CONTACT YOUR REGULAR PHYSICIAN. APPOINTMENTS — We have clinics in Richmond, Pittsburg, Brentwood, Martinez and Concord. Appointment desks are open weekdays between 7:00 a.m. and 7:00 p.m. (except Brentwood: 8:00 a.m. to 5:00 p.m.). Be sure to tell the clerk that you were referred by the Urgent Care Clinic. RICHMOND 374-3021 MARTINEZ 646-4715 BRENTWOOD 634-1102 PITTSBURG 757-5496 CONCORD 646-4715 ADVICE NURSE—The Advice Nurse is available Monday-Friday from 8 AM to 4 PM—Telephone 370-5277;CCHP members call 1-800-524-2247 (24 hours a day) TEST RESULTS — Tests may have been ordered to assist in your care. X-rays and EKG's interpreted by the Urgent Care Physician will be reviewed later for amore definitinterpretation.You will be notified about any abnormal results not,known at the time of your visit. PATIENT INSTRUCTIONS REVIEW INSTRUCTIONS ABOVE REGARDING: ❑ Head Injury VomitingDiarrhea 0 Tetanus Colds/Flu L ( �� 'I ✓; a�y/� ✓/t t.� I j h aCasts ❑Bronchitis ftunds Middle Ear Infections 1 HAVE READ A THESE INSTRUCTIONS M.D. PHYSICIAN'S SIGNATURE ` PATIENT'S SIGNATURE MR441-0(4/82) White-Clinic Copy Canary-Patient Copy Pink-Chart MARTINEZ URGENT CARE CLINIC Contra Costs County -� Social Service MEDICAL ASSESSMENT DATE OF REFERRAL OF EMPLOYABILITY STATUS PATIENT'S NAME COUNTY MEDICAL SERVICES vsE ONLY OCTAL SECURITY# BIRTHDATE � /J _ � ❑ NEW APPLICATION CASE NAME X— REEVALUATION 4*-.-ke._- SSI PENDING ELIGIBILITY WORKER TELEPHONE NO. � '. yn 313 -1 PATIEP S AU HORIZATION I authorize the release of all information for the purpose of continuity of patient care and verification of disability Public Assistance to Contra Costa County Social Service Department,including information which may be related i alcohol or psychiatric conditions. This authorization Is valid until: or one year from sic P TIENT'S SIGNATURE DATE !� / q� � �� OAMENtSSTATED COMPLAINT/REASON FOR REFERRAL DATE LAST WORKED: USUAL OCCUPA01: TOB CQVKET9YAYPHYS1C1AN DI DEGREE OF EMPLOYABILITY /7❑ EMPLOYABLE WITH NO LIMITATIONS 4),, ,/ ❑ UNABLE TO WORK UNTIL ate ❑ EMPLOYABLE WITH THE FOLLOWING ATI ',� [IPERMANENTLY DISABLED (Please specify) q 02. DIAGNOSIS / 3.J PROGNOSIS Does this patient have alcohol/other substance abuse problems? ❑ YES [] NO ❑ UNKNOWN If'YES',is patient receiving treatment? ❑ YES ❑ NO OS. Does this patient require a special diet? ❑ YES ❑ NO if'YES', Type of diet Duration This is to certify that this patient was last seen on . Next scheduled appointment is v date date -� Doctor's Name/Title Hospital/Clinic Location date Form Completed By date l.. Copy 1: If Copy 2: P . `�,1�} GA 341 (ReY.9JH6) ref: DM 49.120 Copy 3: C h, '� "'"'°'�: '�':"�A �-y � e tea'�'h. �iy �o' >aTe- _�� ''S'-'�ra.x�.� "_' .'E e� w'ge;� �...3'° 'Fa �`i .• ,._.s:".��'?�"t?:e-��,tts•',;� +P,�,.. �L•,F��i�t'#re:»Tca� .. ...�s,•, :3 �. .._..1f. ..3�' •-