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Home My WebLink AboutMINUTES - 12192006 - C.28 ,,LA I NI 0eg BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: DECEMBER 19, 2006 Claim Against the County, or District Governed by ) the Board Of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph 1.V below), NOV 22 200 U given Pursuant to Government Code AMOUNT: 776.70 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT: MARISSA FAMULARO ATTORNEY: UNKNOWN DATE RECEIVED: NOVEMBER 22, 2006 ADDRESS: 758 TORO STREET, BY DELIVERY TO CLERK ON: NOVEMBER 22, 2006 SAN LUIS OBISPO, CA 93401 RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted clailll. JOHN CULLEN, er Dated: NOVEMBER 22, 2006 By: Deputy IL FROM: County Counsel TO: Clerk of the Board of S ervisors ( his claim complies substantially with Sections 910 aild 910.2. ( ) This Claim FAILS to COI11pIy substantially with Sections 910 and 9102, 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 wariling Of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: _ Dated: I l 2 2—aCP By: Deputy County Counsel iii. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated,�� . �9 ,a0� JOHN CULLEN, CLERK, By Depilty Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the date this notice Nvas personal4"served or deposited in the snail to file a court action on this claim.See Government Code Section�A5.6.You may seek the advice of an attorney of your choice in connection Nvith this matter. If you �vant to consult an -attorney,you should do so immediately. *For Additimal V1'arning See Reverse Side ol'This Notice. _ AFFIDAVIT OF MAILING I declare under penalty of perjury that I am no-, , 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 iINilartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated4k_ 4D, '-O � JOHN CLJLLEN, CLERK By Deputy Clerk llr'21i 2006 09936 8055430654 CREATI-VE MEDI,4TION S F"GE 02 BO ARD.01r SUTERVISORS OF CONTRA.COSTA COUNTY 91-P—MMMONS TO 9—,AZW.—E A claim rebs kg to a cause, of nation for death or for injury to persoa or to p6io l idgbo wowitg crovi sbzll be Prase=ed not let= than.six mm-as after the amrual of tha o=a aadon- A cla m xatatng TD say other cause of aofin da bo,pmsexftd not lotm gm onwo yo aft=the ar,=al.of ft muse of action. (00-i. code § 9112) CWw must be filed with the Clerk of the Board of Svpm-vigorst at its of Rea is Room I cow-,,.y Adz@ aist4cm Building„ss l. Piste aft-est marbc4 CA 94553. If claim is si mast a district pvemed by the Board of Supervisors, mtha Om the Comsty, asiie of the I istdot should bo filled UL 1. If the claim:a agdml More tbm one pubHe ev sVwm claims mast'be filed angffi�-nin public entity, d. -ti=,Penal Gude See, 7 2 at the cad of this formEr—aush See I malty for fr=dtient oL w a a am a avid NJ sit IN a w a an lea a In x a ane a a It tZROCK9 to xxxorn Ian&am JCK a a at IN are i I a I%at C[ill leC al M Claim Br, Reword for ClaWs aling, ramp -AA cks Agalrix the Couatp of Contra comft or NOV 2 2006 DisWct) CLERK BOARD SUPERVISORS (FM in the aa=) CONTRA COSTA CO. Th©MMLM-nisried 6 Aim=hadby sakes OWM Akaing ffm Cvamp of Coag.Coaft or the ab dL%tdct iu the M= 3f S Hca.:3 md in support of ilds claim r&prwees as;tbllows: Wizen dial.I he damage or lq=y occur? (Give mut dft and hoir) 2. Where Id the dmage,or injury cj=r? (JZaUdS City Md OourLty) rn`rnp 'Iv-) 3. How did f le dwnan or 1.W"ury om=? (Give JW&U&;use=tm paper if rtquhtd) 4. What PBZ i0UJ8r act Ok Q=iwbn on the pat of oomty or distict officam krant, or amp Y= owumd th) or da=utge MRU-Y V\Xvi� ry-N Cw— A CAUS:\17S Ck What m the mm=of couaty or dist iat of Rom,;mTmts,or employea 63niug+jL6 dalnR 'ON 1N3K39VNVW y816 000 00111 AON J1�'�1,•'��1k16 kfy:;;b �;b5b4JUbb4 i'Jt t-tEUJ�;I JUN �-k {ab � ;. What damag; or injurics do your claim resulted? (Give M Welt of Wuues or-, , •- °clauuerl 'Aft:ch�twa•Gat�rnste�farautodamagc) ;C�ex�•irt�1�..,�..c.C��r`� . rn�) �qqt,� �-•�r�ici �.��i�.c.. �c�s c�rno�evl. Tw.,� 1, How was ti.e =oust claimed above computed? (luclude the esffiu&d a=unt of prospective i ijux"y or d�?.gge.) , \z, `t�tom. •Snf11,.,� �,� , �YY 3C�'��2 S, Names and s ddresses of witnes4es,doctors,and hootals, 9. 'Liar the expo aditures you mads-ou account of tbis accident or WT, PAI A •AMOUNT ssaMoscow asaGtatwalk 2katsoxCNIAst■■RtaaVatt:anis magmas UNEVEN ttt■■satsittsasoNot I*aaat a=L .Gov.Code See. 910?Fovides'Me claim shat be signed by the claimant or by some pence on his beWL- -SIZQN0 LA=O-T) Name and address of Attorney Mairnar (Address) • ) arc-, t�S cr-, .C`,+4 `�Y.—,�.�1 TeIghona No. _ )Telephone No, 1 , t INWAN AaAWNW NUN 4.?Manna tIts RRaWAR aaeatsit haus*ttRRZEN IaxaAzkMis/ttkitZt/RtsMan aIt1tt• itaxf PUBLIC RECORDS NOTICE: Please be advised 1 hat bis OWM farm;or eay claim filed with'Bat CcMty Veda'the Test C18 W A&,is Mg r'a to public; dkolomm .mda the Caiif=k Public Records Act. (Gov, C:od% 55 6300 et seq.) F=-& any attz�dbmmctc,adder Anw,or supplcmemu sttaebed to&m claim ftam, inclu ft medical records,w eislao Bat to public disclosure, lana Raaaaka Ral i►NR.►sass■A■nWax at a as a s 9 it 0 ax a 9 a s Rta:at NoncE.. AaVan 72 o frhe.'m d Code,prvvidea: `• Every peram wh:,,ith innmi to dafbwd,presmts Ir ellovmzoe or fin payment to ark swe boa'td or ,or to any =m'LY, r-V, or dismi t board or c0c, c xs orized to 'auaw or pay the same if R9any or ftaudulent ebajIm b4 acccumt voucher, or wrifmi;is pauishable erthe r by imprisoame a is the ,auaty for a Period of not me to than one year, by a f4ne of Act mweeding cue thousand dollars ($1,000.00),dor by such imprls= mt az d fes, or by lmprivonmemt in the state prisons; by a fine of not ens= fns tem io1� dollfn X 10,000},or by both such bprisommOlit VW fAC, r ( d B81 O'N 1N3W30VNVW ?ISIS 000 NVL0-6 9002 I AON 11: 21/�ZUIJb UJ::;b iiU!DbWJ 7bn4 Uf-,L:A 11vL HLLli I lUN b F,;-;UL U4 10/3E/200'6 10:13 9258300674 SAN RAMON POLICE SVC PAGE 02 Y vv a Vr 41I.r.mhw TRAFFIC: COLLISION REPORT , CHP 6 Pc Ike i Rev.e•9 OP1042 P". of >reanlcoiuomil• - "1'ffAFF OITY Alow:wtfi�Tlecr LOUkRbDzrNURW k4mo GMFrR '�G,( r, .Uln 11RsRuw ICOUM EAT OAF'- V,c O Co 21 (ol auwt ND=Amo OM M0. DAT "-&A TWAT CUM omm• OPFlCER 1.4 o �►,� � r80 OfTr UA.hf 10 Z.g 06 1-71Z 07 00 52 q �r n wcmv T w DAT OF WRK TOW AWAY PT101 OOIUv116 6T: ❑NONE m!mm op M T W T F 3 ❑YES MO 401TVICSR d AT M SWuaT1cm YIl'RI erATTi NIK WL a c.. S RY0� T4s M No 'AIMVrPMfl LD� ELAMIMAM I W- ATATE QA C ""fet -Z005 -f;-?.p Curl V1G0�11A l(Q�-05 C�1 tmm ?A (pi 9 MIWA ULS77 P -k �A1 N1-TE - ll pi"W q ' - C-SAA °"MRfpO.1�'ANMP AH"M� ASURr4ft 1rIMMAXAM �'�.0 (—A CoOtI.1D 6x OvwQft ANN ❑ SAME AS DRIVER j crlWAl11N' q4 IJ �D•1�� ca• �1 y 5'ZSD 0� 4 NTION aF V94iaa ON onDFlw eE F]OFFICER l t mrvM❑OTHIM mx tom EYES JVXIM VfflMrr w NUMATE MACE r( AWP+ ❑ '%LIS 1W (0-1-- 1�o Q9 3 PR*A MEOWINIOALDWECTt: NONQAI'PAA@R AURTOWAMT10 /MO NONE�R W! MMINeas ftm Vb6CW IDERMOATION NLPAtR: ❑ 1�. „�1 4f—�j O Mo ME Ont. onenleEVE)aa,6 nAw 4E eNADC IN DAWIOED ARBA INOURANO.;1'AwatUn "DUCY NUw wpt VEMCL6 TWE ❑UNK, ❑NONH MINOR rn,�a c�P+4►. Risk new,^�E*�.st C9Z 9'13—Z'�ao ' T1a yVALW-11 MoD. MAJOR ROLI.OVSR DM aFTI M!L ON EMOIT Oh m9Wmrsmog MT ' S $ -L-(OoBO CrT piMP T5CAL-T OR —TOPPS ►mqw . PARTY C9IVQR7 L Cl INM 1fWMMR STATE CL%m 6AFIITy, '",Y TMAKC*WDEjraXOM LICENSE NN0111R RTATC 2 X1,3�'3 .� C.A IL � )9116I oNbA N-4iL 3'TE3A683 Gl 0/I[l W1NE tfiRt AIID048 ward ��• --- ---- __- __ _.. AmY�Aa OWERENAui ❑ BAMEI19DRIUl1R � MOW AD'FMw -7' � emorATE a 1, ti /� q (� 1-)9 �`��T�7�Y�'• W 1 � 1 7 01 ❑�. T, (��S O VI5?o ` A• 13-1 O MUMSMONOFVEN ONOPMR11OF: OFFICER®DRIWR "M clllf ElJI OR me MIQMT 1A'ECHT DRIMATE 111AAM Yn, 001 ❑ �' ' 'k- 5r- i 3 a o 1 18 o PRroR MEtTIANtOAL Dly[CrF; uoIlE APpARDtT R&F&R TO NAImAiMc onml NOME VNar.' pU6�N•tS PHONE vE1NKfe ID�rwIOAneN NUNDER:� �� LLl 805 z01^S sg l 5 b 05 S 9— LTA U19 ONLY DESCJm VCH—E MACE —� "ON IN DAMAGED AREA WAUPAhae r RRIER ►oucY NMIEER VEMau TYpE 10UNK ❑NONE JKMINOR t 1reI♦1 C.vV5 Cio MOD, ❑MAJOR❑ROU4VER C DR 0PTM4 a JCW WMMT OR NIONWAT arem lWR u OOT S 8 -6 ofd rA�P �+ CALT rcPa�eC �Jmalll PARTT CRWOR'9UG71CW-W 11 -STATE aUEE Ir.oVY NDIYEM MAK24tomm/aaLoR umwrhUNDER W ATE F,OLN, 3 amw ANYi ri-DMUaTI - - ---- - ---- - -- ---- -- orINFR8NA76 ❑ S M6ASDRIVER .Da ll.-6r ADDI P IA ADviaEw ❑ AS DRIVER E Omn„TATbi P DIepO51TOh at VDllcalc au ORDERS Ofl �� .UM 119048 OTHER DC7f K 11 lyra NFlGIR OM b11elIDATe RACE �4'-�-I W, O.I YbT U _ PR"W-C MMGL uw mTS; NOTO NA1{MTNE slrel r+CaE DNoNC n161NEe-S VghlGLE lOWWCATICII IRAVM; ❑ -Fl aMF too m-T DEr2Ri0a%4"CLE DAAUWCE N tKA ED AER IfImltlwK.'G a.A.rr.'w Policy NUM _ YE„1CL07TPa ❑UNK NONEMINOR IR OF TRAVei I]N eVMtt-NK7MNAY NOD. ❑IrrA.iop❑ROLL•OVfiR ePMD UMtT >J1 CA DOT CAL.? _ MFA ec OIAfATCNMOTIFED REVIEWEg9NOME z �'+ ❑YSR NO p/A DATE R6lllElM1¢D 1j1 L1f G�JUb U'J:jb 5rJ554'i!'Jb54 ll�;tr;l lvt. f ItLlr;I lUIV 5 11/16/2006 at 11 :20 AM Job Number: 15988 B & H COLLISION REPAIR License # :BAR-aj235652 federal ID #:201 .4.74531 EPA # :CA000285664 BEST IN THE BUSINESS 84.5 FIERO LANE SAN LUIS OBISPO, CA 93401 (805) 541-2771 Fax: (805) 541-2775 PRELIMINARY ESTIMATE Written By: JENNIFER ROBINSON Adjuster: Insured: Claim # Owner: MARISSA FAMULARO Policy # Address: 758 TORO ST Deductible: SAN LUIS OBSZPO, CA 93401 Date of Loss: 10/29/2006 Other: (805) 801-5615 Type of Loss: Collision Point of Impact: 6 . Rear Inspect B & S COLLISION REPAIR Business: (805) 541-2771 Location: BEST IN THE BUSINESS 845 PIERO LANE SAN LUIS OBISPO, CA 93401 Insurance Company 3 Days to Repair 1996 HOND CIVIC DX 4-1 . 6L-FI 2D CPE silver Int: VIN: 1HGEJ6221TL091322 Lia: 3tba683 CA Prod Date: Odometer: 1.40557 Condition: Good Rear Defogger Tilt Wheel Intermittent Wipers Tinted Glass Body Side Moldings Dual Mirror, Clear Coat Paiza,t Metallic Paint Power Brakes AM Radio FM Radio Stereo Driver Air Bag Passenger Air Bag Bucket Seats Recline/Lounge Seats 5 Speed Transmission --- -------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT --- ---------- 1 REAR BUMPER 2 O/H bumper assy 0 0 . 00 1 . 5 0 . 0 3 Rept Bumper cover sedan, coupe 1 186 . 03 Incl . 2 . 6 4 Add for Clear Coat 0 0. 00 0 . 0 1 . 0 54 Rpr TINT COLOR 0 0 . 00 1 . 0 0. 0 6# Rpr CUT & RUE 0 0 . 00 1 . 0 0 . 0 7# Subl HAZARDOUS WASTE REMOVAL 1 3 . 00 X 0 . 0 0 . 0 ------------------------------------------------------------------------------- Subtotals =_> 189 . 03 3 . 5 3 . 6 1 11 i 21 2006 09: 36 3055490654. UREH' 11VE 1-1EL)iA f lUN 5 F"'UE bb 11/16/2006 at 11 : 20 AM Job Number: 15988 PRELIMINARY ESTIMATE 1996 HOND CIVIC DX 4-1 . 6L-FI 2D CPE silver Int: Parts 186 . 03 Body Labor 3 . 5 hrs @ $ 65 . 00/hr 227 . 50 . Paint Labor 3 . 6 hrs @ $ 65 . 00/hr 234 . 00 Paint Supplies 3 . 6 hrs @ $ 32 . 00/hr 1:15 . 20 Body Supplies 2 . 0 hrs @ $ 4 . 00/hr 8 . 00 Sublet/Misc. 3 . 00 ---------------------------------------------------- SUBTOTAL $ 773 .73 Sales Tax $ 309 . 23 @ 7 .2500% 22 . 42 ---------------------------------------------------- GRAND TOTAL $ 796 . 15 I hereby authorize the above repair work to be done along with necessary materials . You and your employees may operate vehicle for purposes of testing, inspection or delivery at my own risk. An, express mechanic ' s lien is acknowledged on vehicle to secure the amount of the repairs therto . You will . not be held responsible for loss or damage to vehicles left in vehicle in. case of fire, theft, accident or any other cause beyond your control . Signed, Date FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES : B-BODY LABOR D=DIAGNOSTIC F.=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS : ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RELY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/_=WITH/_ SYMBOLS : #=MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER' S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. 2 lli cli 1Ubb U'J: �3b 6'Ubb4yJUbb4 UKt;4I1Vt NLL)iAI1UN b HAUL !Jr 11/16/2006 at 11 : 20 AM Job Number : 15988 PRELIMINARY ESTIMATE 1996 HOND CIVIC DX 4-1 . 6L-FI 2D CPE silver Int: Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARG4431 Database Date 10/2006, CCC Data Date 10/2006, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be providedby or through alternate sources other than the OEM vehicle dealership-q- OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships_ Asterisk (') or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source_ Tilde sign (-) items indicate MOTOR Not-included Labor operations. Non-original. Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Rep! Parts which stands for competiti-•e Replacement Parts. Used parts are described as LKQ, Qual Racy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times_ NAGS labor operation times are not included. Pound sign (S) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. 3 11i 21i 2UUb u11j: ib b lb!D4JUb�i4 Uh,LAI l'Vt P-1LI)iAI 1UN 5 r'AIUt VJb 11/15/2006 at 01 : 41 PM Job Number: 49856 VILLA'S AUTO BODY License *:AM 197376 Federal ID # : 770188774 "OUR FAMILY TAKING CARE OF YOUR FAMILY" P.O. BOX 13660 34 SOUTH STREET SAN LUIS OBISPO, CA 93406-3660 (805) 781-3925 Fax: (805) 781-3948 PRELIMINARY ESTIMATE Written By: JASON MATEJCEK #008 Adjuster : Insured: MARISSA FAMULARO Claim # Owner: MARISSA FAMULARO Policy # Address: 265 SOUTH ST SUITE A Deductible.- SAN eductible:SAN LUIS OBISPO, CA 93401 Date of Loss: Cellular: (805) 549-0442x306 Type of Loss: Point of Impact: 6. Rear Inspect VILLA' S AUTO BODY Business: (805) 781-3925 Location: P .O. BOX 13660 34 SOUTH STREET SAN LUIS OBISPO, CA 93406-3660 Insurance Company; 3 Days to Repair 1996 HOND CIVIC DX 4-1 . 6L-FI 2D CPE Int: VIN: 1HGEJ6221TLO91322 Lic: 3TBA683 CA Prod Date: Odometer: 140544 Air Conditioning Rear Defogger Tilt Wheel Intermittent Wipers Tinted Glass Body Side Moldings Dual Mirrors California Emissions Clear Coat Paint Power Brakes AM Radio FM Radio Stereo Driver Air Bag Passenger Air Bag Bucket Seats Recline/Lounge Seats Automatic Transmission -------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT -------------------------------------------------------------------------------- 1 REAR BUMPER 2_** Repl RECOND Bumper cover sedan, 1 141 . 00 1 . 2 2 . 6 coupe 3 Add for Clear Coat 1 . 0 4 Repl Energy absorber coupe 1 70. 37 0 . 2 5# Tint Color 1 10 . 00 1 .0 64 Subl HAZARDOUS WASTE REMOVAL 1 3 . 00 X 7# Repl FLEXABLE ADDITIVE 1 10 . 00 -------------------------------------------------------------------------------- Subtotals =_> 234 . 37 2 . 4 3 . 6 1 11/21/Ll'lU'b IBJ: ;:ib 'U-'U!D!D4`J V_lbn4 ljNLA I I' L f1tll1A I lUN j r' :at UJ 11/15/2006 at 01 : 41 PM Job Number: 49856 PRELIMINARY ESTIMATE 1996 IJOND CIVIC DX 4-1 . 6L-FI 2D CPE Int: Parts 231 .37 Body Labor 2 . 4 hrs @ $ 67 . 00/hr 160 . 80 Paint Labor 3 . 6 hrs @ $ 67 . 00/hr 241 . 20 Paint Supplies 3 . 6 hrs @ $ 32 . 00/hr 13.5 . 20 Sublet/Misc. 3 . 00 ------------- SUBTOTAL $ 751 - 57 Sales Tax $ 346 . 57 @ 7 . 2500% 25. 13 --,------------------- GRAND TOTAL $ 776. 70 ADJUSTMENTS : Deductible 0 . 00 ------------------ CUSTOMER PAY $ 0 . 00 INSURANCE PAY $ 776 .70 I hereby authorize the repair work to be done along with the necessary material and grant you and/or your employees permission to operate the vehicle herein desribed on streets, highways, or Elsewhere for the purpose of testing and/or inspection . An express mechanics lein is hereby acknowledge on above vehicle to secure the amount of repairs thereto. ------Date----- BE ate_ --_BE. IT ACKNOWLEDGED that I, ------, of that undersigned, do hereby granted a limited and specific power of attorney to Villa Automotive of San Luis Obispo, as my attorney-in -fact . Said attorney-in-fact shall have full power and authority to undertake and perform only the following acts on my behalf: Sign and/or endorse insurance check (s) or draft (s) The authority herein shall include such incident acts as are reasonable required to carry out and perform the specific authorized granted herein for Villa Automotive to repair my vehicle . This limited power of attorney is effective upon execution. This limitec power of 2 11:`21.'2006 09: 26 2055490654 Uk"EA 11'JE 11EDiA I lUN b f AUU 1 U 11/3.5/2006 at 01 : 41 PM Job Number: 49856 PRELIMINARY ESTIMATE 1996 HOND CIVIC DX 4-1 . 6L-FI 2D CPE Int: attorney may be revoked by me at an.y time and shall automatically be revoked upon my death, provide any person relying upon this limited power of attorney shall have full rights to accept and rely upon the authority of my attorney-in-fact until in receipt of actual notice of revocation. Sign under seal this day of. 200__ Signature WITNESS by John Villa Signature: x Date VILLA AUTO BODY AGREES TO PERFORM REPAIRS WHICH SERVE TO RESTORE THE DAMAGED VEHICLE TO ITS PRELOSS CONDITION RELATIVE TO SAFETY, FUNCTION AND APPEARANCE AND FUTHER AGREES TO WARRANT WORKMANSHIP INCLUDING REFINISHING, IN WRITING, FOR AS LONG AS YOU OWN YOUR VEHICLE. MECHANICAL REPAIRS ARE WARRANTED FOR A PERIOD OF 1 YEAR OR 12, 000 MILES . UPON REQUIRING WARRANTED REPAIRS VILLA AUTO BODY WILL, IF NECESSARY, PROVIDE TOWING AND A LOANER CAR AT NO CHARGE TO VEHICLE OWNER. 3 09: 36 0'055490654 CREATIVE MEDIATION S PAGE 11 11/15/2006 at 01 : 41 PM Job Number! 49856 PRELIMINMY ESTIMTE 1996 HOND CIVIC DX 4-1. 6L-FI 2D CPE Int: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PATNT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA-MCERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT . PRICE=UNIT PRICE MULTIPLIZD .BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS WON-ADJ=NON ADJACENT O/K=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPI, PARTS=COMPETITIVE REPLACEMENT FARTS RECOND=RECONDITION RErN=REFINISH REPL=REPLACE R&T=REMOVE AND INSTALL R&R-REMOVE AND REPLACE RFR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/-=WITH/ SYMBOLS: #:-MANUAL LINE ENTRY *=OTHER [TE. .MOTORS DATABASE INFORMATION WAS CHANGED] --=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTUR8R' S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide ARG4431 Database Date 10/2006, CCC Data Date 10/2006, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships- OPT OEM (Opti,onal OEM) or. ALT OEM (Alternative OEM) Parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships- OPT OEM or Aj.T OEM parts may reflect some specific, special, Or unique pricing or discount. OPT OEM or. ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (') or Double Asterisk (**) indicates that the Parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-included Labor. operations.. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual RePl Parts or Comp Repl Parts which stands for competitive Replacement Pasta. Used paits are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned, parts are described as Recon. Recored parts axe described as Recore. NAGS Pa.,rt Numbers and Benchmark Prices are Provided by National Auto Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor Operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways A product of CCC Information services Inc. 4 11/21/2006 09:36 8055490654 CREHTI'v'E HEDIH'f I0N S PAGE 11 7,1/15/2006 at 01 : 41 PM Job Number : 49856 PRELIMINARY ESTIMATE 1996 HOND CIVIC DX 4-1 . 6L-FT 2D CPE Int: ALTERNATE PARTS SUPPLIERS 2 RECOND Bumper, cover sedan, Part No. H01100178R Price $141 . 00 Keystone - FPPP (800) 339-5033 4067 WEST SHAW AVE (559) 271-6750 FRESNO, CA 93722 Keystone - FPPP (800) 992-7550 8333 ARJONS DR. SUITE A (858) 547-4401 SAN DIEGO, CA 921.26 Keystone - FPPP (800) 264-7560 367.5 NE 109TH AVE . (360) 260-8400 VANCOUVER, WA 98682 Keystone - FPPP (800) 421-7866 1754 CEDAR ST_ (909) 986-4586 ONTARIO, CA 91761 Keystone - FPPP (509) 534-7844 3200 E . TRENT AVE BLDG 3 STE B SPOKANE, WA 99202 Keystone - FPPP (425) 251-8670 16506 80TH PL. SOUTH SUITE B (800) 843-2886 KENT, WA 98032 Keystone - FPPP (800) 263-9727 632 SOUTH ELDORADO ST. (209) 948-1107. STOCKTON, CA 95203 Keystone - FPPP (360) 733-7585 1538 KENTUCKY STREET (800) 538-3388 BEL.LINGHAM, WA 98229 Keystone - FPPP (800) 2.63-972.7 104.5 E. TRIANGLE COURT (916) 372-0287 W. SACRAMENTO, CA 95605 Keystone - FPPP (800) 243-4340 753, E . KINGS HILL PLACE (310) 329-3624 CARSON, CA 90746 5 :.11 11:' Ll: Ll'Ub YJ'J: .:ib bU00"J bO4 UIIL A I lvr- 1"It111i41 IUIV EGk"91� e ■ NOV 2 `' 2006 Fax Cover Sheet CLERK BOARD OF SUPERVISORS 758 Toro Street CONTRA COSTA CO. San Luis Obispo, CA 93401 805/801 -5615 cell — 805/549-0442 x303 day — 805/549-0654 fax slo_lani@msn.com Date: November 21 , 2006 Page 1 of 12 To: Penny Bailey, Liability Claims Adjuster Fax #: 925/335-1421 From: Marissa Famularo Re: Pending Claim Please call (805) 549-0442 if there are problems with this transmission. Dear Ms. Bailey, Thank you for your assistance in processing my claim. I've attached the completed claim form, a copy of the traffic collision report, and two estimates for repairs to my vehicle. Please contact me if you have any questions or need any further information. Sincerely, penny Bai/e Marissa Famularo Noy 2 1 y 2006 �m y. Penny Bailey NOV 2 1 2006 This transmission is confidentlal and Intended solely for the person or organization to whom it is addressed,It may contain privileged and confidential information. If you are not the intended recipient, you should not copy, distribute or take any action In reliance on it. if you have received this transmission In error,please notify us immediately at 805-549-0442. CLAI(AI BOARD OF SUPLItVISORS OF CONTRA COSTA COUNTY e. 1f BOARD ACTION: DECEMBER 19 , 2006 Claim Against the County, oi- District Governed by ) .the Board of Supervisors, Itouti f nd7§e-r etits� )'r� NOTICE TO CLA11v1ANT and Board Action. All Section r er nc�es1a,' t j L�) `� The copy of this document mailed to California Government Codes. NOU 2 $ 200b ) you is YOU notice of the action taken on your claim by the Board of COUNTY COUNSEL Supervisors. (Paragraph 1V below), MARTINEZ CALIF. given Pursuant to Government Code Section 913 and 915.4. Please note all AMOUNT: IN EXCESS OF $10 ,000 .00 °Warnings". CLAI.NtANT: BARBARA DALLAS ATTORNEY: CANDICE E. STODDARD DATE RECEIVED: NOVEMBER 281 2006 LAW OFFICES OF CANDICE E. STODDARD ADDRESS: 1111 CIVIC DRIVE, Ste'.BMWE.LIVERY TO CLERK ON: NOVEMBER 28 , 2006 WALNUT CREEK, CA 94596 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CUL.LEN, C Dated: NOVEMBER 28 , 2006 By: Deputy IL FROM: County Counsel TO: Clerk of the Board of Su rvisors (leis 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 notifyingclaimant. The Board cannot act for 15 days (Section 910.8). O 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). O Other: Dated: ��'�� By: s� Deputy County Counsel 1.11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV ROARD ORDER: By unanimous vote of the Supervisors present: (1 This Claim is rejected in Hill. ( ) Other: _ I certify that this is a true and correct copy of the Board's Order entered in its minutes for th is date. Dated: oeAW4 JOHN CULLEN, CLERK, ByDeputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(G) months from the date this notice Nvas personalty seined or deposited in the nitail to file a court action on this chitin.Sec 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 immediateh'. *For Additional Warnirxg Stv Reverse Side ofThis N_otice. AFFIDAVIT OF MAILING 1 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 1 deposited in the United States Postal Service in Nlartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated. �`�'4%- ° �'�'�� JOHN CULLL N, CLERK ByDeputy Clerk ORIGINAL. 1 CANDICE E. STODDARD SBN88130 Law Offices of Candice E. Stoddard 2 1111 Civic Drive, Suite 380 Walnut Creek, CA 94596 3 (925) 942-5100 4 Attorney for Claimant, Barbara Dallas A1011 5 C`FgcOOgq� 2 8 Z0Os NTS qq °FSVp 6 cOs7q o9viS0gS 7 8 CLAIM AGAINST COUNTY OF CONTRA COSTA 9 10 RE: Claim by: 11 BARBARA DALLAS 12 13 Against the County of Contra Costa 14 / 15 16 The undersigned claimant hereby makes claim against the County of Contra Costa 17 in the sum UNKNOWN AT THIS TIME AS MEDICAL TREATMENT IS CONTINUING, 18 HOWEVER THIS IS NOT A LIMITED JURISDICTION CLAIM and in support of this 19 claim represents as follows: 20 21 1. When did the damage or injury occur? (Give exact date and hour) 22 May 30, 2006 at approximately 1:00 p.m. 23 2. Where did the damage or injury occur? (Include city and county) 24 Street in front of 3079 Withers Avenue, Unincorporated Contra Costa County (see photos attached). 25 26 3. How did the damage or injury occur? (Give full details; use extra paper i 27 required) Claimant was proceeding on her bicycle when she came upon a pothole surrounding 28 an EBMUD plate which pothole constituted an inherently dangerous condition. This condition caused her front bicycle tire to become wedged in the pothole bringing he 1 I bicycle to a complete stop,launching her 15-20 feet forward,causing serious injuries described below. 2 3 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 4 5 Failure to maintain and failure to repair a dangerous condition. 6 7 5. What are the names of county or district officers,servants,or employees causing the damage or injury? 8 9 Unknown at this time. 10 11 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 12 13 Cervical and back strain;deep laceration inside mouth(between bottom lip and gum) requiring over 30 stitches; chin laceration requiring stitches; concussion; abrasions 14 and contusions to chest and neck. Claimant currently receiving treatment from Ann Honigman at Westside Chiropractic in Emeryville,CA. Claimant missed one week 15 from her employment as a Social Worker at John Muir Medical Center. Full amount of claim unknown at this time, however this is not a limited jurisdiction claim, and 16 specials are in excess of$10,000.00. (See photos of injuries attached) 17 18 7. How was the amount claimed above computed? (Include the estimated amount 19 of any prospective injury or damage). 20 Partial billings and records attached. 21 8. Names, and addresses of witnesses, doctors, and hospitals: 22 Incident was witnessed by claimant's husband, Tim Dallas 23 See partial medical billings and records attached. 24 9. List the expenditures you made on account of this accident or injury: 25 DATE AMOUNT 26 5/30/06 - American Medical Response $ 1,285.35 27 5/30/06 - John Muir Medical Center 3,730.15 Nestor D. Karas, DDS 1,116.00 28 Prescriptions 9.89 (Co-pay) 2 1 Medical Supplies 9.50 REI - Biking jersey 42.22 2 Encina Bicycle Center- Helmut 43.29 Performance Bike - Sun glasses 32.46 3 Partial list only. Medical treatment is continuing. Wage loss verification and 4 amount will be provided. 5 6 7 SEND NOTICES TO: 8 CANDICE E. STODDARD Law Offices of Candice E. Stoddard 9 1111 Civic Drive, Suite#380 Walnut Creek, CA 94596 10 Telephone: 925-942-5100 11 12 Dated: November 27, 2006 13 - CANDI E. S DA , ey for 14 Claimant, BARBARA DALLAS 15 16 17 18 19 20 21 22 23 24 25 26 27 28 3 PROOF OF SERVICE BY HAND I declare that I am employed in the County of Contra Costa, in the State of California. I am over the age of eighteen years and not a party to the within entitled cause. My business address is 1111 Civic Drive, Suite 380, Walnut Creek, California. On November 28, 2006, I served the attached: Claim Presented to the County of Contra .Costa on the parties in said action by placing a true copy thereof enclosed in a sealed envelope, and hand delivering as follows : Clerk of the Board of Supervisors Contra Costa County County Administration Building, Room 106 651 Pine Street Martinez, CA 94553 I declare under penalty of perjury that the foregoing is true and correct, and that this declaration was executed on November 27, 2006, at Walnut Creek, California. SANDRA LEWIS a 1.y�`�k}��{ M1y�g� S�•i a j A. ` I a 1 " �i •.may N ~ e ` Y A � i~a y { w 4 f kxr� aY.N�JY'!�^',t�'.`C'' ••J�•G tt�.": h s d Z �. i ,' ' '�Ay .ate.. .,y �7' `Y kr,�t.,,a:c`„`' A'��'��s t4.:�� tit,•Y � C x. h y. 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X" - ; -:�...�.-�r. .;C�.. � � , �� ..%..-% :� : : ::::: : zii -� : 1,,-, : , , , � � � .-' ...... ..s . A �. .- - .;;.::- . - : -1 . . . . . ;;'q A.190m....zz:� LONGS DRUGS OAK GROVE ROAD - WALNUT CREEK IIIIIiIIIIIIIIIIIIIIIIIIIIIIII ' ' • 1002 10 0035 554 002 A 1975 Diamond Blvd Concord, CA 94520 SUBTOTAL 11 .67 925 ( ) 825-9400 8.25% TAX .96 Cashier 99643 Register 2 TOTAL12.63 SALE Store 5724 6/01/0651:20 PN CASH 20.00 CHANGE 7,37 THANK YOU FOR SHOPPING AT LONGS Live healthy: Live happy. Live Longs. 020046025724060120064000944320 II IIIIIIIIIII IIIIIIi IIIIIiI III MEMBER #.94432 - (06) JUNE 31 2006 4:02 PH 7327340027 NOVARAS/LS CRA 39.00 YL SUBTOTAL 39.00 SALES TAX 8.25x 3.22 TOTAL 42.22 BANKCARO ACCT # ************5308 42.22 AUTH # 155320. DIVIDEND REDUCED 2% FOR CREDIT CARD PURCHASE M (Except for REI Visa Card purchases) Spring is Here! Fri da Anniversary Sale y,Nay 5th through Sunday,Way 14th Proof of purchase required for refund. Thank you for shopping REI 111 T - ;;; Visit REI On- _ -. ._.-.. •:+ ._.:. . Line at WWW.REI.CON Proof ofpurchase required for _ - refund. Page 2 PAT/ENT PRESCR/PT/ON IA. ,RMAT/ON DALLAS , BARBARA cc.nn-- W �1L[Lgd PENICILLIN V POTASSIUM TAB 250 MG (SANDOZ) 738 BANCROFT ROAD PENICILLIN V POTASSIUM 0454 (Adult) WALNUT CREEK, CA 94598 =_ Rx# : 0541855 COPAY: $7.00 combination-type birth control pills. This can result in pregnancy. You may need to use an. additional form of reliable birth control while using this medication. Consult your docto.r. o.r: pharmacist for details. Penicillin may cause false positive results with certain diabetic urine testing products (cupric sulfate-type) . This drug may also affect the results of certain lab tests. Make sure laboratory personnel and your doctors know you use this drug. NOTES : Do not share this medication with others. This medication has been prescribed for your current condition only. Do not use it later for another infection unless told to do so by your doctor. A different medication may be necessary in those cases . With prolonged treatment , laboratory and/or medical tests (e.g. , kidney function, complete blood counts) should be performed periodically to monitor your progress or check for side effects: Consult your doctor for more details. HOW DO I STORE IT? Store at room temperature between 59-86 degrees F ( 15-30 degrees C) away from light and moisture. Do not store in the bathroom. Keep all medicines away from children and pets. WHAT IF I MISS A DOSE? If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up. OVERDOSE : If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1-800-222-1222. Canadian residents should call their local poison control center directly. Symptoms of overdose may include: severe vomiting, persistent diarrhea. irs for refills. Please allow 24 - 48 hours for refills. Please allow 24 - 48 hours for refills. Please allow 24 - 48 hoi 041W O&W O&W rs for refills. Please allow 24 - 48 hours for refills. Please allow 24 - 48 hours for refills. Please allow 24 - 48 hot rs_fnr�pfill� �� _-._.Please-.a11n_w24—AS-hnucsJor refills. Please allow 24 - 48 hours for refills. Plead se allow 24 _ 48 hog 20%/05/3112:51:18 )ALLAS, BARBARA )5/31/2006 4951!Consult R-FILL A_ A 0541856 PCN WC=52 IIII!IIII!Ill!Illllllllllllllllllli!Illllllllllllllllllllllllll )urs for refills. Please allow 24 - 48 hot. OPAY: $2.89 PA TIENT PRESCRIPTION INFORMA TION Page 1 DALLAS, BARBARA HYDROCODONE/APAP 5/500 TAB (WATSON LABS) HYDROCODONE/ACETAMINOPHEN0454.(A738 BANCROFT ROAD Rx# :0541856 COPAY: $$22..89 WALNUT CREEK, CA 94598 89 :OMMON USE(S) FOR THIS DRUG: �} Tom_ - _...J. ....a_,... _- .. ....-.L......a .... ..0 .. -.-.-�.a iL.-J....�..J......\ ....J r. ....... ..w w....ate �� . ...... ... .. ........ ... .. ...?,,..:. .._...:.....:,•- - - 'fir'' ,., ..,... ,.. ... . ...._. , ... � _. .STATEMENT..OF E - .. .34...... . ....... . ..... .. .... .. . . .... ..1_ .:....., ... � - te�: ode: .:D scn tion=:,: "Bal�"n` e -�1+• --`Check#-='�r: �Amount` ace' 05/30/06 Barbara 02 40831 LACERATION 699.00 699.00 05/30/06 Barbara 02 12052 LAYER CLOSURE,WOUND 2.6 TO 417.00 1116.00 06/05/06 Barbara 01 9430 POST OP VISIT N/C 0.00 1116.00 O:z::a+i::Sd'l1:a.FtL+:•:,n�.:3-c�_:,e'+.��:',t.�,ES,:.:=.-.�-'�-.4;„'C`:u2M.ir::r:en-:t;r R";'cTsr-Y'Sto.>•O•-.v'-i,"eitic�:,:3T3"0:'.-.'i:•; :r2''F.Q" ve,;:SrS.�0"'=e`�1'.',,�;l;.�}..O....iv:•.�e;3r'..i:-9-.._.0...e:sr:�•�-�:§.�"._.`O-v.ta�:,'wrS�Er1'..20'+.::-_�L-_..4,,�t+.�ti 2-r0 U6`•=s:P-'Ma'.��i:y:myc4.e1+e:n:t'.�s�'.:i: f�.�.. ,r,-.._.r..4.:.r,•v�•:':-��,r.�.-...+r;rr:-s.-�Nc:.f:.:�z:•,a..r_.;•r_-,._ -s.:W:��,v.�•.yr_�:=.•<�'.a�..''X:::.n,.a,.,_�:.a�`..o-�.:c,F-.4r..L� u-...Faa—:-7��.._-:.� 1116.00 1116.00 0.00 0.00 0.00 0.00 0.00 �� ,r �:- � �. .•..�r-, :t� .: ,._ . ',��{'.3�'_y'x'i�;s "�� •Jc=.r'r�'�? �'�y'v;�::,,�,:�t�.,� 3u'-,.� a'' .s��,`-"� :r}. .w: �:�f .�s�. . ..x�•�� `,� _. ,-.. .- ,... :. r - _ - �: '-;r'�t 'ti.as:+7.ai:'.z, "'¢- _ �ryF <�� '"', g�-�.�.:c�Myi':�'�>F ':rr�y-`.. S.. �7�^...�•�''.-'':'. :F=�. .�c �;-v! .`c ..-S4 -}�'�` y-,, .•hr,' { ��'aa#. .,,,t.": �� .� .� '� "�,.�.. �. '. --y ,.:�Acco�Lntln�o.�'rnatiom•�: � a�� - �Y�:��E��', :. a.. nevi 4'��✓ia::.;,i^ Barbara Dallas Account# 104905 Last Billing 868 Brittany Lane Home (925)686-1386 Last Priv. Payment Concord, CA 94518 Work (925)947-3385 Budget 0.00 -',-w,�gr="�'�.:.�t"°�+rh:�•:::x'iaF:'; .;t' -�..flL=�• =`t.::a`r<.:'< c.,?�%v= t: " i �'l: .. ?. ..H.; i.- .rS"i_:.�'°li �..e::.'.u-JV�'� H.a M-:�✓ - :i_::i•- _�1:a '':41'K3�p :: :;:tl. :{'_3 ..Y'�ti?. z':$':, ;K�< '... ,rt{3:�:F:�' �' :a...i3-.�.,nsx�.,.,::sr�+•r.,»t?,::::i::<a...__� �' '�-�:�',ts�sn_ a=_.:�,.c: ,,.w�s:t- -.rBILLIN _DATE.�v<� Nestor D Karas, DDS (925)933-6190 06/22/06 1800 San Miguel Drive Walnut Creek,CA 94596 1 ....,wd.:.,., .�.<.:_.n. ..a- �=F.:-.-.r.� .w._...... .,. .. .. :......`r ?uY.r_�t„).'"✓:".;y.: ,.y:. -.:a.:::]4 :;c '=X..'�.t•+,•i"" Li":-"' ?i.is ,yq - .h'.. Ae.. ....A. .>tJ.6�._. ..>�l�'i' ..R^: �''¢�:'1�-� �,Y .. ... +•i➢•,c '•�. Via `:3.:mentD - { t�s, - 'r.,.ux ca<.r.,v"r rcS...L+:;ai,xi�.• - Barbara Dallas Thursday, July 20,2006 1:30 PM HOSPITAL SURGERY JOHN MUIR MEDICAL CENTER Thank you for selecting John Muir-Mt. Diablo Health System for John MuirlMt. Diablo Health System your healthcare needs. Quality patient care and dedication to PO Box 39000 patient satisfaction are our highest priorities. Department 33370 San Francisco,CA 94139-3370 2v00004.1 06150-00477 Our records indicate that you have NETWORK SELECT EPO-MM as your primary insurance and you do not have a secondary. If this is not correct, please contact our Customer Service Department at the number listed below. BARBARA J DALLAS We have added preventive healthcare and education news on 868 BRITTANY LN CONCORD CA 94518-3432 the back of the statement. We hope to serve you again, if a health need arises. Statement Date 06/04/06 DESCRIPTION TOTAL CHARGES Service Date(s) 05/30/06 PHARMACY $ 195.00 Patient Name BARBARA J DALLAS DRUGS/TAKEHOME $ 17.65 Account Number 06150-00477 IV SOLUTIONS $ 132.00 What we billed to insurance $3,730.15 DRUGS/OTHER $92.00 What's pending with insurance $3,730.15 IV THERAPY $314.00 Your payments/adjustments $0.00 DX X-RAY $371.00 CT SCAN/HEAD $0.00 What you owe now $0.00 EMERGENCY ROOM/SERVICES $2,515.50 Drugs/Detail Code $93.00 TOTAL CHARGES $3,730.15 Information TOTAL PAYMENTS/ADJUSTMENTS $0.00 Please confirm that information is correct. InquirieslChangeslUpdates PRIMARY Insurance NETWORK-SELECT EPO-MM . Billing questions or changes in insurance coverage? Group/Plan 01190 (925)947-3336 8:30 am to 4:15 pm weekdays . Written correspondence. ID Number 00004254401 John Muir/Mt. Diablo Health System-Attn. Patient Accounts PO Box 39000 SECONDARY No secondary on file. Department 33370 Insurance Please call if incorrect. San Francisco,CA 94139-3370 Group/Plan ID Number Please Note: Your physician will bill separately for tlreir professional services. HBOCFB02 A JOHN MUIR MEDICAL CENTER john Muir/Mt. Diablo Health Systern PO Box 39000 Account Number: 06150-00477 Department 33370 San Francisco,CA 94139-3370 PServkesatient Provided(Cont , DESCRIPTION TOTAL CHARGES TOTAL ACCOUNT BALANCE $3,730.15 HBOCFB04x PATIENT NAME. %`ACCOUNT NO. TRfP.NO ..,. >: .',,. INVtaICE BARBARA DALLAS 003067160-0001 401-66138017-00 106/05/20( DAl r SER1%ICE`FROM; 05/30/2006 WITHERS AVE/PLEASANT HILL RD OHN MUIR MEMORIAL HOSPITAL ...:.R i.. . .. ..t... ...A'. �.,�:`.'�•^...�,..,+„:,,}.........:..:..:. - nf,- y..,yn.-r[+Fye•_ :[.. •''IMf' RT NT-�N1E A E •:r A r. .. .A:....,. .....n.:,.[..te .. „.:...........:-,S� .:-:..n.'-.::,J_:•,., _ - sic^` :;? _'is,''.�:�,s. Please advise us of any medical insurance that may cover this service . If you do not have insurance, please remit payment in full . Please contact our Customer Service Department at (800)913-9106 if you have any questions. Thank you. �i9 FfiY7 '�:kC•R;-'+. - i�F:+ t fA n R°' Y' nF.« _ t'-". ,T..1.. ..:C_ .'iK+..'•},s j, ^�j; t v ..- •.;(.,'..Tt,, C' S.. -Y'. .ax tk 1��'=J' y4 •�:CO -s '•� '.t;:�.�. _D.E -RtPTI ,-,N.- ;.:-r.. k.x.. Is .r= r H •E�. >:r �'. �",'��_; OTAI-..CFIAEiG ..'•:Y\`....... ......s<..:;�, ...T:v.......'i....ts::A%_..r-..,'Crlc[,•' .s?.,. s'.' ,.F�,:�� gid: t�� .t�+ .'L:':'��.+sr'.......-..�.'...ti[Aa.,�... .4k:;.,:. - ...._. A0427 ALS1 EMERGENCY 1 1, 061 . 61 1,061.6, A0425 ALS MILEAGE 11 20. 34 223.71 CALL RCVD: 23:45 ! ;a� ,A1,:: y EN.V.tIE 1,285.3 5 DIAGNOSIS: 9598 '"> SEE REVERSE SIDE FOR INSURANCE INFORMATION Send billing inquiries to: American Medical Response, P.O. Box 3429, Modesto, CA 95353 one Number: 1-800-913-9106 Keep this portion for your records. Local Number: 1-209-238-4710 GIP 17,IS2 _-,_ A1P 14,196 www.amr-iric.com American Medical Response - AMERICAN ED 'CAL RESPONSE WEST P.O. Box 3429 Modesto, CA 95353 TRIP:#` ;.: :: 401-66138017-0 0 Acca.# `: 003067160 ...... ..........: .. —� PAVENTNAIVI.E>; ;; BARBARA DALLAS .� DATE.OF SERI ;; 05/30/2006 ACCOUNT NUMBER. 003067160 AMOUNTDUE.. '. 1 285. 35 t7UEi ar ;. 06/28/2001 , BARBARA DALLAS REMIT PAYMENT TO: 668 BRITANNY LN CONCORD, CA 94518 AMERICAN MEDICAL RESPONSE FILE 73329 PO BOX 60000 SAN FRANCISCO, CA 94160-3329 PLEASE CHARGE MY: ❑VISA 0 MASTERCARD ACCOUNT [I❑❑❑❑❑❑❑❑❑❑❑❑❑❑[1 EXPIRATION DATE [I❑0[1 SIGNATURE PLEASE ENTER AMOUNT PAID: $_ PLEASE DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT ..-:.,..•., : ., •'_ .... �......_.: _ ..._....w - •:�::. :.n,.nxc*: X24:iP - •:.3y""'••./t .-,.. .,...•--•. ...., ...... .PATIENT NAME. ..::. , .,..�... '�.�::}"...: .,��;� a:T:IP:� �k:';.. .�U �ACCOUNI"'fVO ;�:=: �';:.:��'" R Nd�-. -:.INVOIC:1= ATE:;q �.tt.,-.:i:..�....,:•:.�!;{f....:.:c?�-..,EE'.^.:�..y....:.........•. ._.,i..........,4ir._.-`;;SL: =J$ ':rG— y+4 �a'n ((�� BARBARA DALLAS 003067160-0001 401-66138017-00 06/08/2006 . :w .. ..t .......... ::m-�.:.......;.,.:i -. ;:1; _ _ ;'••.Y.?:`:.s..:r s?i::.* +-W •.±:r::: ._ .SERVICE , . m..:.: _ ,.. ,e . .,.•. : .�..SERVI.CE'�FRO�IiA- ..ti:. •,. ,: SEEii�IC i... ..3:'' 05/30/2006 WITHERS AVE/PLEASANT HILL RD JOHN MUIR MEMORIAL HOSPITAL K.. f ...... 4'u � - .-. .c,... .. .,�..,. .... - ...„ `.,},._..a...�,:y..,:��•se"-, :-c+11i/1P.��RTAN�� .,. :,;h�s^°�_.. .. •::a: r�.„�.. � :,-.� .:, Q T MESSAGES;::, Please advise us of any medical insurance that may cover this service. If you do not have insurance, please remit payment in full. Please contact our Customer Service Department at (800)913-9106 if you have any questions. Thank you. ;:fUNITRA NT $2:OIAL�. aa�anti..an..�• CHARGE, A0427 ALS1 EMERGENCY 1 1 ,061 .61 1 ,061 . 61 A0425 ALS MILEAGE 11 20 . 34 223 . 74 A :; .:.:�.- -s•:,:u^ -�<#�.•��;,t�y`;'::n= =:�✓ :moi.,;:: � 's. I CALL RCVD: 13:45 = T: TAL ;F ARGES}D:U.E :. 1 , 285. 35 ' DIAGNOSIS: ' D I AGNO S I S : 9598 :_� � _ { ,•:.:;' ; i:;;:;. E 7 SEE REVERSE SIDE FOR INSURANCE INFORMATION Send billing inquiries to: American Medical Response, P.O. Box 3429, Modesto, CA 95353 Phone Number: 1-800-913-9106 Keep this portion for your records. Local Number: 1-209-238-4710 i I i NESTOR D. KARAS DDS. MO SPECIALIZING IN Oral,Facial,&Implant Surgery Diploma te,American Board of Oral and Maxillofacial Surgery i A PROFESSIONAL CORPORATION 1800 SAN MIGUEL DRIVE ■ WALNUT CREEK, CA 94596 PHONE 925-933-6190 ■ FAX 925-945-7320 DIAGNOSIS: :..:\;' v DIET: Dietary instructions to be given in outpatient clinic (call 947-5314 for appt): ❑Yes ❑No SIGNS & SYMPTOMSTO REPORTTO MD: ACTIVITIES:Ambulation: ' = -Vo". OK to drive: MYes ❑No Date: Precautions: Confidential Morbidity Report: ❑Yes ❑No Equipment: Company/Phone: OXYGEN: Company/Phone: SPECIAL INSTRUCTIONS: Minor Head Injury Information/Given by Social Service per protocol: ❑N/A ❑Yes Date: WOUND CARE: �21�,�`. r, recce .�.k`- �� :,t�t��,.— Supplies: G4 41. liJ r-�.-' 3)� .�4,1 c�P_G`4-- G�7✓ri. i?1-.S U''`` [)C-1,lI;'.- �'-�S'wr� �`�^J 5s-�•.f?'- G�,I% RETURNTO WORK: Date: 0'-k0-? 1c'& Restrictions:, ;.,�-'°'�`�' HOME CARE AGENCY: Phone: Outpatient/Home Care: ❑PT ❑OT ❑Speech ❑Neuropsych ❑ RN Treatment: LAB.WORK: THIS IS YOUR ORDER FOR LABORATORY TESTS. TAKE THIS FORM WITH YOU TO THE LAB. Tests: Where: When: OTHER: MD APPOINTMENT: MD: �`�� ,f`a•��a� Phone: 033- 6(40 When: �� s CALL OFFICE FOR APPT. MD: Phone: When: SEND COPIES WITH PATIENT: [:]H&P ❑Lab ❑OP Note ❑XRay ❑Progress Note ❑Consultations ❑ have read and understand these instructions. DATE PATIENT SIGNATURE Transcribed by: RN/Date: Reviewed w/pt: RN/Date: RELATIONSHIP IF OTHER THAN PATIENT Date Discharge Summary Dictated: Medication Strength Qty(ENTER 0 I PATIENT ALREADY HAS MED) Directions L. GENERIC OR P+T APPROVED THERAPEUTIC EQUIVALENT WILL BE DISPENSED UNLESS CHECKED❑ NO MEDS❑ M.D.SIGNATURE r DATE M.D.(PRINT) ` PHONE. _ n0 �9 -ls It°V ADDRESSCITY CA LICENSE ` DEFE , t t �. is 4t � JOHN MUIR MEDICAL CENTER John Afitir/Alt. Diablo Health System TRAUMA DISCHARGE SHEET 5265(5/03) III II III III IIII IIII I I II II III 2PTIN Physician: David Soohoo, MD Date/Time: 30-May-2006 18:47 INTRAORAL LACERATION: Your exam shows you have a cut inside your mouth. If it is deep or bleeds too much, stitches may be needed to hold it together. Most cuts in the mouth are minor and heal in 4-5 days. If stitches were used inside your mouth, they will usually come out on their own within one week. To control bleeding you may apply direct pressure to the cut by squeezing it between your thumb and finger with a piece of gauze for several minutes. Sucking on an ice cube or popsicle will reduce the pain and swelling. For the next 2-3 days eat a soft diet, avoid citrus juices, and stay away from salty or spicy foods. Rinse your mouth out with warm water right after you eat to remove any food particles from the cut. Watch for signs of wound infection. These include unusual pain and swelling or pus drainage from around the cut. See your doctor or return here right away if you think your wound is infected. You may need a tetanus booster if you have not had one within 5 years. Patient/Representative Signature Staff Signature JOHN MUIR John Muir Medical Center III'IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Walnut Creek Campus 0615000477 1601 Ygnacio Valley Road, Walnut Creek, CA 94598 DALLAS, BARBARA 925-939-5800 Page 1 of 1 5044818 DOB: 4114/1954 52y1F IIIIIIIIIIIII VIII IIIIIIIIIIIIIII 2PT1N Physician: David Soohoo, MD Date/Time: 30-May-2006 18:47 HEAD INJURY: You have suffered a minor head injury. You do not need to stay in the hos- pital any longer, but you should have someone with you to check your condition every few hours for the next 24 hours. You may go to sleep, but someone should wake you up several times during the night (every 2-4 hours) to make sure you know who and where you are, and that you are able to talk and move around normally. You should see your doctor or go to the emer- gency room at once if any of the following symptoms develop over the next few days: * Severe headaches not helped by pain medicine. * Vomiting more than 2-3 times. * Mental confusion, restlessness, or personality changes. * Increasing weakness, sleepiness, blackouts, or seizures. * Loss of balance or trouble with movement or coordination. * A clear or bloody drainage from the nose or ear. You should get plenty of rest over the next 2-3 days. Avoid using aspirin or alcohol; take acetaminophen (Tylenol) as needed for headache or other pain. Head injuries may cause a moderate headache, weakness, dizziness, nausea, and depression for up to a week or more after the injury. This post-injury state usually gets better with bed rest and mild pain medicine. If any of these symptoms last for more than a week, you will need further medical attention. Please call the emergency room or your doctor if you have any questions or concerns about your head injury. Patient/Representative Signature Staff'Signature JOHN MUIR John Muir Medical Center IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII Walnut Creek Campus 0615000477 1601 Ygnacio Valley Road, Walnut Creek, CA 94598 DALLAS, BARBARA 925-939-5800 Page 1 of 1 5044818 DOB:4/14/1954 52y/F AMR -E - JOHN 'MUIR MI'DIABLO mergency ervices -------------------------------- ------------------- -------------------I...... H C. ?" E. -f �1*: 1-'0 1 s T Fw M Patient Name: DALLAS, BARBARA Date of Birth: 411411954 MR Number. 5044818 Sex., F Account Nuthber: 0615000477 FACESHEET SOCIAL GECUNTYNO. AGE ADkITTED BY 087382763 52y ALK MARITALSTATUS RNAKAALCLASS PATIENT TYPE ARRIVAL WOE AUWI IiME ADWI DATE MARRIED M10 ERO AMBULANCE 14:30 05130106 PATIENTADDRESS QNCL.AFT.NO) C4 TY 0:1 TOM STATE DP CODE 868 BRITTANY LANE CONCORD CA 94518 ALTERNATE ADDR:SS(LINE 1) --IW®RKTELCPH=14E PATTEN-TELEPHONE 9259522960 9256861386 ALTERNATE ADDFESS(1-INE 2) ALT PHONE 1 (926)686-1386 PATIENT EMPLOYMENT EMPLOYER EMPLOYER PHONE OCCUPATION EMPLOfMtEN T STATUS JOHN MUIR MED CENTER (925)952.2960 2 EMPLOYED PART TIME EMPLOYER ADORES;S EMPLOYER EMP.STATE EMP.ZIP 1601 YGNAGIO VALLEY RD NUT CREEK CA 94596 GUARANTOR GUARAN-OR NAME GUARANTCR ADDRESS BARBARA DALLAS 868 BRITTANY LANE 1 CONCORD,CA 94518 GLIA A EMPLOY.STATUS GUARANTCR,:N UARANTIF GUAR RELATION GUARANTOR OCCUPATION 7382763 861386 GUARAN-OR EMPLOYER GU.4.9 E MPLOYER P26EO X1 GUARANTOR EMPLOYER ADDRESS JOHN MUIR MED CENTER 92-5952 1601 YGNACIO VALLEY AD WALNUT CREEK,CA 94596 INSURANCE INSUREDNAME INSURANCE COMPANY PHONE NSURANCE IN51JPI'DSSN INSURANCItPLANDISCRIPTIO'l BARBARA DALLAS 9259522960 F254401 0873827W NETWORK SELECT (EPO)+ 'D (925 "mul -INWHNNL,-IL;UI&ANY ALIUMtb6 "�'9=NLECT(EPO)+ 01-190 "N' HAr1'(iHUU')'952 2887 PO BOX 5107 WALNUT CREEFCA 94596 SECONDARY I NSURANOE COMPANY SECONDARY INCURANCE POLICY# SECONDARY INS GROUP# -TOINWRANCE GROUP NAME I SECONDARY GROUPPI PNC -NDARY SECONDARY INSURANCE COMPANY ADDRESS NEXT OF KIN INFORMATION NEXT Of ION#I NLXT OF KIN RELATIOK N I NEXTOFKIN TELEPHOIE#I TIM DALLAS SPOUSE 9256861386 NEXT CC ION ADDRESS 01 NEXT OF KINCIIY OR TOYM p1 I NE XIOFKiNS-ATE#I I NEX-OFKINZIPNI 868 BRITTANY LANE I CONCORD CA 94518 NEXT OF KIN#2 NEXT OFKIN RELATION 42 NEXT O=KIN TELEPHONE$2(H) I NEXT OF KIN TELEPHONE 02(W) MEDICAL INFORMATION REFERRINGIF-HYS3DAN PHY9 -.4 ATTENDING PHYSICIAN 8673-EZ2;T,MONA M,MD 8690-SOO1I00,DAVID,MD 14ATLILE OF ACCIDENT'. ACCMMfr 7TPZ ACCIDENTDATIE. -FCODENI TIME BICYCLE ACCIDENT 2006 45:00 rA71ENT.UA50N FOR VISIT ADMII-11=4UX Fall FALL ti l AMR Page 1 of 15 ..... ....... JohnMuirMedica.I....Center -. . -Walnut a.Inu-t. Creek -CA94598 - Patient: DALLAS,BARBARA DOB:4/14i1954 Age/Gender: 52 F 5/30/200614:30 Fall MR#: 5044818 Acct#. 0615000477 Private Phys: 8673-EZZAT,MONA M, MD ED Phys: David Soohoo, MD CHIEF COMPLAINT: Enc.Type: ACUITY: Fall Initial Urgent Additional Complaints: Physicians caring for patient: David Soohoo, MD Dental-Oral Surgery HISTORY OF PRESENT ILLNESS NOTE Notes: <Y 05/31/06 11:21:09> REPORT NOT FINAL UNTIL SIGNED TIME OF EVALUATION: 2:30 p.m. CHIEF COMPLAINT: Bicycle accident with head injury. HISTORY OF PRESENT ILLNESS: This is a 52-year-old female who is generally healthy and who was riding her bicycle downhill when apparently she struck a pothole causing her to flip over the handle bars. According to her husband who was with her at the time, she fell forward and struck her head. Fortunately she was helmeted and there was no witnessed loss of consciousness although the patient apparently had repetitive questioning at the time of the incident. At the scene she was noted to have contusion and abrasion to her forehead as well as contusion and laceration to the chin as well as a laceration inside the lower Up. The patient upon arrival is coherent and alert and she complains mostly of pain to the mouth and she denies any severe headache, nausea or visual changes, neck pain or chest pain or shortness of breath or abdominal pain. She does have pain with an abrasion of the left shoulder upon arrival. At this time there are no other modifying factors regarding her acute presentation. Printed by 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS BARBARA MR 5044818 52y DOB 04/14/1954 F I FIN 0615000477 Medical Chart Page 2 of 15 Sohn Muir Medica.1-Center......Walnut-Creek ,-_CA94598 Patient, DALLAS,BARBARA DOB:4/14i1954 Age/Gender- 52 F 5/30/200614:30 Fall MR#: 5044818 Acci#: 0615000477 Private Phys: 8673-EZZAT,MONA M, MD ED Phys: David Soohoo, MD PAST MEDICAL HISTORY: Negative. MEDICATIONS: Ibuprofen as needed. ALLERGIES: No known medical allergies. SOCIAL HISTORY: The patient is married and her physician is Dr. Delaney. She is employed as a social worker at John ?4u:Lr Medical Center, Walnut Creek Campus. FAMILY HISTORY: Negative. HABITS: None. REVIEW OF SYSTEMS: All other systems are reviewed and are negative. PHYSICAL EXAMINATION: VITAL SIGNS: Please refer to the HMED chart for vital signs. Oxygen saturation is 99 percent on room air consistent with normal oxygenation. GENERAL APPEARANCE: This is an alert middle-aged female in no acute distress. SKIN: Warm and dry and pink. HEENT: The patient has a contusion abrasion to the forehead without stepoff. Tympanic membranes are clear and pupils are equal and remctive and extraocular movements intact, mid face is stable, dentition appears intact. The patient has a contusion over the left jaw and chin without malocclusion with full range of motion of the mandible. The patient has a 1.5 am laceration over the tip of the chin. In addition the patient has an intraoral laceration involving the buccal mucosa near the inferior sulcus measuring up to 5 am. There do not appear to be any dental fractures and the neck is nontender, no adenopathy or stridor. BACK: Atraumatic without spinal tenderness. CHEST: Clear to auscultation without wheezes or rales. Ribs are nontender. Printedby 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F I FIN 0615000477 Medical Chart Page 3 of 15 John,Muir_M—ed-i-ca-1-Center- Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14i1954 Age/Gender. 52 F 5/30/"300614:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673-EZZAT, MONA M,MD ED Phys: David Soohoo, MD CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs or gallops. Distal pulses are intact. GI: Nontender and nondistended and no rebound or guarding. PELVIS: Stable to compression. EXTREMITIES: There is an abrasion to the left shoulder with some tenderness but range of motion is preserved, otherwise there are no deformities of the extremities noted. NEUROLOGIC: At this time mental status and cranial nerves and motor and sensation and coordination are grossly intact. EMERGENCY DEPARTMENT COURSE: The patient appears to have had a significant head injury. Fortunately she was wearing her helmet but she did have repetitive questioning and probably has had a concussion. In addition she has a significant intraoral laceration. She remained hemodyn&mically stable while in the emergency department. Her evaluation included a CT scan of the head and neck, both of which were read as normal by the radiologist. An x-ray of the left shoulder I interpreted as showing no apparent fracture or dislocation or acute bony abnormality. At this time I consulted with Dr. Karas, the oral surgeon, who was kind enough to come to the emergency department and evaluate the patient for her intraoral laceration and the patient received IV penicillin for this laceration. She also received a Tetanus booster. The patient received IV fluid hydration with one liter of normal saline over an hour for mild dehydration following which she seemed clinically improved. She declined any pain medicine while in this emergency department initially. Dr. Karas repaired the patient's laceration and will follow her as an outpatient. The patient will be discharged with a prescription for penicillin and Vicodin to take for pain. She is also discharged with closed head injury precautions and will be with her husband. If she has any further problems in the meantime she will return to the emergency department. EMERGENCY DEPARTMENT DIAGNOSIS: 1. Bicycle accident. 2. Closed head injury consistent with concussion. 3. Facial abrasions and contusions. 4. Intraoral laceration. 5. Left shoulder contusion abrasion. Printed by 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS BARBARA MR 5044818 52y DOB 04/14/1954 F I FIN 0615000477 Medical Chart Page 4 of 15 John Mui.r...Medical Center------Walnut--- ..C.-reek CA 94.598 Patient: DALLAS,BARBARA DOB:4/14i1954 Age/Gender: 52 F 5/30/200614:30 Fall MR#: 5044818 Accifi: 0615000477 Private Phys: 8673-EZZAT,MONA M, MD ED Phys; David Soohoo, MD PAT. NAME: DALLAS, BARBARA ADM. DATE: 05/30/2006 PHYS. : DAVID SOOHOO, MD MR#:504-48-18 DOB: 04/14/1954 Doc ID#: 740637 Acct#: 0615000477 DD: 05/30/2006 DT: 10:45 P Job # 000196609 CC., BILLING COPY ER COPY ER PROCEDURES CONSULTATION Consult MD called: Nestor Karas, DDS; DENTAL-ORAL SURGERY- (925) 933-6190 AK1 05/30/06 16:49 AK1:Anna Laurae Kevning, LDCLK 05/30,'06 16:49 DIAGNOSIS BLUNT HEAD INJURY DAVS:David Soohoo, MD 05/30106 18:42 DISPOSITION PHYSICIAN Pertinent physical findings: oral lac, chin lac, head contusion Condition:Good Disposition-Discharged from ED: Follow-up with: Nestor Karas, DDS- 1800 San Miguel Drive,Walnut Creek 94598 (925) 933-6190 Discharged home. Printed by 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS BARBARA MR 5044818 52Y DOB 04/14/1954 F I FIN 0615000477 Medical Chart Page 5oJ15 ----- ---- - — - Juum vuwu Medical Cemu~u - vouxut Creek -,-CA 04508 '-- '--- 9adoao DALLAS,BARBARA DOB:4/14i1954 Age/Gender. 529 58020O614:3OFall MR#.. 5O44818 Acct#: 0615000477 Private Phys: 8673'1---ZZAJ',&{[NAM, MD Q0 P|q/n, Duvid3oohoo, MD ._.,.-~..-~.........-.-~-...-~�..-.....-,-...,...,~-.....-._,..-~-....�._..-~-,_.-~.� M88| EK43 MBS| %RAY DAVG:David Soohno. MDOS/3O/0818:45 DAVS-David Soohuo.W1OOS/3O10G18-47 NURSING Discharge assessment: patient ambulatory and vital signs stable Discharge: Mode:ambulatory Discharged to: home Discharge instructions given to: patient and other family |\/discontinued with catheter intact. 8teh|o dressing applied to site. Rx given to Patient and spouse Education: Barriers bzLearning: Topic:foikow- medications and symptom management Method:written and discussion Outcome: patient famity/support person verbalized understanding Time patientd|mcharged from the ED:Tuesdmy,K8my, 30,200620:46 N|B:Nioo\eBokker. RN 05/30/06 18:12 JH3:Joanno Hoag, AND5/3[VOS2O:45 AK1:Anna Lauxoo hJovning. LOCLKO5/3O,100 21:47 AFTERCARE INSTRUCTIONS Head Injury English Intraoral Laceration English DAVS:Dovid800hoo. KADDW3[yDG18:47 ORDERS PRESCRIPTIONS Oioponnodmed:Vicodin 5mg. #58ivei1q4-6hour prn. NorofiUu.David8onhoo.K8D5/3O/2OOGi8�44 Vicodin 5mg. #8O (Tvw»nty). 1 q4-Ghour prn. NorofiUa.DavdGuohoo. K8D5/3O/2DOG18:44 PenVeeK 250 mg tabs, 40 Take one tablet four times daily. Take modirected oruntil you run out. Nnrefills.David 800hoo. W1D5/3U/ODU618:45 MEDICINE Tebanus/dipthoha; 0.5ml; |K8DavidSnohoo. K8D5/8Oi8)0815:54 Penicillin 8; 8million units; |VOuvidSoohon. MD 5/30/2006 17:07 Versed; 2mg; IVP; Once; K/.[}, read back) bvNestor Kanas. DDGJoanneHoag, RN5/3O/2OUG19:32 RADIOLOGY Test: CThead/brain vvocontrast; Transportation: Gurney; David Soohon. &4D 5/30/2006 14:40 [Rofarenoo: 917543^PCyN] Test: CT cervical spine wmonntnunt; Transportation: 8urney; Reason- pain David 800hoo' MD 5/30/200014:40 [Reference: 817544^PCN] Toot Shoulder limited |P; Transportation: Gurney; Prompt: Left; Reason: pain DavidSoohoo. MD 51301200814:40 [Refnrenoe:917545^PCM] Printed 6y701125ouMonday,June,O5.%0869-34:4gAMCoopl«acChart DALLAS BARBARA &{R 5044818 52y DOB 04/14/1954 F l FIN 0615000477 Page 6 of 15 John h n Mu ir Medical c a I Center Walnut Creek Patient: DALLAS,BARBARA DOB:4/14i1954 4,e/Gender: 52 F 5/30/200614:30 Fall MR#; 5044818 Acct#: 0615000477 Private Phys: 8673-EZZAT,MONA M,MD ED Phys: David Soohoo, MD, CONSULTATION Contact: Please contact the doctor on call for Dental- Oral Surgery David Soohoo, MD 5130/2006 16,32 RESPIRATORY/IV Insert saline lock David Soohoo, MID 5/30/2006 17:04 Order: Normal saline Rate: bolus I liter wide open David Soohoo, IVID 5/30/2006 17:04 RESULTS RADIOLOGY Test: CT head/brain wo contrast; Transportation: Gurney; Result I User N. Interface 5/30/2006 14:55 Test:CT head/brain wo contrast;Transportation:Gurney; Test Flag Value Units Ret.Range Status Read By 99.5955'SAURARH K PATEL • F Report Noncontract bead CT(70450)-05/30/06 F Report F Report History-Fall(959.8). F Report F Report Comparison-MRI of the brain dated 04128/06. F Report F Report Technique-Axial 5 nun noncontrast CT from the skull base to vertex. F Report F Report Findings-The ventricles,cisterns and sulci are normal.No midline F Report shift.No abnormal attenuation within the brain parenchyma.No F Report intracranial hemorrhage or bernatoma.No extra axial fluid collections.The F Report orbits are unremarkable.Mild left frontal scalp soft[issue swelling is noted. F Report the mastoids and visualized sinuses are clear.No fractures. F Report F Report Impression- F Report F Report No acute intracranial abnormalities. F Report F Released By 995955^SAURABH K PATEL • F Result 2 User N. Interface 5/30/2006 14:55 Test: CT head/brain wo contrast;Transportation: Gurney; Printed by 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F I FIN 0615000477 Medical Chart Page 7 of 15 .... ...... John Mu ir Medical Center - Walnut Creek CA 0508 Patient: DALLAS,BARBARA DOB:4/14il954 Age/Gender: 52 F 5130/200614:30 Fall 114 R#: 5044818 Acct#: 0615000477 Private Phys: 8673-EZZAT,MONA M, MD ED Phys: David Soohoo, MD Test Flag Value Units Ref.Range Status Read By 995955'SAURABH K PATEL • P Report Noncontrast bead CT(70450)-05/30106 P Report r Report History-Fall(959.8). P Report P Report Comparison-MRI of the brain dated 04/28/06. P Report P Report Technique-Axial 5 mm noncontract CT from the skull base to vertex. P Report P Report Findings-The ventricles,cisterns and sulci are normal.No midline F Report shift.No abnormal attenuation within the brain parenchyma.No P Report intracranial hemorrhage or hematoma, P Report P Report No extra axial fluid collections.The orbits are unremarkable.Mild P Report left frontal scalp soft tissue swelling is noted.The mastoids and P Report visualized sinuses are clear.No fractures. P Report P Report Impression- P Report P Report No acute intracranial abnormalities. p Test: CT cervical spine wo contrast; Transportation: Gurney; Reason: pain Result 1 User N. Interface 5130/2006 14:55 Test:CT cervical spine wo contrast;Transportation:Gurney;Reason:pain Test Flag Value Units ReL Range Status Read By 995955^SAURA131i KPATFL F Report CT cervical spine without contrast including reformats(72125)- F Report 5130106 F Report F Report CT reconstructions(76375) F Report F Report History-Neck pain(723.1) F Report F Report Comparison-None. F Report F Report Technique-Axial 2.5 nun noncontrast CT through the cervical spine with F Report sagittal and coronal reformats. F Printed by 701125 on Monday,June 05,2006 9:34:49 AMCoFnplete Chart DALLAS BARBARA MR 5044818 52y DOB 04114/1954 F I FIN 0615000477 Medical Chart Page 8 of 15 John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14il954 Age/Gender. 52 F 5/30/9200614:30 Fall MR#; 5044818 Ace[#: 0615000477 Private Phys: 8673-EZ71AT,MONA M, MD ED Phys: David Soohoo, MD Test:CTcervical spine wo contrast;Transportation:Gurney;Reason:pain Test Flag Value Units KeL Range Status Report F Report Findings-No acute fracture or malalignment.The visuali7ed lung F Report apices are clear.Both thyroid lobes appear heterogeneous and sruill. F Report thyroid nodules arc not excluded.Prevertebral soft tissues are within F Report normal Limits. F Report F Report 1111pl-cssion- F Report F Report No acute abnormality identified. F Report P Released By 995955^SAURABH K PATEL s F Result 2 User N. Interface 5130/2006 14:55 Test: CT cervical spine wo contrast;Transportation:Gurney; Reason: pain Test Flag Value Units Rell Range States Read By 995955^SAURABH K PATEL P Report CT cervical spine without contrast including reformats(72125)- P Report 5/30/06 P Report CT reconstructions(76375) P Report P Report History-Neck pain(723.1) P Report P Report Comparison-None. P Report P Report Technique-Axial 2.5 mm nonconwast CT through the cervical spine with P Report sagittal and coronal reformats. P Rcport P Report Findings-No acute fracture or malalignment.The visualized lung P Report apices are clear.Both thyroid lobes appear heterogeneous and small P Report thyroid nodules are not excluded.Prevertebral soft tissues are within P Report normal limits. P Report. P Report impression- P Rcport P Report No acute abnormality identified. P Printed by 701125 on Monday,June 05,2006 9:34:49 AMCornpiele Chart DALLAS BARBARA MR 5044818 52y DOB 04114/1954 F I FIN 0615000477 Medical Chart Page 9 of 1 --------....... ................................... .. ....... . ..... 5... John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14il954 Age/Gender: 52 F 5/300100614:30 Fall MR#: 5044818 Acc-94: 0615000477 Private Phys: 8673-EZZAT, MONA M,MD ED Phys: David Soohoo, MD Test: Shoulder limited IP; Transportation: Gurney; Prompt: Left; Reason: pain Result I User N. Interface 5/30/2006 15:10 Test:Shoulder limited IP; Transportation:Gurney;Prompt:Left)-Reason:pain Test Flag Value Units Ref.Range Status Read By 995955^SAURABH K PATEL s F Report Left sbouldor one view-S/30/06 F Report F Report History-Pain. F Report F Report Comparison-5110106. F Report F Report Findings-Single limited view demonstrates no acute fracture, F Report malalignment,or significant bony abnormality.Previously demonstrated F Report calcific tendinitis is difficult to evaluate on this single view. F Report F Report Impression-No acute osseous abnormality. F Report F Report F Released By 995955^SAURABH K PATEL It F Result 2 User N. Interface 5/30/2006 15:10 Test: Shoulder limited IP;Transportation: Gurney;Prompt:Left; Reason: pain Test Flag Value Units Ref.Range Status Read By 995955 A SAURABH K PATEL • P Report Left shoulder one view-5/30106 P Report P Report History-Pain. F Report P Report Comparison-5110106. P Report P Report Findings-Single limited view demonstrates no acute fracture, P Report malalignment,or significant bony abnormality.Previously demonstrated P Report calcific tendinitis is difficult to evaluate on this single view. P Report P Report Impression-No acute abnormality. P Report P Result 3 User N. Interface 5/30/2006 15:11 Printed by 701125 on Monday,June 05,2006 9:34:49 AMCornplete Chart DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F I FIN 0615000477 Medical Chart Page 10 of 15 - ---------- John Muir Medical Center Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4114i1954 Age/Gender: 52 F 5/30/200614:30 Fall MR#. 5044818 Ace(#: 0615000477 Private Phys: 8673-EZZAT, MONA M,MD ED Phys: David Sooboo, MD Test, Shoulder limited IP;Transportation: Gurney;Prompt: Left-, Reason: pain Test Flag Value Units Her.Range Status Read By 995955^SAURABH K PATEL P Report Left shoulder one view-5/30106 P Report P Report History-Pain. P Report P Report Comparison-None. P Rcpoit P Report Findings-Single limited view demonstrates Do acute fracture, P Report malalignment,or sigufficant bony abnormality. P Report P Report Impression-No acute abnormality. P VITAL SIGNS Initials/Date/Time Temp(Q Rt. Pulse Resp Syst Diast Pos. 02 Sat Pain FiO2 JKB 5/30/2006 14:35 37 0 73 16 128 75 L 99 2 Room Air NIB 5/30/200616:40 66 18 122 74 L 100 1 Room Air I H3 5/30/2006 20:06 63 20 122 77 L 100 2 Room Air TRIAGE Patient's initial encounter:Tuesday, May 30, 2006 14:27 Arrival: Patient arrived by gurney via ambulance from field accompanied by EMT/paramedic Patient's reason for visit Bicycle accident JKB:joel K. Billens, RN 05130106 14:30 A01 Alicia Ott, FINCO 05130106 16:29 NURSING SYSTEMS REVIEW ASSESSMENT Breathing:Patient is able to breathe without difficulty. Pulse: Pulse is strong, regular, non rapid. Skin signs: Skin is warm, dry with normal color. Orientation level: Patient is awake, alert and oriented x4. HPI: History of present illness: Pt. Was riding her bicycle down an — 10% grade when she hit a pot hole and crashed. Pt has good recall of events. There was no LOC. Pt. sustained a laceration to the chin and inside lower lip. Paramedics describe repetitive questions but A&Ox3. Historian: The history is provided by the patient. Historian: The history is provided by a paramedic Allergies: Printed by 701125 on Monday,Jun-,05,2006 9-34-.49 AMComplete Chart DALLAS BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart Page 11 of 15 John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB,4/14i1954 Age/Gender: 52 F 5/30/200614:30 Fall MR#: 5044818 Accl#: 0615000477 Private Phys: 8673-EZZAT, MONA M, MD ED Phys: David Soohoo, MD Medication allergy: Septra Patient has no known latex allergy. Medications: Current meds: Ibuprofen PO Medications were taken prior to arrival to the ED. No significant past medical history. LMP LMP NIA: Patient is post menopausal. Patient has not had influenza vaccination. 'We are concerned about the safety of our patents, so we ask everyone, do you feel safe in your home?" Patient response is"Yes'. Airway patent, normal, maintained independently. Respirations normal, regular, non-labored,denies shortness of breath. Pulses normal, strong, regular, mucous membranes moist,denies chest pain. Patient is awake,alert and oriented x 4, speech is clear and coherent, sensory motor grossly normal. Abdomen soft flat, patient denies abdominal pain. Denies genitourinary complaints. Notes: <NIB 05-30-2006 14:47>Pt denies neck pain or discomfort, pt denies back pain. Pt alert/oriented x 3. Integ Assessment:laceration. <NIB 05/30/2006 14:46>to chin and abrasion <NIB 05/30/2006 14:46> left shoulder Secondary assessment complete. JKB:Joel K. Billens, RN 05/30106 14:31 NIB:Nicole Bekker, RN 051'30/06 14:43 FLOWSHEETS MEDICATION ADMINISTRATION Tetanus/diptheria-,0.5 ml; IM David Soohoo, MD 5/30/2006 15:54 Yes,given NIB 5130/2006 16:03 No adverse reaction N113 5/30/2006 16:36 Notes: <NIB 05-30-2006 16:04>EXP DATE 19 December 07 Lot# U1786BA <NIB 05-30-2006 16:05>Given to right deltoid Penicillin G; 3 million units; IV David Soohoo, MD 5/30/2006 17:07 Yes,given.Route/Location: IV via pump MW5 5/30/200618:53 No adverse reaction 3H3 5/30/2006 20:09 Printed by 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS BARBARA MR 5044818 52y DOB 04/14/1954 F I FIN 0615000477 Medical Chart Page 12 of 15 John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14i1954 Age/Gender: 52 F 5/30/200614:30 Fall MR#; 5044818 Acd4; 0615000477 Private Phys: 8673-EZZAT, MONA M,MD ED Phys: David Soohoo, MD Versed; 2 mg; IVP; Once; (V.0., read back) by Nestor Karas, DDS Joanne Hoag, RN 5/3012006 19:32 Yeo,given. Route[I.ocation: IV 1113 5/30/2006 19:33 Positive response J H3 5/30/200619:33 Printed by 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F I FIN 0615000477 Medical Chart ----------- ------ bc M ray y en CO 0\ C) ` n a ... 'T z Z6 CD OM j z ci " lop At 0 00 oo (-,t oto r-- 00 ,0 VI :!42 Page 14 of 15 John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14i1954 Age/Gender: 52 F 5/30/200614:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673-EZZAT, MONA M,MD ED Phys: David Soohoo, MD .............. NURSING NOTES 05!30/0614:35 Temp(C) Rt. Pulse Resp Syst Diast Pos. 02 Sat Pain FiO2 37 0 73 16 128 75 L 99 2 Room Air 05/30/06 14:42 Comfort measures:The patient was informed of status.The patient was given a blanket.The patient was repositioned to a 30 degree incline.<NrB> 05/30/06 14!42 C-spine immobilization! Back board removed Hard C-collar remains in place CMSTP Intact x 4 by MD.<NmB> 05/30/0614:56 Patient in radiology: Patient in X-ray department.Transported by transporter<AB3> 05/30/06 15:11 Patient radiology exam complete: Patient back from X-ray department.<AB3> 05/30/06 15:11 Patient in radiology: Patient in Cr department.Transported by transporter<AB3> 05/30/06 15:35 Patient radiology exam complete: Patient back from CT department.<JP4> 05/30/0616:03 MAR Given:Tetanus/diptheria;0.5 ml;IM Yes,given 05/30/0616:05 MAR Notes <NIB>EXT DATE 19 December 07 Lot#U1786BA 05/30/06 16:05 MAR Notes <NIB>Given to right deltoid 05/30/0616:06 Procedure-Nursing Note: <NIB;>Pt awake/alert and oriented x 4,resting in nad.Awaiting sutures placement by md,suture set placed at bedside. 05/30/0616;36 MAR Response;Totanus/dipthoria;0.5 ml; IM No adverse reaction 05/30/0616:40 Temp(C) Rt. Pulse Resp Syst Diast Pos. 02 Sat Pain FiO2 66 18 122 74 L 100 1 Room Air 05/30/06 16:42 C-spine immobilization: Hard C-collar removed CMSTP Intact x 4 by MD.<NM> 05/30/06 17:05 IV fluid flowsheet Fluid:NS Bag Volume: 1000 ml Rate:Wide.open Act: hung and infusing Bag Number: 1 05/30/06 17:05 IV placement:IV site ff 1 : a/an 20 gauge was inserted in the left antecubital area.Attempts: I <Nm> 05/30/06 18:53 MAR Given: Penicillin G;3 million units; IV Yes,given.Route/Location: IV via pump 05/30/0619:33 MAR Given;Versed;2 mg; IVF;Once-,(V.0.,read back)by Nestor Karas,DDS Yes,given. Route/Location: IV 05/30/06 19:33 MAR Response: Versed;2 mg; IVP; Once;(V.O., read back)by Nestor Karas, DDS Printed by 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS BARBARA MR 5044818 52y DOB 04/14/1954 F I FIN 0615000477 Medical Chart MOHR Page 15 of 15 John- Muir-Medical Center Walnut-Creek CA94598 Patient: DALLAS,BARBARA DOB:4/144954 Age/Gender: 52 F 5/30/200614:30 Fall MR#: 5044818 Aced/: 0615000477 Private Phys: 8673-EZZAT, MONA M,MD ED Phys: David Soohoo, MD Positive response 05/3G/06 20:06 Temp(C) Rt. Pulse Resp Syst Diast Pos. 02 Sat Pain FiO2 63 20. 122 77 L 100 2 Room Air 05/30/0620:09 MAR Response: Penicillin G;3 million units;IV No advtmtir,reaction 05/30/0620:44 IV discontinued with catheter intact.Sterile dressing applied.<JIB> Nursing Data electronically signed by:Joanne Hoag, RN 5/30/2006 20A6 Bed Assignments: RM9 JKB 5/30/2006 14:30 Chart electronically signed by: David Soohoo,MD 5/30/200618:49 This chart documented by: BS2: Britnie Snyder, FINCO JP4:James Prasad, TRANS JH3: Joanne Hoag, RN MW5: Minnie Wango, RN NIB:Nicole Bekker, RN DAYS: David Soohoo, MD BL: Bev Loiselle, RN UNI: User N. Interface A01:Alicia Ott, FINCO JKB:Joel K. Billens, RN AKII:Anna Laurae Kievning, LDCLK AB3:Andrea Brown,TRANS Patient released 5/30/2006 20:46 Released by Joanne Hoag,RN --------------------- Printed by 701125 on Monday,June 05,2006 9:34:49 AMComplete Chart DALLAS ,BARBARA MR 5044818 523F DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart RI AMR **************** REPORT NOT FINAL UNTIL SIGNED **************** PATIENT NAME: DALLAS, BARBARA DATE OF SURGERY: 05/30/2006 SURGEON: 14ESTOR D. KARAS D.D.S, M.D. PREOPERATIVE DIAGNOSES: I. Chin laceration x 1 cm. 2. Oral laceration in the mandible x5 cm. 3. Multiple facial abrasions. PROCEDURE: 1. Primary closure of 5-cm stellate laceration of the oral cavity. 2. Revision, with primary closure of 1-cm laceration of the chin. INDICATION FOR PROCEDURE: The patient is a 52-year-old white female who fell off of her bicycle today, resulting in multiple facial abrasions and lacerations. These lacerations require closure. No evidence of facial fractures identified. SUMMARY OF PROCEDURE: After the patient was given 2 mg of Versed for sedation, local anesthetic was injected using 1 percent Xylocaine with 1:100, 000 epinephrine x 7 ml, both intraorally and extraorally. The wounds were irrigated with copious amounts of normal saline irrigation and debrided. The oral wounds were closed first, using a 3-0 chromic in an interrupted and running-locking fashion. Identification of the mental nerve in the wound was identified, but no evidence of laceration was seen. The wounds were closed, and then the chin laceration was then addressed. The wounds of the chin laceration were freshened with a #15 blade, followed by a small amount of undermining. Layered closure was completed using 4-0 Vicryl in a subcutaneous fashion and then 6-0 Prolene for closure of the skin. Steri-Strips were then placed. No complications were encountered. The patient was then discharged with amoxicillin 500 mg t.i.d. , instructions for oral and facial wound care, as well as for Vicodin x 30 tablets. Follow-up will be in five days. *** Edit/authenticate report in e-MAPS *** :tcc DD: 06/01/2006 9:26 A DT: 05/31/2006 12:39 P Doc ID: 740778 Ext DOCID: 55321830092 Job# 000196767 Acct#: 0615000477 cc: NESTOR D KAKAS, MD MR#:5044818 Acct:0615000477 Name:DALLAS, BARBARA Report: Operative report JOHN MUIR MEDICAL CENTER WALNUT CREEK CAMPUS pg.l 1601 Ygnacio Valley Road Walnut Creek,CA 94598 Authenticated by Nestor D Karas, M.D. On 2006-06-06 15:38:36.94 $ Jo)'r',,3vZ' CI# 1531402 EXAM 1060 SHOULDER LTD IP (1 VW) (73020) *L Left shoulder one view- 5/30/06 History- Pain. Comparison- 5/10/06. Findings- Single limited view demonstrates no acute fracture, malalignment, or significant bony abnormality. Previously demonstrated calcific tendinitis is difficult to evaluate on this single view. Impression- No acute osseous abnormality. T-05/30/2006 CH /Read By SAURAB11 K PATEL/ /Released By SAURABH K PATEL/ FINAL AN# 0615000477 ----------------------------------------------------------------------------------- DALLAS, BARBARA DATE 05/30/2006 1456 MR 5044818 ORD SOOH00, DAVID BD 04/14/1954 F ATT JMMC, EDPHYSICIANS LOC ERS PCP DELANEY, ELIZABETH JOHN MUIR MEDICAL CENTER WALNUT CREEK CAMPUS MEDICAL IMAGING REPORT pg. 1 **************** REPORT NOT FINAL UNTIL SIGNED **************** PATIENT NAME: DALLAS, BARBARA DATE OF CONSULTATION: 05/30/2006 DICTATING PHYSICIAN: NESTOR D KAKAS, MD REASON FOR CONSULTATION: The patient is a 52-year-old, white female who was involved in a bicycle accident where she fell off her bicycle resulting in multiple facial and upper extremity abrasions, as well as a 1 cm laceration to the chin and a 5 cm oral laceration. There was no loss of consciousness. The patient has no difficulties with occlusion or evidence of teeth luxation. Oral examination shows multiple abrasions to the upper and lower lip and chin area. There is a stellate 1 cm laceration of the inferior aspect of the midline of the chin, which does not extend to the bone. Oral examination shows a stellate laceration that extends from the anterior mandibular vestibule posterior approximately 5 cm. Exploration of the wound shows the mental nerve deep into the wound area with no evidence of laceration. The patient, at this point, has no complaints of numbness over the lip and chin. Oral examination shows that the oropharynx is clear with no evidence of adenopathy. The uvula is midline. There is no evidence of teeth mobility. Occlusion is stable. No evidence of mandibular or maxillary mobility. No step deformities in the midface. The pupils are equal and reactive to light. Extraocular muscles are intact. X-rays show no evidence of facial fractures. IMPRESSION / PLAN: A 52-year-old, white female, status post bicycle accident with both extraoral and intraoral lacerations, which will require primary repair. The procedure will be done under local anesthesia with mild sedation in the emergency room. The procedure, as well as the potential risks of pain, swelling, bleeding, infection and scar tissue formation was reviewed. *** Edit/authenticate report in e-MAPS *** :tcc DD: 05/31/2006 9:23 A DT: 05/31/2006 11:00 A Doc ID: 740725 Ext DOCID: 55314230072 Job # 000196761 Acct#: 0615000477 MR#:5044818 Acct:0615000477 Name:DALLAS, BARBARA Report: Consultation JOHN MUIR MEDICAL CENTER WALNUT CREEK CAMPUS pg. l 1601 Ygnacio Valley Road Walnut Creek,CA 94598 cc: NESTOR D KAKAS, 14D MR#:5044818 Acct:0615000477 Name:DALLAS, BARBARA Report: Consultation JOHN MUIR MEDICAL CENTER WALNUT CREEK CAMPUS pg.2 1601 Ygnacio Valley Road Walnut Creek,CA 94598 Authenticated by Nestor D Karas, M.D. On 2006-06-06 15:38:36.813 �'N$"��'� .......................-- CI# 1531401 EXAM 8300 CT HEAD/BRAIN WO CNTRST (70450) Noncontrast head CT (70450)- 05/30/06 History- Fall (959.8) . Comparison- MRI of the brain dated 04/28/06. Technique- Axial 5 mm noncontract CT from the skull base to vertex. Findings- The ventricles, cisterns and sulci are normal. No midline shift. No abnormal attenuation within the brain parenchyma. No intracranial hemorrhage or hematoma. No extra axial fluid collections. Tile orbits are unremarkable. Mild left frontal scalp soft tissue swelling is noted. The mastoids and visualized sinuses are clear. No fractures. Impression- No acute intracranial abnormalities. T-05/30/2006 TP /Read By SAURABH K PATEL/ /Released By SAURABH K PATEL/ FINAL AN# 0615000477 ----------------------------------------------------------------------------------- DALLAS, BARBARA DATE 05/30/2006 1454 MR 5044818 ORD SOOHOO, DAVID BD 04/14/1954 F ATT JMMC, EDPHYSICIANS LOC ERS PCP DELANEY, ELIZABETH JOHN MUIR MEDICAL CENTER WALNUT CREEK CAMPUS MEDICAL IMAGING REPORT pg. 1 • �i�lo�F6�t�� ... ........ _. CI# 1531403 EXAM 8313 CT C-SPINE WO CNTRST (72125) CT cervical spine without contrast including reformats (72125)- 5/30/06 CT reconstructions (76375) History- Neck pain (723.1) Comparison- None. Technique- Axial 2.5 mm noncontract CT through the cervical spine with sagittal and coronal reformats. Findings- No acute fracture or malalignment. The visualized lung apices are clear. Both thyroid lobes appear heterogeneous and small thyroid nodules are not excluded. Prevertebral soft tissues are within normal limits. Impression- No acute abnormality identified. T-05/30/2006 VO /Read By SAURAB11 K PATEL/ /Released By SAURABH K PATEL/ FINAL AN# 0615000477 ------------------------------------------------------=---------------------------- DALLAS, BARBARA DATE 05/30/2006 1455 MR 5044818 ORD SOOHOO, DAVID BD 04/14/1954 F ATT JMMC, EDPHYSICIANS LOC ERS PCP DELANEY, ELIZABETH JOHN MUIR MEDICAL CENTER WALNUT CREEK CAMPUS MEDICAL IMAGING REPORT pg. 1 Page I of 11 John Muir Medical Center`-:Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673 -EZZAT,MONA M,MD ED Phys: David Soohoo,MD CHIEF COMPLAINT: Enc.Type: ACUITY: Fall Initial Urgent Additional Complaints: Physicians caring for patient: David Soohoo,MD Dental-Oral Surgery VITAL SIGNS Initials/Date/Time Temp(C) Rt. Pulse Resp Syst Diast Pos. 02 Sat Pain Fi02 JKB 5/30/2006 14:35 37 0 . 73 16 128 75 L 99 2 Room Air NIB 5/30/2006 16:40 .6618 122 74 L 100 1 Room Air DIAGNOSIS BLUNT HEAD INJURY <DAVS:David Soohoo.MD 05/30/06 18:42> DISPOSITION PHYSICIAN Pertinent physical findings: oral lac, chin lac, head contusion<DAVS 05/30i0618:46> Condition: Good<DAVS 05/30/06 18:46> Disposition--Discharged from ED: Follow-up,with: Nestor Karas, DDS- 1800 San Miguel Drive,Walnut Creek 94598(925)933-6190<DAVS 05130/0618:46> Discharged home.<DAVS 05/30/0618:46> MBSI EM3<DAVS 05/30/06 18:47> MBSI XRAY<DAVS 05/30/0618:47> AFTERCARE.INSTRUCTIONS Head Injury.- English<DAVS 05/30/06 18:47> Intraoral Laceration- English<DAVS 05/30/06 18:47> ORDERS' PRESCRIPTIONS Dispensed med: Vicodin 5mg, #5(five), 1 q 4-6 hour prn:No refills. David Soohoo,MD 5/30/2006 18:44 Vicodin 5mg,#20(Twenty), 1 q 4-6 hour prn:.No refills.,David Soohoo,MD 5/30/2006 18:44 PenVeeK 250 mg tabs, 40 (forty), Take one tablet foue.times daily.Take as directed or until you run out. No refills. David Soohoo,MD 5/30/2006 18:45 MEDICINE Printed by Anna Laurae Kievning,LDCLK on Tuesday,May30,2006 7:10:24 PM Preliminary draft-not part of the permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits / Page 2 of 11 John Muir Medical Center, - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/19.54 Age/Gender: 52 F 5/30/2006 14:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673-EZZAT,MONA M,MD ED Phys: David Soohoo,MD Tetanus/diptheria; 0.5 ml; IM David Soohoo,MD 5/30/2006 15:54 Penicillin G; 3 million units; IV David Soohoo.MD 5/30/2006 17:07. RADIOLOGY Test: CT head/brain wo contrast; Transportation: Gurney; [Reference: 917543^PCM]<David Soohoo, MD 5/301200614:40> Test: CT cervical spine wo contrast; Transportation: Gurney; Reason: pain [Reference: 917544APCM]<David Soohoo,MD 5/30/2006 14:40> Test: Shoulder limited IP; Transportation: Gurney; Prompt: Left; Reason: pain [Reference: 917545^PCM]<David Soohoo,MD 5/30/2006 14:40> . CONSULTATION Contact: Please contact the doctor on call for Dental=Oral Surgery<David Soohoo,MD 5/30/2006 16:32> RESPIRATORY/IV Insert saline lock<David Soohoo,MD 5/30/2006.17:04> Order: Normal saline Rate: bolus 1 liter wide open.<David Soohoo,MD 5/30/2006 17:04> RESULTS RADIOLOGY Test: CT head/brain wo contrast;.Transportation: Gurney;' Result 1 <User N.interface 5/30/2006 14:55> Read By 995955^SAURABH K PATEL :,..:::. * F Report Noncontract head CT(70450)-05/30/06: F Report F Report History-Fall(959.8). F Report F Report Comparison-MRI of the brain dated 04/28%06. F Report F Report Technique-Axial 5 mm noncontrast CT from the skull base to vertex. F Report F Report Findings-The ventricles,cisterns and sulci are normal.No midline F Report shift.No abnormal attenuation within the brain parenchyma.No F Report intracranial hemorrhage or hematoma.No extra axial fluid collections.The F Report orbits are unremarkable.Mild left.frontal scalp soft tissue.swelling is noted. F Report The mastoids and visualized sinuses are clear.No fractures. F Report F Printed by Anna Laurae Kievning,LDCLK on Tuesday,May 30,2006 7:10:24 PM Preliminary draft-not part of the permanent record. DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits Page 3 of 11 John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673 -EZZAT,MONA M,MD ED Phys: David Soohoo,MD n t Report Impression- F Report F Report No acute intracranial abnormalities. F Report F Released By 995955^SAURABH K PATEL * F Result 2 <User N.Interface 5/30/2006 14:55> Read By 995955^SAURABH K PATEL * I' Report Noncontrast head CT(.70450)-05/30/06 P Report P Report History-Fall(959.8). P Report P Report Comparison-M.RI of the brain dated 04/28/06. . P Report P Report Technique-Axial 5 tnm noncontract CT from.the skull base to vertex. P Report P Report Findings-The ventricles,cisterns and sulci are normal.No midline P Report shift.No abnormal attenuation within the brain parenchyma.No P Report intracranial hemon•hage or hematoma. P Report P Report No extra axial fluid collections.The orbits are unremarkable.Mild P Report left frontal scalp soft tissue swelling is noted.The mastoids and P Report visualized sinuses are clear. No fractures. P Rcport P Report Impression- P Report P Report No acute intracranial abnonualities. P Test: CT cervical spine wo contrast; Transportation:..Gurney; Reason: pain Result 1 <User N.Interface 5/30/2006 14:55> Read By 995955^SAURABH K PATEL >:::.: .' * F Printed by Anna Laurae Kievning, LDCLK on Tuesday,May 30,2006 7:10:24 PM Preliminary draft-not part of the permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits Page 4 of 11 John Muir Medical Center- Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOW.4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MR#!: 5044818 Acct#: 0615000477 Private Phys: 8673 -EZZAT,MONA M,MD ED Phys: David Soohoo,MD e e n Report CT cervical spine without contrast including reformats(72125)- F Report 5/30/06 F Report F Report CT reconstructions(76375) F Report F Report History-Neck pain(723.1) F Report F Report Comparison-None. F Report F Report Technique-Axial 2.5 mm noncontrast CT through the cervical spine with F Report sagittal and coronal reformats. F Report F Report Findings-No acute fracture or malalignment.The visualized lung F Report apices are clear.Both thyroid lobes appear heterogeneous and small F Report thyroid nodules are not excluded.Prevertebral soft tissues are within F Report normal limits. F Report F Report . Impression- F Report F Report No acute abnormality identified. F Report F Released By 995955ASAURABH K PATEL * F Result 2 <User N.Interface 5/30/2006 14:55> Read By 995455^SAURA13H K PATEL * P Report CT cervical spine without contrast inchiding retornints(72125)- P Report 5/30/06 P Repoii CT reconstructions(76375) P Repoli P Report History- Neck pain (721.1) 1' Report P Report Comparison None, P Report P Printed by Anna Laurae Kievning,LDCLK on Tuesday,May 30,2006 7:10:24 PM Preliminary draft-not part of the permanent record . DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits Page 5 of 11 John Muir.Medical Center Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673 -EZZAT,MONA M,MD ED Phys: David Soohoo,MD Report Technique- Axial 2.5 mm'noncontrast CT through the cervical spine with P Report sagittal and coronal reformats. P Report P Report findings- No acute fracture or malalignment.The Visualized lung P Report apices are clear. Both thyroid lobes appear heterogeneous and small P Report thyroid nodules are not excluded. Prevertebral soft tissues are within P Report normal limits. P Report P Report Impression- P Report P Report No acute abnormality identified. P Test: Shoulder limited IP; Transportation: Gurney; Prompt: Left; Reason: pain Result 1 <User N.Interface 5/30/2006 15:10> a Read By 995955ASAURABH K PATEL * F Report Left shoulder one view-5/30/06 F Report F Report History-Pain. F Report F Report Comparison-5/10/06. . F Report F Report Findings-Single limited view demonstrates no.acute fracture, F Report malalignment,or significant bony ab itPreviously demonstrated F Report calcific tendinitis is difficult to evaluate on this single'view. F Report F Report Impression-No acute osseous abnormality. F Report F Report F Released By 995955ASAURABH K PATEL * F Result 2 <user N.Interface 5/30/200615:10> Printed by Anna Laurae Kievning,LDCLK on Tuesday;IMay 30,2006'7;10;24 PM Preliminary draft-not part of the permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chait with Audits Page 6 of 11 John Muir Medical Center'-Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673-EZZAT,MONA M,MD ED Phys: David Soohoo,MD Raid By 995955^SAURABH K PATEL * I' Report Left shoulder eine view-5/30/06 P Report P Repoli History-Pain. f' Repoli P Report Comparison-5/10/06. P Report P Report Findings-Single limited view demonstrates no acute fracture, P Report malalignment,or significant bony abnormaliry..Previously. demonstrated P Report calcific tendinitis is difficult to evaluate on this single view. P Repoli P Report Impression-No acute abnormality. P Rel)ort P Result.3 <User N.Interface 5130/200615:11> Rcad By 995955^SAURABH K PATEL *. P Report Lcft shoulder one view-5/30/06 P Repoli P Report History- Pain. I' Report P Report Comparison- None. P Report P Report Findings-Single limited view detnonstrate.s.no acute fracture,.:. P Report malaligmnent,or significant bony abnormality., P Report P Report Impression-No acute abnormality. P TRIAGE Patient's initial encounter:Tuesday, May 30, 2006 14:27<JKB 05/30/06.14:30> Arrival: Patient.arrived by gurney via ambulance from field accompanied by EMT/paramedic<JKB 05/30/06 14:30> Patient's reason for visit: Bicycle accident<JKB 05/30/06.14:31>': ... NURSING SYSTEMS REVIEW Printed by Anna Laurae Kievning, LDCLK on Tuesday,May 30;2006 7:10:24 PM Preliminary draft-not part of the permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits Page 8 of 11 John Muir Medical Center.. Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MRN: 5044818 Acct#: 0615000477 Private Phys:.8673 -EZZAT,MONA M,MD ED Phys: David Soohoo,MD N113 5/30/2-006 16:o4> No adverse reaction NIB 5/30/2006 16:36 <N113 5%30/1-006 16:36> Notes: <NIB 05-30-2006 16:04>EXP DATE 19 December 07 Lot#U1786BA <NIB 05-30-2006 16:05>Given to right deltoid Penicillin G; 3 million units; IV<David Soohoo,MD 5/30/200617:07> Yes, given.Route/Location: IV via pump MW5 5/30/2.006 18:53 .. <M W 5 5.30/2006 18:53>. Printed by Anna Laurae Kievning,LDCLKon Tuesdayi:May.30,2006 7:10:24 PM Preliminary draft-not part of the permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits Page 7 of 11 John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673 -EZZAT,MONA M,MD ED Phys: David Soohoo,MD ASSESSMENT Breathing: Patient is able to breathe without difficulty.<JKB 05/30/06 14:31> Pulse: Pulse is strong, regular, non rapid.<JKB 05/30/0614:31> Skin signs: Skin is.warm, dry with normal color.<JKB 05/30/06 14:31> Orientation level: Patient is awake, alert and oriented x4.<JKB 05/30/06 14:31> HPI:<JKB 05/30/06 14:31> History of present illness: Pt. was riding her bicycle down an— 10% grade when she hit a pot hole and crashed. Pt has good recall of events. There was no LOC. Pt: sustained a laceration to the chin and inside lower lip. Paramedics describe repetitive questions but A&Ox3.<JKB 05/30/06 14:35> Historian:The history is provided by the patient:<JKB 05/30/06 14:35> Historian:The history is provided by a paramedic<JKB 05/30/06 14:35> Allergies:<JKB 05/30/06 14:36> Medication allergy: Septra<JKB 05/30/0614:36> Patient has no known latex allergy.<JKB 05/30/06 14:36> Medications:<JKB 05/30/06 14:37> Current meds: Ibuprofen PO<JKB 05/30/06 14:37> " Medications were taken prior to arrival to the ED.<JKB 05/30/06 14:37> No significant past medical history.<JKB 05/30/06 14:37> LMP<JKB 05/30/06 14:37> LMP N/A: Patient is post menopausal.<JKB 05130/061.4:38> Patient has not had influenza vaccination:<JKB 05/30106.14:39>:.. "We are concernedabout the safety of our patients;so we ask everyone, do you feel safe in your home?"<JKB 05/30/06 14:38> Patient response is "Yes".<JKB 05/30/06 14:38> Airway patent, normal, maintained independently.<NIB.05/30/06 14:43> 'Respirations normal, regular,non-labored, denies shortness of breath:<NIB 05/30/0614:43> Pulses normal, strong, regular, mucous membranes moist,.denies chest pain.<NIB 05/30/06 14:43> Patient is awake, alert and oriented x 4, speech is clear and coherent, sensory motor grossly normal.<NiB 05/30/0614:43> Abdomen soft,flat, patient denies abdominal pain.<NIB 05/30/06 14:46 Denies genitourinary complaints.<NIB os/so/o6.1.4:46>: . Notes: <NIB 05-30-2006 14:47>Pt denies neck pain or discomfort, pt denies back pain. Pt alert/oriented x 3. Integ Assessment: laceration . <NIB 05/30/200614:46>to chin and abrasion <NIB 05/30/2006 14:46> left shoulder<NIB 05/30/06 14:45-WB 05/30/06 14:46>. Secondary assessment complete.<NIB 05/30/06.14:47 FLOWSHEETS MEDICATION ADMINISTRATION Tetanus/diptheria; 0.5 ml; IM <David Soohoo,MD 5/30/2006 15:50 Yes,given NIB 5/30/2006 16:03 Printed by Anna Laurae Kievning, LDCLK on Tuesday,May 30,2006 7:10:24 PM Preliminary draft-not part of the permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits Page 8 of l 1 John Muir Medical Center Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall M11#: 5044818 Acct#: 0615000477 Private Phys: 8673-EZZAT,MONA M,MD ED Phys: David Soohoo,MD <NIR;/30/2006 16:uJ> No adverse reaction NIB 5/30/2006 16:36 NIR 5/30;'_'006 16:36> Notes: <NIB 05-30-2006 16:04>EXP DATE 19 December 07 Lot#U1786BA <NIB 05-30-2006 16:05>Given to right deltoid Penicillin G; 3 million units;.IV.<David Soohoo,MD 5/30/2006 17:07> Yes, given.Route/Location: IV via pump MW5 5/30/2006 18:53 <MW5 5/30/2006 18:53 Printed by Anna Laurae Kievning, LDCLK on Tuesday,May 30,2006 7:10:24 PM Preliminary draft-not part of the permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F l FIN 0615000477 Medical Chart with Audits r � O ,. U S U �. m ,q 0 u d q s. d d q w .o C9 Z a 0 v 41 4- Ql w cl ou q w n N o eo C- cn w b a -4-J N c .> .- N p � ab 3 N o M U Cd p n! > o en C> H CJ 04 0 a U cq ►---� �N H N _ o cC 1 p Vi w y pq tr, a3 C P� � � oo Q � op, Zw h a V) It Ln aoo � � O 44 � a" z ? -- - CaCaw Page 10 of 11 John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MR#: 5044818 Acct#: 0615000477 Private Phys: 8673 -EZZAT,MONA M,MD ED Phys: David Soohoo,MD NURSING NOTES 05/30/06 14:35 Temp(C) Rt. Pulse Resp Syst Diast Pos. 02 Sat Pain Fi02 37 O 73 16 128 75 L 99 2 Room Air Entered:<J KB 5/30/2006 14:36> 05/30/06 14:42 Comfort measures:The patient was informed of status.The patient was given a blanket.The patient was repositioned to a 30 degree incline.Entered:<NIB 5/302006 14:42> 05/30/06 14:42 C-spine immobilization:Back board removed Hard C-collar remains in place CMSTP Intact x 4 by MD..Entered:<NIi3 5/30/2006:14:42> 05/30/06 14:56 Patient in radiology:Patient in X-ray department.Transported by transporter Entered` :At33 5/30/2(K)614:56> 05/30/06 15:11 Patient radiology exam complete:Patient back from X-ray department.Entered:<AB3 5/302006 15:1 1> 05/30/06 15:11. Patient in radiology:Patient in CT department.Transported by transporter Entered:<A63 5/30/2006 15:1 I> 05/30/06 15:35 Patient radiology exam complete:Patient back from CT department.Entered:M14,513012006 15:35> 05/30/06 16:03 MAR Given:Tetanus/diptheria;0.5 ml;IM Yes,given I nterect:<NIB 5/30/_'006 16:04> 05/30/06 16:05 MAR Notes <NIB 05-30-2006 16:04>EXP DATE 19 December 07 Lot#U1786BA 05/30/06 16:05 MAR Notes <NIB 05-30-2006 16:05>Given to right deltoid 05/30/06 16:06 Procedure-Nursing Note: <NIB 05-30-2006 16:06>Pt awake/alert and oriented x 4,resting in nad.Awaiting sutures placement by md,suture set placed at bedside. 05/30/06 16:36 MAR Response:Tetanus/diptheria;0.5 ml;IM No adverse reaction Entered:<NIB 5/30/2006 16:36>.. 05/30/06 16:40 Temp(C) Rt. Pulse Resp .. Syst Diast Pos. 02 Sat Pain Fi02 , 66 18 122 74 L 100 1 Room Air Entered:<N113 5/302006 16:41> 05/30/06 16:42 C-spine immobilization: Hard C-co 11 ar.removed.CMSTP Intact x 4 by MD.Entered:<NIB 5/30/2006 16:42> 05/30/06 16:49 Consult MD called:Nestor Karas,DDS;DENTAL-ORAL SURGERY-(925)933- 6190 Entered:<AK1 5/30/2006 16:49> 05/30/06 17:05 IV fluid flowsheet Fluid:NS Bag Volume: 1000 ml. Rate:Wide open Act:hung and infusing Bag Number: 1 Printed by Anna Laurae Kievning,LDCLK on Tuesday,May 30,2006 7:10:24 PM Preliminary draft-not part of the.permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits Page 1 I of 11 John Muir Medical Center - Walnut Creek , CA 94598 Patient: DALLAS,BARBARA DOB:4/14/1954 Age/Gender: 52 F 5/30/2006 14:30 Fall MRP: 5044818 . Acct#: 0615000477 Private Phys: 8673-EZZAT,MONA M,MD ED Phys: David Soohoo,MD Entered:<N113 5/30/2006 17:0> 05/30/06 17:05 IV placement:IV site# I : a/an 20 gauge was inserted in the left antecubital area.Attempts: I Fnicred:<N[B 5/30/2006 17:05> 05/30/06 18:53 MAR Given: Penicillin G;3 million units;IV Yes,given. Route/Location: IV via pump Entcrcd:<MWS 5/30/2006 13:53> Bed Assignments: RM9 <JKB 5/30/2006 14:30> Chart electronically signed by: David Soohoo, MD'5/30/200618:49 This chart documented by: JP4: James Prasad, TRANS MW5: Minnie Wango, RN NIB: Nicole Bekker, RN DAYS: David Soohoo, MD A01: Alicia Ott, FINCO JKB: Joel K. Billens, RN AK1: Anna Laurae Kievning, LDCLK A63:Andrea Brown,TRANS Printed by Anna Laurae Kievning,LDCLK on Tuesday,May 30,2006 7:10:24 PM Preliminary draft-not part of the permanent record DALLAS ,BARBARA MR 5044818 52y DOB 04/14/1954 F 1 FIN 0615000477 Medical Chart with Audits CLArn>i BOARD OF SUPERVISORS OF CON'i'R.k C0S".1'A COUN'T'Y • BOARD ACDON. DECEMBER L9, 2006 Claim Against the County, or District Govemed by ) the. Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken on your claim by the Board of NOV 2 Supervisors. (Paragraph IV below), 9 2006 given Pursuant to Government Code AMOUNT: $297.45 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "`'earnings". CLAIMANT: JOHN P. ROONEY ATTORNEY: UNKNOWN DATE RECEIVED: NOVEMBER 29, 2006 ADDRESS: 3701 SILVER OAK PLACE BY DELIVERY TO CLERK ON: NOVEMBER 29, 2006 DANVILLE, CA 94506-4646 BY MAIL POSTMARKED: NOVEMBER 28, 2006 FROM: Clerk of the Board of Super-visor-s TO: County Counsel Attached is a copy of the above-rioted claim. JOHN CULLEN, r k Dated: NOVEMBER 29, 2006 By: 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). O 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: II-��?-O(o By: m Deputy County Counsel 1.11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). ]V.,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:,OLC. /9 JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) months Imin the date this notice Nvas personalty served or deposited in the nail to file a com-t action on this claim.See Gove,-nment Code Section 945.6.You may seek the advice of an attorney of your choice in connection wide this matter. [I*youWyant to consult an attorney,you should do so immediately. 'For Additional N�'ar��iir;See Reverse Side ofThis Notice AFFIDAVIT OF MAILING 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. DatedJire, o JOHN CULLEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Cleric 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 fiaudulent claims,Penal Code Sec. 72 at the end of this form. e t e t e e t t t e e t t t e e e e t e i■ ■e e t e t 11.Q Rosso t e t e e l t 9 t Mason Oct e a O t e a f e a e t a{a men a t a t e canal RE: Claim By: Reserved for Clerk's filing stamp .�o�h �• �oo ne� ) 370/ 5 10i(g QAK PL. DANYIWEM. ?150 RECOVED Against the County of Contra Costa or ) [—i 29Z006 District) CLERK BOARD OF SUPERVISORS (Fill in the name) ) CONTRA COSTA CO. The undersigned claimant hereby des claim against the County of Contra Costa or the above-named district in the sum of$ 2 9 7.y S and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. %erd did the damage or injury occur? (Include city and county) 7890 LRmiNo -65511J,40- RV. 1.7#v:Jw 60vr/1- o1r BKHLfi-j p 1.47,011,63 A100A Sic d�R�r RAO��I R, 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 dama e? ff}lLJ1Rf �'o R�,PA� o�I�N�E PAinit 5 What are the names of county or district officers,servants, or employees causing the damage or injury? {r 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. -Attach-two estimates for auto damage.) Rr?«cEp RlIn ivlrlf e3O &m hILJ4AIM . 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 TIIyIE AMOUNT ■ ■amsoamaaaaaaads aasElko asamamanaa■sgas asitu asass sanus ass soaaaamaKits asaamaamaaaanaaaaaI ) .Gov. Code Sec. 910.2 provides "The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attomev) ) Name and address of Attorney ) �Xo 0 (Claimant's Si tore) ) �2S yd� 9225J' Telephone No. )Telephone No. 11.0 m m a m m a m m a a a a m m noun ones a a a made m a m a s m m a s s a m a,m down Kits Box IKUNSINSERKIZZ Nunn mama own a a a al PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 at seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■ saaaasaasaaaaaasaasaaaa■ aaaaamamaaaaamsaasass maaaasmaasaaraassssassasaaaasasaaaaaas� NOTICE: Section 71 of the Penal Code provides: Every person vvho, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisonment and fine. ' . . NC) REFUNDS ONDEPOSITS BIG O TIRES OF DUBLIN [)RGPE��|ALC�ROERS 7121 DUBiIN BiVD -�� ' ' DUBmxnowALCUSTOMER SERVICE iIN CA 94568 ' v PHONE#8Unou1'u44O 925 829-1950 CUSTOMER MUST PRESENT COPY OFINVOICE FOR ANY WARRANTY Invoice# 1-86059 PaQe: 1 Date 11/24/2006 Emp: 1-101 NM / 1-3 SALES In Nov 22, 2006 8.47 am * X. * I N V O I C E * * * Dut Nov 24, 2006 4:25 pm Sold To Ship To Other Info. : JOHN ROONEY Veh : 96 VOLVO 850 TURBO 3701 SILVEROAK pL Lic: 3KLC632 DANVILLE, CA Mil : ln: 135,254 Out. 135,25A 94506 Vin#: PO#: Bus: 925~788-9225 x I.-In):: 925-736-9225 Bar ID: AK169274 EPA ID: CAL000045296 Slam Mech Part 0 QTY Description Parts Labor FET Total 101 WKNS 1.00 WHEEL 16X6.5 ALUMINUM RIM 200.00 0.00 0.00 200.00 101 K[TUME 1.00 LUG NUT R[C: RE-TORQUE AFTER 25 M 0.00 0.00 0.00 0.00 � SEE BACK FOR DETAILS 101 UBAL4W 1.00 ALIGNMENT ALIGNMENT 4 WHEEL 0.00 79.95 0.00 79.95, `AHEDlCAN EXPRESS CC N »***»***3721 Exp.Date - Auth# Amount $297.45 'ignature: ============================================================================= Cash Check Card Charge Parts: 200. 00 0J00 0. 00 297. 45 0. 00 1 abor: 791195 Change Subtotal : 279.95 0. 00 Check #: Sales Tax : 17. 50 Total : 297. 45 /ACKNOWLEDGE NOTICE AND ORAL APPROVAL opANY INCREASE/wTHE ORIGIN ALESTIMATED PRICE: TERMS: (NET loth PROX. UNLESS OTHERWISE SPECIFIED) PAST DUE CHARGE IS COMPUTED BY A "PERIODIC RATE"OF 1.5%PER MONTH ON UNPAID BALANCE WHICH IS AN ANNUAL PERCENTAGE RATE TERMS AC44LEDGED&RECEIVED BY OF 18%.IF NECESSARY TO INSTITUTE LEGAL ACTION TO ENFORCE COLLECTION OF THE AMOUNT DUE UNDER THIS INVOICE,BUYER AGREES roPAY ALL NECESSARY COSTS AND ATTORNEY'S FEES. x � �� 0/�� ALIGNMENT xxxo�� m�xx�� u��xm�� *�xx��~om� �xxn�x� MapQuest: Maps Page 1 of 1. MALPIM T PRINT. DON'T REPRINT. Avoid clogs and smears. s uc. 7895 Camino Tassajara Use Original HP Inks. 57.: Pleasanton CA Brilliantly Simple- 94588-9431 US Notes: r [hlv:l IiApPaVEST�,�' l 800m 4 0�-�zaoon land Rd It I x: \/ ;-`y lis �. Camp Parks 1t ,.� Reservation 's / F L, 02QQ5 MapQuest,Inc...._.... X2006 NAVTEQ / Q All rights reserved. Use Subject to License/Copy_right This map is informational only. No representation is made or Warr given as to its content^User assumes all risk of use. MapQu st d it5�suppliers assume no respons' ility or any loss or delay resulting m such use 9 Z 2� http://www.mapquest.com/maps/print.adp?ma ata=p5kgyoo6yZJPLNW%252bzZQ%25... 11/20/2006 Big O Tires 7121 Dublin Blvd. Dublin, Ca 94568 (925) 829-1950 Name Address Telephone Vehicle(VIN) License Technician Mileage Time Printed 11/24/06 3:04 PM 850:: Front Wheel,.Drive :,1.993-97. _ Front Left Front : Right Actual Before Specked Range Actual Before Specified Range -0.11 0.0' -1.001.00 Camber -0.10 -0.2° -1.001.00 2.61 2.6' 2.30 4.3' Caster 2.9* 2.90 2.3'4.30 0.160 0.16, 0.12'0.22' Toe 0.96' 0.ZG* 0.12'0.22' 14.60 14.6' SAI 14.6' 14.6* 14.6' 14.6' Included Angle 14.60 14.60 -6.70'-0.600 Turning Angle Diff. -6.70--3.50- Front Actual Before Specified Range Cross Camber 0.11 0.21 -1.0* 1.00 Cross Caster -0.21 -0.2' -1.001.00 Cross SAI -0.11 -0.2' Total Toe 0.32" 0.61. 0.23 0.43' Cross Tum Diff. Rear: Left Rear: Right Actual Before Specked Range Actual Before Specified Range -0.91 -0.90 -1.50-0.60 Camber -0.9' -1.01 -1.50 -0.50 0.04' 0.38` -0.06'0.13' Toe 0.01, ID A GO -0.06'0.130 Rear Actual Before Specified Range Cross Camber 0.0' 0.1' Total Toe 0.05' 0.64' -0.110 0.260 Thrust Angle 0.02- 0.91` -0.26' 0.26* � C4 Q CLAIN'1 C76 BOARD OF SUPERVISORS OF CONTRA COSTA COLIN"('Y BOARD ACTION: DECEMBER 19, 2006 . Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to California Govei nment Codes. �' ) i ; D you is your notice of the action taken on your claim by the Board of NOV 2 1�- Supervisors. (Paragraph IV below), COUNTY COUP given Pursuant to Government Code AMOUNT: UNDETERMINED MARTINEZ CAL.• . Section 913 and 915.4. Please note all "Warnings". CLAIMANT: CHIKAO ANDERSON, a minor whose legal guardian is MARY FOUNTAIN ATTORNEY: HERMIN A. DOWE DATE RECEIVED- NOVEMBER 29, 2006 ADDRESS: DOWE LAW BY DELIVERY TO CLERK ON: NOVEMBER 29, 2006 13925 SAN PABLO AVENUE, SUITE 203 SAN PABLO, CA 94806 BY MAIL POSTMARKED: NOVEMBER 28, 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, i k Dated: NOVEMBER 29, 2006 By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( tyliiis 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 wai-ning of claimant's right to apply for leave to present a late claim (Section 91 1.3). ( j Other: Dated: /tea �(��D By: fY')CR4—)��_Deputy Couiity Counsel 111. FROM: Clerk of the Board TO: ' County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. ARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: I cei-tify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DatedA!�• •i9-240,-, JOHN CULLEN, CLERK, By _ Deputy Clei•k WARNING (Gov. code section 913) Subject to certain exceptiois,you have only six(6) months frons the date this notice was peisonally sei--ed or deposited in the mail to life a com-t action on this claim.See Goveriunent Code Section 945.6.You may seek the advice of an attorney of your choice in connection witli this matter. If you want to consult an attorney,you should do so ininnediately. "For Additional NVarniig See Reveise Side of This Notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I ani now, and at all times herein mentioned, have been a citizen of' the United States, over abe 18; and that today I deposited in the United States Postal Service in Ylartinez, California, postabe fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: /�� •°2�'� JOHN CULLEN, CLERK By Deputy Clei-k 4 DowE LAW HERMIN A DOWE, RN, ATTORNEY AT LAW TEL 51 0.233.7700 13925 SAN PABLO AvENUE, SUITE 203 FAX 510.233.7705 SAN PABLO, CALIFORNIA 94806 INFOCa DOWELAW.COM November 27, 2006 RECOVED Clerk of the Board of Supervisors NOV 2- 9 2006 Contra Costa County — CLER-BOARD OF SUPERVISORS 651 Pine Street, Room 106 C::MT9A COSTA CO. Martinez, CA 94553 CLAIM FOR DAMAGES This office represents Chikao Anderson, a minor whose legal guardian is Mary Fountain, in a claim for undetermined damages against Contra Costa County by and through the George Miller Jr. Memorial Center in Richmond. On August 23, 2006, Chikao Anderson participated in a group bowling trip to the Albany Bowl under the supervision of the George Miller Memorial Center. Due to a failure in supervision, Anderson was allowed to engage in behavior resulting in a fall, breaking his wrist. Claimant: Chikao Anderson Address: 440 - 34 th Street, Richmond, CA 94805 Phone: 510-260-0182 SSN: 605-50-4286 DOB: 9/6/91 DOI: 8/23/06 Time: approx. 4:30 pm Locn: Albany Bowl, 540 San Pablo Ave Emergency treatment: Childrens Hospital ER, Oakland Amount of claim: Undetermined (pain and suffering, treatment-related expenses, guardian's missed work time) Notices to: Hermin A. Dowe, Esq., Dowe Law, 13925 San Pablo Avenue, Suite 203, Acan Pablo C.. 40fle Thank you for your attention to this matter. Hermin A. Dowe Attorney at Law r� „r i r r cn o CO O G a co a L1 V �9 t.: d N 1 a Q tic may too cr. te- t0 CC Y a " a 't 4 V 0. t1t tit 0- OM 4 � Q c N b 1 C LA 1M alp, BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: DECEMBER 19, 2006 Claim Against the County, or District Govemed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken qn your claim by the Board of upervisors. (Paragraph IV below), NOV 3 0 2006 iven Pursuant to Government Code AMOUNT: Section 913 and 915.4. Please note all $5.,000,000.00 COUNTY COUNSEL "Warnings". MARTINEZ CALIF. CLAIMANT: SHAWN ALLEN RAY ATTORNEY: MICHAEL D. MEADOWS DATE RECEIVED: NOVEMBER 30, 2006 CASPER, MEADOWS, SCHWARTZ ADDRESS: & COOK BYDELIVERY TO CLERK ON: NOVEMBER 30, 2006 2121 N. CALIFORNIA BLVD. , #1020 WALNUT CREEK, CA 94596 BY MAIL POSTMARKED: HAND DELIVERED FROM.: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. NOVEMBER 30, 2006 JOHN CULLEN le " Dated: By: 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 waiiiing of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: /e;q, 0By: Deputy County Counsel [II. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. B ARD ORDER: By.unanirnous vote of the Supervisors present: ( This Claim is rejected in full. O Other: 1. certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 45 • JOHN CULLEN, 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 nutil to file a coma actin on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection Nvidt this matter. If'you want to consult an attoriey,lou should clo so immediately. *For Additional NVarning See Reverse Side of This Notice. AFFIDAVIT OF .MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in N'tartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:Ae` 06e- cgf' V JOHN CULLEN, CLERK By Deputy Clerk BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT I� A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any.other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code§ 911.2.) B. Claims must be filed with the Clerk of.the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. , i C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of to District should be filled in. D. If the claim is against more ti= 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.' aseosae000eoseeeeeee•eeeeosmove meeee■agoraeoleomagma eenoun e,seeseseeeoeesesoeses RE: Claim By: Reserved for Clerk's filing stamp t Shawn Allen Ray ) C CO Against the County of Contra Costa or ) NOV U C�FRK 2005 District) CON RgCpSVpERV/ (Fill in the name) ) °STgCo SORB The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$5,000,000.00 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) September 23, 2006 at approximately 3:25 am 2. Where did the damage or injury occur? (Include city and county) San Pablo Dam Road, 401 feet west of Bristlecone Drive, unincorporated Contra Costa County 3. a How did the damage.or injury occur? (Give full details; use extra paper if required) See attached California Highway Patrol':Number:'9-290,:_F�hibit".'-'A':. 4. What particular act or omission on the pan of county or district officers, servants, or employees caused the injury or damage? Negligent maintenance of the roadway which allowed a leaking sub-surface pipe lto;'cause the roadway to buckle and resulted in claimant losing control of his vehicle. 5 What are the names of county or district officers; servants, or employees causing the damage or injury? Unknown, pending discovery through litigation. . 7 6. What damage or iniuries do vour claim resulted? (Give full extent of iniuries or damages claimed. Attach two estimates for auto damage.) Fractured hip, pelvis and femur; multiple facial fractures; injuries. to shoulder and neck; closed head injury. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or darnage.) $2,500,000 for lost income and medical expenses and $2,500,000 for general damages. 8. Names and addresses of witnesses, doctors, and hospitals: See police report for names of investigation officers and. attached medical summary (Exhibit "B") for information regarding medical providers. 9. List the expenditures you made on account of this accident or injury: DATE TDVS AMOUNT See attached bill from John Muir Hospital, Exhibit "C". 6ascooseemaeaoemoeam■oesson■wmapes■loomegasaeeso'eeeeeraeeersso■ ■ao■eesagoV,mooe.neemaar ) Gov. Code Sec. 910.2 provides "The.claim.shali be ) signed by the claimant,or by some person on his behalf." I SEND NOTICES TO: (Attorney) Name and address of Attorney ) Michael D. Meadows L"'.., Casper, Meadows, Schwartz 6 Cook] atmant's Signature) 2121 N. California Blvd. #1020 �) Walnut Creek, CA 94596 �. (925) 947-1147 ) 2121 N. California Blvd., Suite 1020: (Address) +� Walnut Creek, CA 94596 i ) Tele hone_No. i p ) Telephone No. (925) 947-1147 eaemaseaeeae'nee■aaee■■.aaa■■a'a■anaaeaoeo eea eoenseven Enos ea■e■o• lossr■sea■r eesdeae�rsoer I' PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the.County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seg.) Furthennore, any attachments, addendums, or supplements attached.to the claim form, including medical records, are also subject to public disclosure. I loans"90415490 Gave Boom swoon Oman osevan agoras@ asoneawaveasse.00 age* ofteddeasna ago Clio offsew"d J' NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or . to any county, city, or district board or. officer, :authorized to allow or .pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. SI:ATE OF CALTFORNrA TRArFIC COLLISION REPORT I 9 t CHP 555 CARS Page 1 (Rev 1-03)OPI 061 Page or SPECIAL CONDITIONS NUMBER HIT&RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER INJURED IELONY I ("-1 UNINCORPORATED BAY lot NUMBER WLLED HIT&RUN COUNTY REPORTING DISTRICT BEAT 9-290 MISDEMEANOR 0 _I CONTRA COSTA 12 COLLISION OCCURRED ON: MO DAY YEAR TIME(2400) NCIC p OFFICER I.D. Z SAN PABLO DAM ROAD 9/23/2006 0325 9320 016279 O MILEPOST INFORMATION. DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: r NONE Q SATURDAY X I YES NO I ROLL.35 MM I�I U F_]AT INTERSECTION WITH: STATE HWY REL BY R. YOUNG 1XOR: 401 FEET WEST OF BRISTLECONE DR j YESKi NO 8999 PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG SAFETY EQUIP. VEH.YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE A 1799109 CA C L G 2001 VOLKS JETTA BLK 4SHW311 CA .i DRIVER NAME(FIRST,MIDDLE,LAST) FX-:! SI IAWN ALLEN RAY OWNER'S NAME i SAME AS DRIVER . _ PEDES- STREET ADDRESS MARCY K1kIATKOWISKI TRIAN —� 5419 WOODHOLLOW CT OWNER'S ADDRESS y i SAME AS DRIVER PARKED CITY/STATE/ZIP VEHICLE CONCORD CA 94521 DISPOSITION OF VEHICLE ON ORDERS OF: I X OFFICER DRIVER OTHER f LD C IST SEX HAIR EYES HEIGHT WEIGHT BIRTHDATE RACE AMERICAN TOW-(925)682-8122 M BRN BLU 6-0 190 9/25/1971Mo y Year W pR10R MECH.DEFECTS X iNONE APP. REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: (925)359-0457 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA TOP VIEV INSURANCE CARRIER POLICYNUMBEREi UNK El NONE JMINOR HOSPITALIZED 01 IMOD IX MAJOR jjROLL-OVER DIR OF TRAVEL 1 ON STREET OR HIGHWAYSPEED LIMIT CA DOT SAN PABLO DAM ROAD 35 CAL-T MCIMX PARTY DRIVER'S LICENSE NUMBER STATECLASS AIR BAG SAFETY EQUIP. VEH.YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE 2 DRIVER NAME(FIRST,MIDDLE.LAST) " OWNER'S NAME SAME AS DRIVER PEDES- STREET ADDRESS TRIA_N —i OWNER'S ADDRESS j SAME AS DRIVER PARKED CITY/STATE/ZIP VEHICLE DISPOSITION OF VEHICLE ON ORDERS OF: I OFFICER i (DRIVER (OTHER BICY- _JSEX JHAIR EYES HEIGHT WEIGHT BIRTHDATE RACE CLIST Mo Day Year __ ElPRIOR MECHANICAL DEFECTS iNONE APP. REFER TO NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: I.] VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER 1:1 LINK 1NONE �IMINOR u_ I 0 MOD MAJOR (ROLL-OVER DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT CAL-T TCP/PSC MC/MX PARTY DRIVER'S LICENSE NUMBER STATE CLASS AIR BAG I SAFETY EQUIP. VEH.YEAR IMAKEIMODEL1.01L.13 LICENSE NUMBER STATE 3 DRIVER NAME(FIRST.MIDDLE,LAST) OWNER'S NAME I�i SAME AS DRIVER PEDES- STREET ADDRESS L . TRIAN OWNER'S ADDRESS (SAME AS DRIVER PARKED CITY/STATE/ZIP _J VEHICLE I DISPOSITION OF VEHICLE ON ORDERS OF: `-(OFFICER —(DRIVER ;OTHER L BICY- SEX HAIR "EYES HEIGHT WEIGHT BIRTHDATE /LICE CLIST MD Day Year F__1. - PRIOR MECHANCIAL DEFECTS I NONE APP. REFER 10 NARRATIVE OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: 1 VEHICLE TYPE DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER SUNY. I (NONE (MINOR IMOD [�`IMA.IOR--'"'DROLL-OVER "------ '-- -" """""-----"—'—"-" rFAVEL ON STREET OR HIGHWAY SPEED LIMIT CA DOT CAL TCP/PSC MC/MX PREPARER'S NAME DISPATCH NOTIFIED REVIE 'S NAME DATE REVIE�D 13. W. F_LL.EDGE 016279 - ' 'X'YES IND IN/A 'Figi 'STATE Of-CALWORNI�C TRAFFIC COLLISION CODING CHP 555 CARS Paget(Rev. 1-03)OPI 061 Page 2 Or B DATE OF COLLISION(MO. DAY YEAR) TPME12900) NCIC# OFFICER I.D. NUMBER 9/23/2006 0325 9320 016279 9-290 OWNER OWNER ADDRESS NOTIFIED PROPERTYj_JYES [II NO DAMAGE DESCRIPTION OF DAMAGE SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCUPANTS L-AIR BAG DEPLOYED M/C BICYCLE-HELMET i A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED DRIVER PASSENGER A-CELL PHONE HANDHELD B-CELLPHONE HANDSFREE B-UNKNOWN N-OTHER v NO X-NO C-LAP BELT USED P-NOT REQUIRED W-YES Y-YES C-ELECTRONIC EQUIPMENT D-RADIO/CD 1 2 3 1-DRIVER D-LAP BELT NOT USED E-SMOKING E-SHOULDER HARNESS USED S 6 2 TO 6-PASSENGERS CHILD RESTRAINT EJECTED FROM VEHICLE F•EATING F-SHOULDER HARNESS NOT USED I 7-STA.WGN REAR Q•IN VEHICLE USED G•CHILDREN G-LAP/SHOULDER HARNESS USED 0-NOT EJECTED I 8-RR.OCC TRK.OR VAN R-IN VEHICLE NOT USED H-ANIMALS H-LAP/SHOULDER HARNESS NOT USED 1-FULLY EJECTED 9-POSITION UNKNOWN S-IN VEHICLE USE UNKNOWN I- PERSONNEL HYGIENE 7 J-PASSIVE RESTRAINT USED 2-PARTIALLY EJECTED 0-OTHEP, K-PASSIVE RESTRAINT NOT USED T- VEHICLE IMPROPER USE 3,UNKNOWN J-READING I U-NNONE IN VEHICLE K-OTHER ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(`)SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES ) i2 i3 SPECIAL INFORMATION 1 2.1MOVEMENT PRECEDING I LIST NUMBER(#)OF PARTY AT FAULT I✓ COLLISION VC SECTION VIOLATED: CITEDES IA CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED A ;- O B CONTROLS NOT FUNCTIONING' B CELL PHONE HANDHELD IN USE X I ! B PROCEEDING STRAIGHT I I8 OTHER IMPROPER DRIVING' IC CONTROLS OBSCURED - C CELL PHONE HANDSFREE IN USE —Fj_C RAN OFF ROAD I D NO CONTROLS PRESENT/FACTOR' X D CELL PHONE NOT IN USE D MAKING RIGHT TURN X IC 0 OTHER THAN DRIVER' TYPE OF COLLISION E SCHOOL BUS RELATED E MAKING LEFT TURN ID UNKNOWN' JA HEAD-ON I F 75 FT MOTORTRUCK COMBO _ F MAKING U TURN �- B SIDE SWIPE G 32 FT TRAILER COMBO G BACKING �I C REAR END _ H- H SLOWING/STOPPING WEATHER (MARK 1 TO 21TEMS) D BROADSIDE I - _ - I I PASSING OTHER VEHICLE X A CLEAR X E HIT OBJECT J J CHANGING LANES _jB CLOUDY F OVERTURNED - K I K PARKING MANEUVER C RAINING G VEHICLE/PEDESTRIAN L L ENTERING TRAFFIC I D SNOWING —H OTHER': - -- IM - - M OTHER UNSAFE TURNING IE FOG/VISIBILITY FT. ; IN N XING INTO OPPOSING LANE IF OTHER:' MOTOR VEHICLE INVOLVED WITH O O PARKED G WIND IA NON-COLLISION �! IP _ P MERGING LIGHTING 1B PEDESTRIAN S IQ I Q TRAVELING WRONG WAY ,I�A DAYLIGHT -IC OTHER MOTOR VEHICLE I 0 3 OTHER ASSOCIATED FACTORS I I R OTHER': I I B DUSK-DAWN I D MOTOR VEHICLE ON OTHER ROADWAY (MARK 1 TO 2 ITEMS) I - X C DARK-STREET LIGHTS 7E PARKED MOTOR VEHICLE A LAVC SECTIONVIOTED CITED �— � D DARK-NO STREET LIGHTS I F TRAIN _ �YES NO ! ; VC SECTION VIOIAI ED CITED I E DARK-STREET LIGHTS NOT IG BICYCLE ��': (g3 B VES -I- j FUNCTIONING' >::3 Hy ---- ---� H ANIMAL: ?)�i i SOBRIETY•DRUG ROADWAY SURFACE F { " IC VC SECTIONVIOU7E0 CITED DYES I 12 - PHYSICAL A DRY X I FIXED OBJECT: " I (MARK 1 TO 2 ITEMS) I XB WET RAISED CURB ! ID :;n+`;:'"+.'' i ; "�=`+',•;;;�r•ir�';a�:,;x.X I ; A HAD NOT BEEN DRINKING __ ? -IC SNOWY-ICY -I J OTHER OBJECT: FIE VISION OBSCUREMENT: I 1 8 H6U-UNDER INFLUENCE D SLIPPERY(MUDDY,OILY,ETC.) I -- I F-INATTENTION': - _ I I C HBD_NOT UNDER INFLUENCE' i ROADWAY CONDITION(S) ! I G STOP&GO TRAFFIC D HBD-IMPAIRMENT UNKNOWN' ; (MARK 1 TO 2 ITEMS) PEDESTRIAN'S ACTIONS i H ENTERING/LEAVING RAMP I I E UNDER DRUG INFLUENCE- I A HOLE DS EEP RUT' X A NO PEDESTRIANS INVOLVED ; I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL' I i B LOOSE MATERIAL ON ROADWAY' B CROSSING IN CROSSWALK I J UNFAMILIAR WITH ROAD I G IMPAIRMENT NOT KNOWN C OBSTRUCTION ON ROADWAY' I-AT INTERSECTION K DEFECTIVE VEH.EQUIP. CITEU I H NOT APPLICABLE I D CONSTRUCTION-REPAIR ZONE C CROSSING IN CROSSWALK-NOT vES I I I SLEEPY/FATIGUED E REDUCED ROADWAY WIDTH AT INTERSECTION -I- - No -I F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE ;X I G OTHER':BUCKLED ROAD E IN -INCLUDES SHOULDER 1_1 M OTHER': --H NO UNUSUAL CONDITIONS F NOT IN ROAD X I I N NONE APPARENT IG APPROACHING/LEAVING SCHOOL BUS I j 10 RUNAWAY VEHICLE SKETCH FOR SKETCH DIAGRAM, SEE PAGE 4 �:---� MISCELLANEOUS DOT i INDICATE NORTH �.R CRf,'R 1 �DA n/SO C�7;;E,� STATE-OF CALIFORNIA INJURED/WITNESSES / PASSENGERS CHF'555 CARS Page 3(Rev 1-03)001 061 Page s °r e DATE OF COLLISION(MO. DAY YEAR) TIME(2400) NCIC# OFFICER 1.D. NUMBER 9/23/2006 0325 9320 016279 9-290 1MTNESS .PASSENGER EXTENT OF INJURY('X'ONE) INJURED WAS('X'ONE) PARTY SEAT AIR SAFETY ONLY AGE SEX NUMBER EJECTED ONLY POS. BAG EQUIP. FATAL SEVERE OTHER VISIBLE COMPLAINT DRIVER PASS. PED. BICYCLIST OTHER INJURY INJURY INJURY OF PAIN -1# LI 34 M ;-1 ❑ ii Xl `--I X; 71 -1 C:-I 1 1 L . G 0 NAME I D.O.B.I ADDRESS TELEPHONE SHAWN ALLEN RAY (09/25/1971) 5419 WOODIIOLLOW CT CONCORD CA 94521 (925)359-0457 (INJURED ONLY)TRANSPORTED BY: TAKEN TO: REACH IOHN MUIR MED CENTER DESCRIBE INJURIES: BLUNT FORCI TRAMA TO HEAD L-1 VICTIM OF VIOLENT CRIME NOTIFIED I ol, `--- LI LF NAME/D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN T0: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED Ei NAME/D.O.B.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY. TAKEN TO: DESCRIBE INJURIES: I- I VICTIM OF VIOLENT CRIME NOTIFIED NAME!D.O.B./ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES: Ll VICTIM OF VIOLENT CRIME NOTIFIED NAME/D.O.B.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED F NAME I D.O.B.]ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY TAKEN TO: DESCRIBE INJURIES: VICTIM OF VIOLENT CRIME NOTIFIED PREPARER'S NAME I.D.NUMBER M0. DAY YEAR REVIEWER'S NAME MO. DAY YEAR B.W.ELL17DGE 016279 9/23/200(; STATE OF CALIFORINTIA SKETCH DIAGRAM CHI,555 Parc QlZcv.8-97) OPI 042 PAGE 4 OF 9 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 09/23/2006 0325 1 .9320 1 016279 9-290 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED(SCALE= ) San Pablo Dam Rd. Not to scale W2 'W1 E1 ' E2 I I I i Tree I I I I I 1 I I I I 2 I I I I Bristlecone Dr. V1 I I I I 1 I I I I I I I I I I V1 l .i i i i i i i I I I I I -- — Buckle inroad I Dashed white fine Double yellow line I 1V1 I I - Raised curb I I r Painted white line 7 ft.412 ft. 12 ft. 12 ft.►I.12 ft.►I ,\ PREPARED BY I.D. NUMBER DATE --[REVIEWER'S NAME DATE B. W. ELLEDGE 016279 09/23/2006 ;TATE OF OALIFORNIA =ACTUAL DIAGRAM :HP 555 Page 4(Rey. 1-03) OPI 061 Page j or 1 %ATE'OF COLLISION !MO. DAY YEAR; .TIME(2400) NCIC 4 OFFICER I.D NUMBER ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE UNLESS STATED (SCALE_ ) x — --. . .-i _------------ IV INDICATE NORTH C I j I I ; I 1 I I I I I I � I � I I i11 . IN 3 I I I I I y I I INDICATE /� --------- --- I I NORTH I e I I i f •-----........---- .....-I----'--. - O I i I .?fes• � I`: � i I i I i � I i 1- I I , i I i I V1 - -• INDICATE ij I NORTH I i si I i I , I i I'i I i I I I I i PREPARED BY ` NAM r !.D.NUMBER 7DA YEAR REVIE`NER'S E MO. DAY YEAR (�//`� �:C ifirwR fG fT• i OSP 03 75578 J07�/114 m 00 VO / 0J7114111V11 V=G1 11 114 1 VINaO--Jil;'O-�O 3dV Is STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE 6 of 9 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 09-23-06 0325 9320 16279 9-290 PHYSICAL EVIDENCE LEGEND: STATION LINE: A station line was established along the north roadway edge line of San Pablo Dam Rd. Station 0+00 was established at the west roadway edge prolongation of Bristlecone,Dr. The station line increases as you proceed from east to west. All measurements were taken at right angles to the station line. PHYSICAL EVIDENCE LOCATION/DESCRIPTION: . , .: . D1 ... :..:.� . ...�.:�,;.,:-.. .:; DES`CRI>PTI'ON-•:;;, «;.,:::.;..:,,.:: : 1 0+96 16' N Tree, AOI# !1 2 1+00 23' N L/F tire of V-1 3 1+08 32' N R/R tire of V-1 4 1+18 8' N End of tire friction mark 5 1+28 8' N Start gouge marks on curb 6 1+33 8' N Gouge mark on curb, AC,11t 2 7 1+34 8 N End,of tire friction mark 8 1+42 At At Tire friction mark 9 1+43 2' S End of gouge inroad . 1.0 1+51 5' S Start of gouge marks in road 11 1+81 12' S End of gouge marks in road 12 1+86 14' S Start of gouge marks in road 13 1+95 19 S Start tire friction mark 14 2+13 29' S Start tire friction mark 15 2+26 23 S End of gouge marks in road 16 2+31 24 S Start of gouge marks in road 17 2+76 30 S End of gouge marks in road 18 2+85 30 S Start of gouge marks in road 19 3+75 37 S End of buckle in road 20 4+01 36 S Start buckle in road 21 4+26 35 S End of buckle in road 22 4+43 35 S Start of buckle in road, RED BY I.D.NUMBER DATE REVIEWER'S NAME DATE PREPA J. Lockhart 16887 9-23-06 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE 7 OF DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 09/23/2006 0325 9320 016279 9-290 1 FACTS 2 NOTIFICATION: 3 1 was dispatched to a call of a solo vehicle collision at approximately 0340 hours. I responded 4 from SR-4 at Cummings Skyway and arrived at the collision scene at approximately 0355 5 hours. All'times, speeds, and measurements in this investigation are approximate. 6 Measurements were taken by roll meter and visual estimation. 7 8 SCENE: 9 At the scene of this collision, San Pablo Dam Road is an eastbound/westbound aligned 10 roadway within the town limits of EI Sobrante. The roadway consists of two lanes in each 11 direction. Eastbound traffic is separated from westbound traffic by a .two way left turn lane. 12 The roadway is straight, level and is composed of primarily asphalt. The roadway was wet due 13 to a water main, which had broken under the street, and the weather at the time of my arrival 14 was clear, cool and dry. See physical evidence legend and factual diagram for further scene 15 description. 16 17 PARTIES: 18 Party # 1 (PAIL was contacted at the collision scene and was identified by a California 19 Driver's License. P1 was placed as a party in this collision by the following: 20 • P 1's location. 21 • P1 is the registered owner of V-1. 22 • P1's injuries. 23 24 Vehicle # 1 (Volkswagen): Was located at its point of rest facing in a southerly direction. 25 Vehicle # 1 sustained major damage as a result of this collision including damage to the 26 following: 27 • Front bumper crushed. 28 • Engine compartment intrusion. 29 • Hood crushed. 30 • Grill crushed. PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE B. W. ELLEDGE 016279 09/23/2006 STATE OF CALIFORNIA NARRATIVE/SUPPLEMENTAL PAGE £ OF 9 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 09/23/2006 0325 9320 016279 9-290 1 • Windshield crushed. 2 • Body and frame buckled. 3 • Right and left front fenders crushed: 4 • Supplemental Restraint System (steering wheel air bag deployed). 5 • Supplemental Restraint System (passenger side air bag deployed). 6 Supplemental Restraint System (side air bags deployed). 7 No prior vehicle damage was claimed or noted. 8 9 PHYSICAL EVIDENCE: 10 Damage sustained to Vehicle # 1 resulting from this collision. Refer to physical evidence 11 legend and factual diagram for further information. 12 13 OTHER FACTUAL INFORMATION: 14 At the scene of the collision, I contacted East Bay Municipal Utility district supervisor Walter 15 Nobrega II, who advised me the utility district had received a call of a broken/leaky pipe under 16 the roadway on September 19, 2006. The work order number is 1161192. 17 18 STATEMENTS: 19 STATEMENTS ARE NOT VERBATIM AND ARE WRITTEN IN SUMMARY FORM. THE STATEMENTS WERE READ BACK TO THE 20 INVOLVED PARTIES FOR VERIFICATION. 21 PartV# 1 (f 4yh was unable to remember any of the events which led up to the collision. P1 22 was only able to remember leaving work. 23 24 OPINIONS AND CONCLUSIONS: 25 THE SUMMARY,AREA OF IMPACT(S)AND CAUSE WERE BASED ON PHYSICAL EVIDENCE, VEHICLE DAMAGE AND STATEMENTS. 26 27 SUMMARY: 28 Party # 1 (RR ) was driving Vehicle # 1 (Volkswagen) e/b on San Pablo Dam Road in the # 1 29 lane at an unknown rate of speed. P1 was approaching a defect in the #1 lane ahead of him. 30 The defect was not visible due to the time of day, the defect being wet and the lack of lighting. 31 V1 ran over the defected portion of roadway, which caused him to loose control. V1 traveled PREPARED BY I.D.NUMBER DATE REVIEWER'S NAME DATE B. W. ELLEDGE 016279 09/23/2006 STATE OF CALIFORNIIA NARRATIVE/SUPPLEMENTAL PAGE 9 OF 9 DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER 09/23/2006 0325 9320 016279 9-290 1 out of control crossing the double yellow line, the w/b #1 and #2 lanes, colliding with a raised 2 curb on the north shoulder. After colliding with the raised curb V1 continued w/b colliding head 3 on with a eucalyptus tree causing major damage to V1. 4 5 AREA OF IMPACT: 6 7 A.O.I. # 1 (V-1 vs. Raised concrete curb ) was located approximately 133 feet west of the west 8 roadway edge prolongation of Bristlecone Dr, and approximately 8 feet north of the north 9 roadway edge of San Pablo Dam Rd. 10 1.1 A.O.I:# 2 (V-1 vs. Tree ) was located approximately 96 feet west of the west roadway edge 12 prolongation of Bristlecone Dr, and approximately.16 feet north of the north roadway edge of 13 San Pablo Dam Rd. 14 15 CAUSE: 16 The primary cause of this collision is other than driver. P1 was unable to see the defect in the 17 roadway in front of him. At the time of the collision the area was dark and there was a lack of 18 lighting. The defected area was also wet making it harder to see. There were no signs in the 19 area warning oncoming traffic of the defect. The defected portion was approximately 1 foot 20 high. Due to the height of the buckle and the roadway being wet due to the leaking water 21 main, as V1 traveled over the buckle it caused P1 to lose control and threw V1 into an 22 unrecoverable skid. 23 24 RECOMMENDATIONS: 25 None. PREPARED BY I.D. NUMBER DATE REVIEWER'S NAME DATE B. W. ELLEDGE 016279 09/23/2006 MEDICAL PROVIDERS—SHAWN RAY DOI 9/23/06 Richmond Fire Departme.°it 11/23/06: First response M, B 1401 Marina Way S. Richmond, CA 94804 (510) 307-8031 American Medical Response 11/23/06: Paramedic response, transportation to helicopter site 1,179.08 4701 Stoddard Road S: C/o rt hip pain; 34 yo male in single MVA on San Pablo Dam Modesto, CA 95356 Road. Pt traveling appx. 40 mph down San Pablo Dam Rd. when (209) 492-0760 drove through area where water pipe had broken, causing Ig. amt. 10/19/06 of water flowing on st. and Ig. chunks of road broken in street. Per witnesses, pt. lost control of vehicle, spun around several times, struck Ig. tree head on down sm. embankment. Entire front end of vehicle pushed into and up in passenger space—major damage, steering wheel bent down and under. Pt. struck windshield, put entire face completely through windshield. Pt's. rt lower leg &foot pinned under dash deformity and pedals. Drivers & passenger side doors bent in, both side airbags deployed as well as front. Richmond FD cut open door to unpin rt. foot and extricate pt.from vehicle. .O: Severe rt hip pain on any movement, palp. GCS 14; A& 0 x 3;speech confused. Multiple abrasions/lacerations to whole face; pts head went through windshield; lac. to neck w. bruising; contusions to whole I. chest; lung sounds diminished; pt states painful to take deep breath. Rt. LBP; abdominal pain, abrasions; severe rt. pelvic pain, pos. shortening; unstable pelvis. B/L wrist pain, some swelling to rt wrist. Rt. foot deformity to ankle. Moderate blood loss A: significant blunt injury abdomen, head, pelvis, thorax, chest, back P: leg immobilized, morphine for pain control en route to helicopter landing zone. Reach Air Medical Services 11/23/06: Air ambulance to John Muir Medical Center S: "my chest 12,509.23 451 Aviation Blvd., Ste. 201 and rt. leg hurts". Per report, in solo MVA; mid-sized vehicle slid Santa Rosa, CA 94596 out of control on wet surface and struck a few trees. Major front (707) 575-6886 end damage to vehicle; pt. head went through windshield and legs 10/16/06 were caught under dashboard. Unknown LOC. 20 min extracation time; pos. seatbelt, airbag deployment. O: rt leg slightly rotated w. foot pointing outward; mult. abrasions to head, face; pelvis very painful to any stimulation, movement; multiple abrasions, lacerations to extremities; GCS 12 A/P: Morphine, Fentanyl given for extreme pain; pt continued to c/o extreme pain to chest&rt leg, Fentanyl repeated. John Muir Medical Center 9/23/06—10/7/06: ER eval and tx, surgery and hospitalization 260,362.38 1601 Ygnacio Valley Road 9/23/06: ER Eval. and tx: S: C/o rt hip and abdominal pain Walnut Creek, CA 94598 restrained driver in head on MVA; hit wet road, spun out, hit a tree. (925) 947-5373 No remembrance of event. O: CT pelvis shows rt acetabular fx w. 10/23/06 dislocation of rt femoral head. CT abdomen shows rt hip dislocation . intra articular fragments,fx of posterior column of acetabulum, abdominal wall hematoma. CT thorax shows I anterior 8th rib fx, pneumomediastinum, (gas in chest space between lungs), extending into neck; rt middle lobe contusion. Ct maxillofacial shows tripod type fx on I, involving maxillary antrum, I. lateral orbital wall, lateral pterygoid, zygomatic arch; nondisplaced nasal bone fx on rt; possible but doubtful hard palate fx, sinus changes. CT rt hand shows soft tissue swelling over metacarpal region, no fx. CT spine, head/brain, rt knee neg. A: multisystem trauma, closed rt. hip fx and dislocation, concussion P: reduction of hip dislocation, admission,traumatic brain injury protical. 9/23/06: Plastic Surgery Consult(Leung, MD): S: s/p single vehicle MVA O: CT maxillofacial area shows I. zygomaticomaxillary complex fx w. blood in I. maxillary sinus. Associated orbital floor blowout fx likely, but no coronal view available at this time. A: I. side zygomaticomaxillary complex fx, likely orbital floor blowout fx P: CT scan of orbit w. coronal views ordered. L. sided zygomaticomaxillary complex fx will require ORIF to prevent double vision at a later date when edema subsides. 9/26/06: Ophthalmology Consult(Lui, MD): S: seen per request of Dr. Leung to do intraocular injury; pt reported slight blurring vision I. eye. A: s/p MVA w. I. zygomaticomaxillary facial fx; no clinical evidence of blowout fx of orbits P: surgical repair of facial fx per plastic surgeon; will be glad to see pt once discharged. 9/26/06: PROCEDURE: (Finch, MD) interior vena cavagram and IVC filter placement under conscious sedation 9/26/06: SURGERY: (Coufal, MD) 1.) Open reduction internal fixation of rt. transverse acetabular fx w. associated posterior wall fx 2) open debridement of rt. hip joint fx dislocation Dx: 1) rt juxtatectal transverse acetabular fx w. associated posterior wall fx dislocation 2) Pipkin type 1 rt femoral head fx 9/28/06: Progress Notes (Leung, MD): S: cont. double vision P; ORIF I.ZMC, orbital floor fx tomorrow 9/29/06: SURGERY: (Leung, MD) Open treatment of left zygomaticomaxillary complex fx and closed tx of nasal bone fx Dx: 1) I. orbital floor blow out fx w. diplopia (double vision) and enopthalmus (sinking of eyeball into orbital cavity) 2) I. zygomaticomaxillary complex fx 3) MVA 4) nasal bone fx 9/29/06: SURGERY: (Hwang, MD) 1) I. orbital floor fx repair w. orbital floor implant placement, Medpor 0.4mm 2) I. lateral canthoplasty(repair of eyelids) 9/30/06: Neuropsych Progress Notes: S: HA, nightmares, dec. memory; bothered by wife's cell phone, people calling O: pleasant, cooperative; slow processing,fine memory difficulties, A/P: cont brain injury protocol (can listen to soft music); no TV, no phone, wife to shut off cell phone; limit visitors to 2 at a time for 15 min. only. 10/3/06: Neuropsych Progress Notes: S: cont. dec memory,word finding, and blurred vision. Some overstimulation reported. HA earlier but denied one currently. Reported cont. nightmares. O: dec. energy, better focus. Processing more efficiently though still slowly; well oriented. A/P: improving; brain injury protocol, discussed w. social services. 10/5/06: Case Mgmt Progress Note: Concerns re discharge needs. Lives in 2 story home, are requesting hospital bed to keep head at 30 deg. Also req. visiting RN; informed pt his insurance doesn't cover home health. 10/6/06: Ortho Progress Note: still having constipation, nausea; GI issues need to be resolved prior to D/C. 10/6/06: Plastic Surgery Progress Note (Leung, MD): S/O: D/C planned tomorrow. Partial numbness I. upper cheek(expected); blurred vision persists; all incisions healing well A/P: doing well; soft diet x 3 mo; OK to brush teeth; all sutures will dissolve, no need for removal; follow up w. Dr. Liu for blurred vision. 10/6/06: Case Management Progress Note: bed and wheelchair for home use ordered from Home Medical Equipment. 10/7/06: Discharge Summary: (McGuiness, MD): Hospital Course: Admitted w. obvious dislocation and fx to rt. hip and acetabular; dislocation manually reduced in ER by Dr. Lazzarini, pins placed, pt placed in traction. Facial fx identified as well.Workup showed no signs of intra abdominal injury; there were signs of I. sided pneumothorax which did not progress. Placed on traumatic brain injury protocol and observed in ICU. Had apparent pulmonary contusion on rt, no signs of respiratory compromise. Improved medically, underwent repair of rt femoral head fx and acetabular fx on 9/26; also placement of temporary inferior vena cava filter. Repair of I orbital blowout fx, I.zycoma fx, nasal bone fx performed on 9/29. Placed on 5 west, had undergone PT, has been ambulating. Has some persistent nausea, but no vomiting. Will follow up w. ortho and plastic surgeon. No discharge diagnoses listed. 10/12/06: OP PROCEDURE: (Goldberg, MD) removal of previously 28,509.35 placed IVC filter; extensive time and assistance of Dr. Finch required. California Emergency Compex 11/13/06 B Physicians Med America Billing Services 1601 Cummins Dr., Ste. D-03 Modesto, CA 95358 (209) 491-7710 John Muir Trauma Physicians Compex 11/13/06 Attn: Trauma Billing Office P.O. Box 9021 Walnut Creek, CA 94598 (925) 947-5331 Bay Imaging Consultants Compex 11/13/06 175 Lennon Lane, Ste. 100 Walnut Creek, CA 94598 (925) 296-7150 Christopher Coufal, M.D. Treating ortho;need to order 2405 Shadelands Dr. Ste.210 Walnut Creek, CA 94598 Timothy Leung, M.D. Treating plastic surgeon, need to order 905 San Ramon Valley Blvd., Ste. 110 Danville, CA 94526 TOTAL TO DATE 302,560.04 ,Nov 29. 06 07: 29p Jane Ferguson 9259387659 p. 2 A-JOHN MUIR MEDICAL CENTER Thank you for selecting Jahn Muir-Mt. Diablo Health System for Jobn Afuir/Mt. Diablo Health System our healthcare Quality O Box 39000 y care neey patient care and dedication to P I.O Box 39 30 patient satisfaction are our highest priorities. San Francisco,CA 94139-3370 2Vo00W•r s55551s715 Our records indicate that you have BLUE CROSS PRUDENT BU as your primary insurance and you do not have a secondary. If this is not correct,please contact our Customer Service Department at the number listed below. SHAWN ALLEN RAY We have added preventive healthcare and education news on CON OR DCA 9452 CT the back of the statement. We hope to serve you again,if a CONCORD CA 94521-5431 P Y 9 , health need arises. Patient Services Proiyided Statement Date 10/12/06 DESCRIPTION TOTAL CHARGES Service Date(s) 09/23/06- 10/07/06 ROOM-BOARD/SEMI $22,975.00 Patient Name SHAWN ALLEN RAY POST ICU $60,255.00 Account Number 55555-19715 PHARMACY $ 18,962.60 What we billed to insurance $260,396.88 IV SOLUTIONS $4.796.00 What's pending with insurance $260,396.88 IV THERAPY $1,952.00 Your payments/adjustments $0.00 MED/SUR SUPPLIES $8,256.00 NON-STERILE/SUPPLY $1,529.50 What you owe now $0.00 STERILE SUPPLY $3,607.00 SUPPLY/IMPLANTS $9,303.00 LABORATORY $20.50 LAB/CHEMISTRY $2,181.91 LAB/IMMUNOLOGY $539.46 Please confirm that information is correct. PRIMARY Insurance BLUE CROSS PRUDENT BU . Billing questions or changes in insurance coverage? Group/Plan 13079G (925)947-3336 8:30 am to 4:15 prn weekdays . Written correspondence? ID Number XDP705A70827 _ John Muir/Mt. Diablo Health System-Attn. Patient Accounts PO Box 39000 SECONDARY No secondary on file. Department 33370 San Francisco,CA 94139-3370 Insurance Please call if incorrect. Group/Plan ID Number Please Note: Your physician will bill separately for tlteir professional services. HBOUB02 14ov 29. 06 07: 29p Jane Ferguson 9259387659 p. 3 A JOHN MUIR MEDICAL CENTER Jobn AfuirAft. Diablo Health System PO Box 39000 Account Number: 55555-19715 Depaftent 33370 San Francisco,CA 94139-3370 Patiew Services Provided (Coidinued...) DESCRIPTION TOTAL CHARGES LAB/HEMATOLOGY $774.64 LAB/UROLOGY $268.24 DX X-RAY $7,737.25 DX X-RAY/ANGIO $2,606.75 DX X-RAY/ARTER $2,598.00 DX X-RAY/CHEST $870.00 CT SCAN/HEAD $0.00 OR SERVICES $35,269.75 ANESTHESIA $6,447.50 BLOODISTOR-PROC $746.10 RESPIRATORY SVC $0.00 PHYSICAL THERP $1,077.00 PHYS THERP/EVAL $238.25 EMERGENCY ROOM/SERVICES $3,504.00 PULMONARY FUNC $75.60 Drugs/Detail Code $17,061.90 TRAUMA LEVEL 2 $9,532.25 RECOVERY ROOM $4,436.25 EKG/ECG $475.50 HOLTER MONT $20,625.00 TREATMENT RM $10,608.25 OBSERVATION SERVICE $0.00 PSTAY TREATMENT $275.10 PSTAY/TESTING $723.58 PRO FEE/EKG $68.00 TOTAL CHARGES $260,396.88 TOTAL PAYMENTS/ADJUSTMENTS $0.00 TOTAL ACCOUNT BALANCE $260,396.68 HBOCFBNX Nov ?9 06 07: 30p Jane Ferguson 9259387659 p. 4 JOHN MUIR MEDICAL CENTER John Muir/Mt. Diablo Health Systan PO Box 39000 Account Number: 55555-19715 Department 33370 San Francisco,CA 94139-3370 Patient Services Provided (Coitfiiwed...) DESCRIPTION TOTAL CHARGES LAB/HEMATOLOGY $774.64 LAB/UROLOGY $268.24 DX X-RAY $7,737.25 r DX X-RAY/ANGIO $2,606.75 DX X-RAY/ARTER $2,598.00 DX X-RAY/CHEST $870.00 CT SCAN/HEAD $0.00 OR SERVICES $35,269.75 ANESTHESIA $6,447.50 BLOOD/STOR-PROC $746.10 RESPIRATORY SVC $0.00 PHYSICAL THERP $1,077.00 PHYS THERP/EVAL $238.25 i EMERGENCY ROOM/SERVICES $3,504.00 PULMONARY FUNC $75.60 Drugs/Detail Code $ 17,061.90 TRAUMA LEVEL 2 $9,532.25 RECOVERY ROOM $4,436.25 EKG/ECG $475.50 HOLIER MONT $20,625,00 TREATMENT RM $10,608.25 OBSERVATION SERVICE $0.00 PSTAY TREATMENT $275.10 PSTAY/TESTING $723.58 PRO FEE/EKG $68.00 ° TOTAL CHARGES $260,396.88 TOTAL PAYMENTS/ADJU.STMENTS $0.00 TOTAL ACCOUNT BALANCE $260,396.88 ,3 S HBOCFBD4x _Nov 29 06 07: 30p Jane Ferguson 9259387659 p. 5 JOHN MUM MEDICAL CENTER • Thank you for selecting John Muir-Mt. Diablo Health System for John Mxir/1Mt. Diablo Health System your healthcare needs. Quality patient care and dedication to PO Box 39000 "Department 33370 patient satisfaction are our highest priorities. D.San Francisco,CA 94139-3370 2VOD03e-r-55555-1 971 5 Our records indicate that you have BLUE CROSS PRUDENT BU as your primary insurance and you do not have a secondary. If this is not correct, please contact our Customer Service Department at the number listed below. SHAWN ALLEN RAY We have added preventive healthcare and education news on 5419 WOODHOLLOW CT CONCORD CA 94521-5431 the back of the statement. We hope to serve you again,if a health need arises. 111111111 oil 11 1111111111111131111111,11111111111111111191 11111 I Provided Statement Date 10/12/06 DESCRIPTION TOTAL CHARGES Service Date(s) 09/23/06- 10/07/05 ROOM-BOARD/SEMI $22,975.00 Patient Name SHAWN ALLEN RAY POST ICU $60,255.00 Account Number 55555-19715 PHARMACY $18,962.60 What we billed to insurance $260,396.88 IV SOLUTIONS $4,796.00 What's pending with insurance $260,396.88 IV THERAPY $1,952.00 MED/SUR SUPPLIES $8,256.00 Your payments/adjustments $0.00 NON-STERILE/SUPPLY $1,529.50 What you owe now $0.00 STERILE SUPPLY $3,607.00 SUPPLY/IMPLANTS $9,303.00 LABORATORY $20.50 LAB/CHEMISTRY $2,181.91 LAB/IMMUNOLOGY $539.46 Please confirm that information is correct. ItiqutrieslCliangeslUpdates PRIMARY Insurance BLUE CROSS PRUDENT BU . Billing questions or changes in insurance coverage? Group/Plan 13079G (925)947-3336 8:30 am to 4:15 pm weekdays . Written correspondence? ID Number XDP705A70827John Muir/Mt. Diablo Health System-Attn. Patient Accounts PO Box 39000 SECONDARY No secondary on file. Department 33370 San Francisco,CA 94139-3370 Insurance Please call if incorrect. E Group/Plan ° . ID Number Please Note: Your ph}sician will hill separately for their professional services. • i HBOCF802 ' .N6'v .29. 06 07: 31p Jane Ferguson 9259387659 p. 6 JOHN MUIR MEDICAL CENTER . Thank you for selecting John Muir-Mt. Diablo Health System for John Muir/Mt. Diablo Health System your healthcare needs. Quality patient care and dedication to PO Box 39000 patient satisfaction are our highest priorities. Department 33370 San Francisco,CA 941139-3370 1v00105.1•5555e-19715 Our records indicate that you have BLUE CROSS PRUDENT BU as your primary insurance and you do not have a secondary. If this is not correct,please contact our Customer Service Department at the number listed below. SHAWN ALLEN RAY We have added preventive healthcare and education news on 5419 WOODHOLLOW CT you again,if a serve P the back of the statement. We hope to a CONCORD CA 94521-5431 Y 9 health need arises. Patient Services Provided Statement Date 10/12/06 DESCRIPTION TOTAL CHARGES j . 3 Service Date(s) 09/23/06-10/07/06 : Patient Name SHAWN ALLEN RAY TOTAL CHARGES $260,396.88 . Account Number 55555-19715 TOTAL PAYMENTS/ADJUSTMENTS $0.00 What.we billed to insurance $260,396.88 TOTAL ACCOUNT BALANCE $260,396.88 i What's pending with insurance $260,396.88 Your payments/adjustments $0.00 What you owe now $0.00 Insurance Information „` ' Please confirm that information is correct. r PRIMARY Insurance BLUE CROSS PRUDENT BU . Billing questions or changes in insurance coverage? Group/Plan 13079G (925)947-3336 8:30 am to 4:15 pm weekdays . Written correspondence. ID Number XDP705A70827 John Muir/Mt. Diablo Health System-Attn. Patient Accounts PO Box 39000 SECONDARY No secondary on file. Department 33370 San Francisco,CA 94139-3370 +. Insurance Please call if incorrect. a Group/Plan ID Number Please Note: Your p1gsician will bill separately for their professional services. HBOGF802 1 PROOF OF SERVICE (C.C.P. §§1013, 2015.5) 2 I am a citizen of the United States and am employed in the County of Contra Costa, State of 3 California. I am over eighteen (18) years of age and not a party to the above-entitled action. My business address is 2121 North California Blvd., Suite 1020, Walnut Creek, CA 94596. 4 On the date below, I served the following documents in the manner indicated on the below- named parties and/or counsel of record: 5 CLAIM AGAINST CONTRA COSTA COUNTY 6 0 U.S. MAIL, with First Class postage prepaid and deposited in sealed envelopes at 7 Walnut Creek, California. ❑ FACSIMILE TRANSMISSION from (925) 947-1131 during normal business hours, 8 complete and without error on the date indicated below, as evidenced by the report issued by the transmitting facsimile machine. 9 ® Hand-Delivery Via Courier ❑ Other: 10 11 Clerk of the Board of Supervisors County Administration Building 12 651 Pine Street Room 106 13 Martinez, CA 94553 14 1 declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and that I am readily familiar with this firm's practice for collection and 15 processing of documents for mailing with the U.S. Postal Service. 16 17 Dated: November 2006 18 Elizabeth A. Phelan 19 20 21 22 23 24 25 26 27 28 CASPER,MEADOWS, SCHWARTZ&COOK 2121 N.California Blvd., Style 1020 Walnut Creek,CA 94596 TEL:(925)947-1147 FAX(925)947-1131 CLAIINI Z BOA111) OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: DECEMBER 19 . 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. �� you is your notice of the action taken v gr D on your claim by the Board of CJEC U -) 2006 Supervisors. (Paragraph I.V below), given Pursuant to Government Code AMOUNT: $2 ,934 . 34 COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings". CLAIMANT: FRANCIS A. FREY ATTORNEY: UNKNOWN DATE RECEIVED: DECEMBER 049 2006 ADDRESS: 3037 ENEA WAY BY DELIVERY TO CLERK ON: DECEMBER 04 , 2006 ANTIOCH, CA 94509-4719 BY MAIL POSTMARKED: DECEMBER O19 2006 FROM/I: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DECEMBER 04 , 2006 JOHN CULLEN, r Dated: By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: Aa Ob By: h1 Deputy County Counsel 1.11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911-3). ]V.*ARD ORDER: By unanimous vote of the Supervisors present: ( "l-his Claim is rejected in full. O Other: i certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated;./, !2 ' JOHN CULLEN, CLERK, B Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have only six(6) months from the(late this notice was personalh,ser•%-ed 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 Wyant to consult an attornrev,you should do so immediately. *For Additional NVar•ning See Reverse Side ofThis Notice. AFFIDAVIT OF MAILING declare under penalty of per jury that 1 am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today 1 deposited in the United States Postal Service in lINIartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: NA:� 020 JOHN CULLEN, CLERK By eputy Clerk F BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY p , INSTRUCTIONS TO CLAIMANT ! A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claire is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. r. D. If the claim is against inore than one public entity, separate claims must be filed against each. public entity. E. Fraud. See penalty for fiaudulent claims, Penal Code Sec. 72 at the end of this form. Noss■s s s l s s s s■s s■■an s■■ ■■Susan■s Q t i S C U t s s e L s L L s t s s s C It Noun Q s s L L L s s A s meanMeanss anal RE: Claim By: Reserved for Clerk's filing stamp Care-, R 2 L R�%ifo FES Against the County of Contra Costa or ) C E0# 0 4. 2006 a CLERK BOARD OF SUPERVISORS h� District) CONTRA COSTA CO. (Fill in the name) Y The undersigned claimant hereby makes claimagainst the County of Contra Costa or the above-named district in the sum of$ q� , �� and in support of this claim represents as follows: T I. When did the damage or injury occur? (Give exact date and hour) U C . 30, 020 o G ._ �: v P/Y1. 2. Where did the damage or injury occur? (Include city and county) n �� r-�-�s-�—�► , �ro-n-�-L�� l�5� �d. 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? S., /t/--30/,D � � 0-e"' � 5 What are the names of county or district officers,servants, or employees causing the damage or injury? 54w4 ti:,,�► ��- (Q ct e. 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. -Attach two estimates for auto damage.) 4V �2e 2444Tz42 Q.std �i4��©�� Jhe �iil/ 1-41Leke.d . 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) /.�.,q, 5�� s�;w��+ �s il- �J►� Cosi-; S. Names and addresses of witnesses,doctors, and hospitals: cis ,f— �o a,Y, F►-e 4 s �• 2, .3 D 3 7n c 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT 0 - Op,i �0 ad A sales I a am malls a as it a Inv a K Ran ONE Susumu 9 gas no am 0 gas am ass AN%2 anon too Ions USK us as as ass Mgt ) .Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) Name and address of Attorney ) L2 (Claimant's Signature) 0aw (Addres Telephone No. )Telephone No. Z 7S7 - rf Z1 ■s s s a a t r a s s t l s a s s s s s s a a s■■ BAZAR a a a a a s s a a s s a s i noun ANN ENNERM an a a s s s a s a■sass nits mamma a s It PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■ Rose MEN a s s s a s a s sigma also o ■ NMI am s a a s s a a s a a a s s us s s s s s s a a s a s a a s a s s s a s a s so ssa ass■a s s f s not NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisonment and fine. 11/30/2006 Clerk of the Board of Supervisors County Admin. Building, Room 106 651 Pine Street Martinez, CA 94553 RE: Accident Claim Form—filed by Francis A. Frey No. 2—Where did the damage occur? In Antioch, Contra Costa County, CA. At the intersection of Somersville Road and south-bound Highway 4 access. No. 3 —How did the damage occur? I was in my car, headed north in the right hand laneon Somersville Rd., stopped at the traffic light for possible cross-traffic from the north to Highway 4. Commute traffic was heavy, and other cars following mine moved to the right lane when we heard the fire- ssiren. The heavy traffic prevented the fire truck driver from getting through on the curved access to east Highway 4, so he came down to make the 90 degree right turn to access east Highway 4. He almost made it; but something cut the left front hub cap and tire, then hooked into the the bumper/grille and pulled me right around the corner with him. No. 4—What act or omission . . . . .caused the damage? The driver turned just a bit too soon for such a large vehicle. (That sharp corner may not have given him much option.) No. 5 —What are the names . . . . . .? I did not get names. The fireman who checked on us provided address, etc. His super. arrived and took some pictures of the front of my car. My car was still driveable, so we followed the fire-truck down the highway to our off-ramp (Contra Loma). EAST COUNTY INSURANCE AGENCY, INC. 2738B W. Tregallas Road • Antioch, CA 94509• (925) 757-4208 • Fax (925) 757-0678 • Lic.#OE08504 V Nov 2, 2006 Contra Costa County Fire District 2010 Geary Rd Pleasant Hill, Ca 94523 Re Accident of 10/30/2006 Claiment Francis Frey 2005 Dodge Stratus CHP report 16339 Enclosed is an estimate from Antioch Auto Body for repairs to Mr Freys auto .The estimate is $2,793.36 plus he had to replace a tire which had the side wall ripped. The bill in the amount of$140.98 from Big O Tire is enclosed. Two more estimates were made by American Auto Body at 3,134.52 and Jims Auto body at 3,288.30. For further settlement you can reach Mr Frey at 925-757-8991. Thanks for taking care of this claim John Slatten Trusted Cho,ceW 11/02/2006 at 11 : 35 AM Job Number: 31033 ANTIOCH AUTO BODY, INC. License # : 37962 Federal ID # : 680336031 1401 VERNE ROBERTS CIRCLE ANTIOCH, CA 94509-7915 (925) 757-3586 Fax: (925) 757-5246 PRELIMINARY ESTIMATE Written By: Gary Rains Adjuster: Insured: FRANCIS A. FREY Claim # Owner: FRANCIS A. FREY Policy # Address: 3037 ENEA WAY Deductible: ANTIOCH, CA 94509 Date of Loss: Day: (925) 757-8991 Type of Loss: Point of Impact: 11 . Left Front Inspect ANTIOCH AUTO BODY, INC. Business: (925) 757-3586 Location: 1401 VERNE ROBERTS CIRCLE ANTIOCH, CA 94509-7915 Insurance Company: Days to Repair 2005 DODG STRATUS SXT 6-2 . 7L-FI 4D SED CHARCOAL Int: VIN: 1B3EL46J45N546719 Lic: 5HIN886 CA Prod Date: Odometer: 28285 Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Theft Deterrent/Alarm Body Side Moldings Dual Mirrors Roof Console Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors Power Trunk/Tailgate AM Radio FM Radio Stereo Search/Seek CD Player Driver Air Bag Passenger Air Bag Cloth Seats Bucket Seats Automatic Transmission Overdrive Aluminum/Alloy Wheels ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 FRONT BUMPER 2** Repl RECOND Bumper cover w/o fog 1 258 . 00 1 . 6 2 . 8 lamps 3 Add for Clear Coat 1 . 1 4 Repl Medallion 1 20 . 50 0 . 2 5 Repl Absorber 1 100 . 00 0 . 2 6 FRONT LAMPS 7 Rep LT Headlamp assy 1 244 . 00 Incl . 8 Aim headlamps 0 . 5 9 HOOD 10 Blnd Hood 1 . 4 11 WINDSHIELD 12 R&I RT Nozzle 0 . 2 1 11/02/2006 at 11 : 35 AM Job Number: 31033 PRELIMINARY ESTIMATE 2005 DODG STRATUS SXT 6-2 . 7L-FI 4D SED CHARCOAL Int: ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 13 R&I LT Nozzle 0 . 2 14 FENDER 15 Repl LT Fender 1 329. 00 2 . 5 1 . 9 16 Add for Clear Coat 0 . 8 17 Add for Edging 0 . 5 18 Deduct for Overlap -0 . 4 19 FRONT DOOR 20 Bind LT Door shell 1 . 2 21 Repl LT Side molding graphite met. 1 76. 60 0 . 3 0 . 5 22 R&I LT Mirror w/o foldaway 0 . 3 23* R&I LT Run charnel upper 0 . 2 24 R&I LT Handle, outside graphite 0 . 4 met . 25 R&I LT R&I trim panel 0 . 5 26 WHEELS 27 Repl LT/Front Wheel cover code W5D 1 51 . 75 from 7-6-01 28# Rept COVER VEHICLE FOR OVERSPRAY 1 7 . 50 0 . 5 29# Repl FLEX ADDITIVE 1 10. 00 T 30# HAZARDOUS WASTE 1 5. 00 X 31# Refn COLOR MATCH 0. 5 ------------------------------------------------------------------------------- Subtotals =_> 1102 . 35 7 . 2 10 . 7 Parts 1087 . 35 Body Labor 7 . 2 hrs @ $ 70 . 00/hr 504 . 00 Paint Labor 10 . 7 hrs @ $ 70.00/hr 749. 00 Paint Supplies 10 . 7 hrs @ $ 30. 00/hr 321 . 00 Sublet/Misc. 15 . 00 ---------------------------------------------------- SUBTOTAL $ 2676. 35 Sales Tax $ 1418 . 35 @ 8 . 2500% 117 . 01 ---------------------------------------------------- GRAND TOTAL $ 2793 . 36 ADJUSTMENTS : Deductible 0 . 00 ---------------------------------------------------- CUSTOMER PAY $ 0 . 00 INSURANCE PAY $ 2793 . 36 2 11/02/2006 at 11 : 35 AM Job Number: 31033 PRELIMINARY ESTIMATE 2005 DODG STRATUS SXT 6-2 . 7L-FI 4D SED CHARCOAL Int: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS : D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRP_ME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS : ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR R--=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS: #=MANUAL LINE ENTRY *=OTHER [IE . .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE . MQVP=MANUFACTURER' S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR3PM01 Database Date 10/2006, CCC Data Date 10/2006, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are ava_lable at OE/Vehicle dealerships. OPT OEM (Optional OEM) or ALT OEM (Alternative OEM) parts are OEM parts that may be provided by or through alternate sources other than the OEM vehicle dealerships. OPT OEM or ALT OEM parts may reflect some specific, special, or unique pricing or discount. OPT OEM or ALT OEM parts may include "Blemished" parts provided by OEM's through OEM vehicle dealerships. Asterisk (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RC:', or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto Glass Specifications. Labor operation times listed an the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (4) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator has a complete list of applicable vehicles. Parts nimnbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. 3 11/02/2006 at 11 : 35 AM Job Number: 31033 PRELIMINARY ESTIMATE 2005 DODG STRATUS SXT 6-2 . 7L-FI 4D SED CHARCOAL Int : ALTERNATE PARTS SUPPLIERS 2 RECOND Bumper cover w/o fog Part No. CH1000407R Price $258 . 00 Keystone - Complete (360) 733-7585 1538 KENTUCKY STREET (800) 538-3388 BELLINGHAM, WA 98229 4 n _ m • man j 100 •• m0 � mezzo .m_n - o� �O o �y �o m ;�s€ •m-TT, _4mm J.J bCJi'.L im p a - nm9m -� 2bor N ❑ < m m> F, mo-v- n rn w ❑❑❑❑ m 7P m �<❑m o m� my g < v mD m 370 T O VI 2 2 -n 71 D D x cJr 9 = n= 3r cn >b C i m rn �Z�O O OI 77 7T m D D D m C m �m av n -i M - +C W r I C C Zm mZ m m m C') T. 37 y-Ir n C-J: T, T. T, pr Dm m 2r Zm T m Kmo am�� W = o r c �� o (D m- % '� z v: a rn cn rn cn m m m m zm 3 m c T� no (n 9y9 .� r.. -% O v m cn z rn Or z a; v 'o O m 2 9 x 0 - m rn a 9 uJ c1 -I --I m v a m = r =1 �' m m m m m r D n z n " ^' J ❑ `L m r QJ p z m = y y C T. O 9 r o'z 0 i� = 9 9� p' o In 9 N:0 C C:O O C1 O O �. 90 ❑❑N cn. m Gz1 m o m =bmm D i s ❑ o -1 x; y: D m `e ,nT�x c m _ m o mo C r 9 S Z cn I O.'D [n. fn.D r D m O. 31 m 00 m n m (n -i ❑.❑❑ m r• r O C SJ C❑C N z m ❑ ❑ tom N ::.-n - m rOv 70 -X!U) %W D D D D O =cn m p�m ..J z o 9❑� ❑z off' jT eo9 RI ?m ❑ p ❑ ❑ mm I =:2 77 ❑. r ❑ s3os 77 ❑ r r -7 O 9� y:... ❑s n r .:;Z 2 7o D ❑ r 0. ❑❑❑❑:D a m O ❑' O _nv,y ;ymxz n '' 9 x ❑':� �3 T�•m mrMs=mXT.mq� ❑ ❑❑m m _ �x ❑ T mm 3731... T STT TTITm. m :omod.m m m ❑ ❑ i`N DD OO.::N � �Ob. .. O3]3J 319 7JT 3JT l�yD j 1:;L.iV b ,�mym i T O o - milnn yZ±T 1 I y a ' D T .1:.....;. ..3 rM C 2 rO mtjmx Foam', .i' EVC ppm: i... :•:... , � ccy D cn-i m z m m m mm El z mm m z 'N:m o m `n 9ycin0 n c7< I ❑❑ c O opz _ ■ .:zmN x • -4 c ❑❑:0 ac c y : D : cn i z0000 C -71� ti y� mx. m z ..m D � N mc1a�D - ❑. -p C '�y p Cp m 1m Z \ z000m :0::! m 1m ' m r ED N m fY rmv ymi m m o a m .� � M \ �zz T ..v G . m o O m opcp O .. m 33 m P7 Z `"imm z 73 !� .f 5i En CI) y 2 �mym < zm :E"mm m A= r O � a 9 0 .:p:..:;.m .:�:':;ir;;..:::_..:•. .. :. ?mem cn m m .. .r::..c' �.y � 4 r: mMDm :�..�.y 1 N 'o r7 z m i m m CGrl 3PKI' "� � � � � � ❑off 3 7 c CUSTOMER COPY Date: 11/ 2/2006 12:08 PM Estimate ID: 2127 Estimate Version: 0 Preliminary Profile ID: AAB *********SHOP POLICY********* REPAIRS/DEDUCTIBLES ARE TO BE PAID UPON DELIVERY OF VEHICLE. PLEASE MAKE ARRANGEMENTS TO HAVE CASH, INSURANCE CHECK, CREDIT CARD, OR CASHIER'S CHECK AT THAT TIME. NO PERSONALL CHECKS. INITIAL HERE: AMERICAN AUTO BODY 3001 NORTH PARK BLVD PITTSBURG, CA 94565 (925) 432-9910 Fax: (925) 432-9936 ,._.. ..>. ,Tax.ID.;.:,68. 0581726..._.B4R_?#,::,,.ABQ76560.._, EPAA.:.,-C.AL000276002.... . . ...:.......... ::.. - -_-•<..,r. Damage Assessed By: Ebay Singh Deductible: NONE Owner FRANCIS FREY Mitchell Service: 918529 Description: 2005 Dodge Stratus SXT Vehicle Production Date: 10/04 Body.Style: 40 Sed Drive Train: 2.41- Inj 4 Cyl 4A FWD VIN: , 1B3EL46J45N546719 License: 5H1N886 CA Mileage: 28,287 OEM/ALT: O Search Code: None Options: ALUM/ALLOY WHEELS, AIR CONDITIONING, POWER STEERING, POWER WINDOWS POWER DOOR LOCKS, TILT STEERING WHEEL, CRUISE CONTROL, ELECTRIC DEFOGGER AUTOMATIC TRANSMISSION, AM-FM STEREO/CDPLAYER(SINGLE) All Crash parts on this estimate are "new" original equipment manufacturer parts, unless otherwise specified. Parts described as rechromed, recored, remanufactured or, reconditiond are considered "rebuilt" parts. Crash parts described as "quality replacement part" a,r••e.=non-.original equipment manufacturer. Line Entry Labor Line Item Part Type/ Dollar Labor Item Number Type Operation. Description Part Number Amount Units 1 802341. BOY REMOVE/REPLACE FRT BUMPER COVER 4805897AB 370.00 1.6 2 AUTO REF REFINISH FRT BUMPER COVER C 3.0 3 802343 BOY REMOVE/REPLACE FRT BUMPER ADHESIVE MEDALLION 4805899AB 20.50 0.1 4 802086 BOY REMOVE/REPLACE FRT BUMPER IMPACT ABSORBER 4805898AB 100.00 0.2 # 5 802349 BOY REMOVE/REPLACE . L FRONT COMBINATION LAMP ASSEMBLY 4805821 AC 244.00 INC 6 AUTO . BOY CHECK/ADJUST HEADLAMPS 0.4 7 800055 REF BLEND HOOD OUTSIDE C 1.0 ESTIMATE RECALL NUMBER: 11/ 2/2006 12:08:29 2127 UltroMote is a Trademark of Mitchell International Mitchell Data Version: OCT-06_V Copyright (C) 1994 - 2003 Mitchell International Page 1 of 3 UltroMate Version: 5.0.215 All Rights Reserved Date: 11/ 2/2006 12:08 PM Estimate 10: 2127 Estimate Version: 0 Preliminary Profile ID: AAB 8 801676 BOY REMOVE/INSTALL R HOOD WASHER NOZZLE 0.2 # 9 801677 BOY REMOVE/INSTALL L HOOD WASHER NOZZLE 0.2 #t 10 800173 BOY REMOVE/REPLACE L FENDER PANEL 5018849AS 329.00 2.0 # 11 AUTO REF REFINISH L FENDER OUTSIDE C 1.7 12 AUTO REF REFINISH L FENDER EDGE 0.5 13 801236 BOY REMOVE/REPLACE L FENDER LINER 4814759AD 52.10 INC 14 801237 BOY REMOVE/REPLACE FRONT BODY BATTERY TRAY 4646511AC 45.25 1.0 15 801942 BOY REMOVE/REPLACE WHEEL COVER WA26PAKAA 51.75 16 L FRONT 17 800776 REF BLEND L FRT DOOR OUTSIDE C 0.9 18 800790 BOY REMOVE/INSTALL L FRT DOOR MIRROR 0.2 # 19 801608 BOY REMOVE/INSTALL L FRT OTR BELT MOULDING 0.3 20 800802 BOY REMOVE/INSTALL L FRT DOOR TRIM PANEL INC 21 800814 BOY REMOVE/INSTALL L FRT OTR DOOR HANDLE 0.6 # 22 ;._ 802606 -GLSREMOVE/INSTALL L FRT DOOR GLASS WEATHERSTRIP Existing 0.3* Y2g.,....-931104 MCH:...._.,.REPAIR:..::..__,.. .......:-. FRONT°'END ALIGfJMENTe... �.....:-.:..:. Sublet;. ... 70 00.. INC 24 936012 ADD'L COST HAZARDOUS WASTE DISPOSAL 3.00 * 25 936014 ADD'L COST FLEX ADDITIVE 10.00 * 26 AUTO REF ADD'L OPR CLEAR COAT 1.9* 27 933003 REF ADO'L OPR TINT COLOR INC 0.5* 28 933005 BOY ADD'L OPR RESTORE CORROSION PROTECTION 8.00 * 29 AUTO REF ADO'L OPR FINISH SAND AND BUFF INC 2.8 30 933018 REF ADD'L OPR MASK FOR OVERSPRAY 5.00 * 31 AUTO ADO'L COST PAINT 304.00 * * - Judgement Item # - Labor Note .Applies C - Included in Clear Coat Calc Add'I Labor Sublet I. Labor Subtotals Units Rate Amount Amount Totals II. Part Replacement Summary Amount Body 6.8 72.00 8.00 0.00 497.60 Taxable Parts 1,212.60 Refinish 12.3 72.00 5.00 0.00 890.60 Sales Tax @ 8.250% 100.04 Glass 0.3. . 72.00 0.00 0.00 .2.1_.60 Mechanical 0.0 90.00 0.00 70.00 70.00 Total Replacement Parts Amount 1,312.64 Non-Taxable Labor 1,479.80 Labor Summary 19.4 1,479.80 III. Additional Costs Amount IV. Adjustments Amount Taxable Costs 304.00 Insurance Deductible 0.00 Sales Tax 8.250% 25.08 Customer Responsibility 0.00 Non-Taxable Costs 13.00 Total Additional Costs 342.08 ESTIMATE RECALL NUMBER: 11/ 2/2006 12:08:29 2127 UltraMate is a Trademark of Mitchell International Mitchell Data Version: OCT-06_V Copyright (C) 1994 - 2003 Mitchell International Page 2 of 3 UltraMate Version: 5.0.215 All Rights Reserved Date: 11/ 2/2006 12:08 PM Estimate ID: 2127 Estimate Version: 0 Preliminary Profile ID: AAB I. Total Labor: 1,479.80 II. Total Replacement Parts: 1,312.64 III. Total Additional Costs: 342.08 Gross Total: .3,134.52 IV. Total Adjustments: 0.00 Net Total: 3,134.52 This is a preliminary estimate. Additional changes to the estimate may be required for the actual repair. Inspection Date: 11/ 2/2006 ESTIMATE RECALL NUMBER: 11/ 2/2006 12:08:29 2127 VltraMate is a Trademark of Mitchell International Mitchell Data Version: OCT_06_V Copyright (C) 1994 - 2003 Mitchell International Page 3 of 3 UltraMate Version: 5.0.215 All Rights Reserved , , '1.•,•• ---- v.wc- s.:.g%Y�"lji'^r.!ll!�.. '1: - .��: ,.. stir. %1�... �°' . ±a 4 V 1• LLJ CD V-100 Vrsil, O']:Lo••Z Ln •[- E EA tCD C cn LO LO ' fit„ .f` 'w.-ti';.'�{o;., fi:�,.:', � �, '�SY' :•# .� �::''''.:t t- ilc':A•• ,r,yi, y.`. .* ,�ti. v�::R• yti � •1 p�9 �. A. Ln ni Ln J roA _-•�;;. :...•�': y.;��n' �.��r �,fp' N.�,r * �.;. ,a�.:.'�; Wit,. r i�• � .�'faFi'til�� ti' T'.`'-YY� ..,.. 1�1t•® IIA rn �c f;`�i"t�r�'� 8 tom; 1':• "�: �� 4. m t. `t•.j '.A., -:,;y,�L' yd,, '. rY . � 'w^,' .• : ro.$-Cm .. + ja bowl M�. ,4 Ai,RP ';.+Jt.ar+1tac.x;w?=;' r, „1"fr. .•, f r Y, '"'_�'.+,•_ .Nei'i:�a:�:�•: _.'�:l�� ' 61�t'�.. 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