HomeMy WebLinkAboutMINUTES - 01162007 - C.5 (15) ' CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY •
BOARD ACTION:JANUARY 16,_ 2007
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
RT .�- - Supervisors. (Paragraph IV below),
given Pursuant to Government Code
AMOUNT: $2 ,000. 00 Section 913 and 915.4. Please note all
DEL c,o96 D�
"Warnings".
CLAIMANT: JOHN BROWN COUNTY r71 1 "^ L
MARTINLG '.
ATTORNEY: UNKNOWNDATE RECEIVED: DECEMBER 18 , 2006
ADDRESS: 1680 DETROIT AVE. #203 BY DELIVERY TO CLERK ON.HAND
18 , 2006
CONCORD, CA 94520
HAND DELIVERED
BY MAIL POSTMARKED:
FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN CULLEN, ler
Dated: DECEMBER 18 , 2006 By: Deputy
11. FROM: County Counsel TO: Clerk of the Board of S ervisors
( This claim complies substantially with Sections 910 and 910.2.
( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so
notifying claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and
send warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: la— / By: Deputy County 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. ,DOARD ORDER: By unanimous vote of the Supervisors present:
( This Claim is rejected in full.
O Other:
I certify that this is a true and con-ect copy of the Board's Order entered in its minutes for
this date.
Dated. o JOHN CULLEN, CLERK, ByA�9�Deputy Clerk
WARNING (M. c de section 913)
Subject to certain exceptions,you have only six(6) months from the date this notice was personally seined
or deposited in the snail 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 widt this matter. If you want to consult an
attontey,you should do so int ne(liately. *For Additional Warning See Reverse Side of'This Notice.
AFFIDAVIT OF MAILIN
1 declare under penalty, of )erjury that I am now, and at all times herein mentioned, have
been a citizen of the Unite States, over age 18; and that today 1 deposited in the United
States Postal Service in plat ntez, California, postage fully prepaid a certified copy of this
Board Order and Notice to Aahnant, addressed to the claimant as shown above.
Dated: J6HN CULLEN, CLERK By eputy 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 inust 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.
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RE; Claire By: Reserved for Clerk's filing stamp
RECEIVED
Against the County of Contra Costa or., ) DEC 1 8 2006
vrr�/ )
District
) CLERK BOARD OF SUPERVISORS
(Fill in the name) I CONTRA COSTA CO.
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named
district in the sum of$ 7, .e CiO and in support of this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
2. Where did the damage or injury occur? (Include city and county)
3. How did the damage or injury occur? (Give full details;use extra paper if r( quired)
4. What particular act or omission on the part of county or district officers, servants, or employees
caused the injury or damage?
5 What are the names of county or district officers, servants, or employees causing the
damage or injury?
6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estiuuates for auto damage.)
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.)
8. Names and addresses of witnesses, doctors, and hospitals:
9. List the expenditures you made on account of this accident or injury:
DATE TI1\4E AMOUNT
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.Gov. Code Sec. 910.2 provides "The claim shall be
signed by the claimant or by some person on his
behalf."
SEND NOTICES TO: (Attornev— a
Name and address of Attorney )
(Claimant's Signature)
(Address)
1,12
Telephone No. )Telephone No.
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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.
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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 alloy 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 imprisomnent and fine.
John Brown
12-18-06
Claim By:
John Brown
Against:
Against the County of Contra Costa or
Contra Costa Regional Medical Center
!. When did the damage or injury occur?
August 29, or the 30`h of 2006
2. Where did the damage or injury occur?
Contra Costa Regional Medical Center, Mental Health Department
2500 Alhambra Ave. Martinez, Ca
3. How did the damage or injury occur?
On August 291h or the 301h, I was transported to the medical center mental health
department for 50-1-50. When I first arrived, I was in isolation then moved to a
room of 8 to 9 beds. In the room was another patient was in the room turning beds
over, throwing things. After falling asleep the other patient came over me and
started punching me in the face, hitting me on the left side of my face and eye. I ask
the head nurse to do an accident report but on was never done, but I was told that
they charted the accident.
4. What particular act or omission on the part of county, or district officers, servants,
or employee cause the injury or damage?
The other person that was in the room with me should have been in isolation, or a
room to himself. When a person is turning beds and throwing things that person is a
danger to others and the nurses over looked that.
5. What are the names of county or district officers, servants, or employees causing
the damage or injury?
Contra Costa Regional Medical Center Mental Health Department,
6. What damage or injuries do your claim resulted?
Ever since I got hit in the face around my eye have been sore to touch, shutting
pain, my eye jumps all the time, it is all was running, in the morning when I wake
up my left eye is caked with puss, my vision has changed, and I was given eye-
drops, the first week the left side of my face was swollen.
7. How was the amount claimed above computed?
For pain and suffering
8. Name and addresses of witnesses, doctors, and hospital
A) Nursing staff at C.0 Regional Medical Center in the mental health
department
B) Eye doctor- DR. Robert Turcios, 61 Chilpancingo PKWY. Pleasant Hill,
CA (925-676-8365)
C) DR. Paul Sarvasy- C.C. Regional Medical Center( Medical Doctor)
9. List the expenditure you made on account of this accident or injury?
I will have to buy new glasses that or going to cost me $139
John Brown