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MINUTES - 06201995 - 1.21
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA June 20, 1995 Clair A;ainst the County, or District governed by) BOARD ACTION Routing Endorsements, TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Governnent Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $282.53 ction 913 and 915.4. Please note all "Warnings',. CLAIMANT: Michael M. Conlon MAY 3 1 1995 ATTO?5E Y: COUNTY COUNSEL MARTINEZCALIF. Date received ADDRESS: 4952 Cache Peak Drive BY DELIVERY TO CLERK ON May 31, 1995 Antioch, CA 94509 BY MAIL POSTMARKED: Hand Delivered via: Risk Mgmt. 1. FROM: Clerk of the Board of Supervisors 70: County Counsel Attached is a copy of the above-noted claim. 8Y DATED- i,3 , 1995 _. JpyH1L BATCHELOR, Clerk : eputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS tocomply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Clair is net timely filed. The Clerk should return claim on ground that it.was filed late and seed warning of claimant's rig*t to a:ply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 3/ S BY: 69:2__=__Peputy County Counsel 111. F;C:4: Clerk of the Beard TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. fi �;:: _ER: By unanimc.;s rete of the Scperviscrs present (�' 1 T!-is Claim is rejected in full. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: °PHIL W CHELOR, Clerk, ByaO.00A�. Deputy Clerk WARNING (Gov. code section 913) S,;tject to certain exceptions, you have only six (6) months from the date this notice was personally served or repcsited in the mail to file a court action on this claim. See Government Code Section 945.6. vc� *r:cy seek the atv•ce of a* attorney of your choice in connection with this matter. If you want to consult ar attcrne,. y::, v c.,lc d: s: immediately. It For Additional Warnine, See Reverse Side Of This -Notice. AFFIDAVIT OF MAILING 1 rE:Ia-e under penalty of perjury ;tat I am now, arc at all times herein mentioned, have been a citizen of the *=:e� States, over aoe 1:; and that tctay I dE.-osited in the United States Postal Service in Martinez, Ca' .f:-nia, pcstace fully pre;aia a cert.`ec ::Dy c' tt4s h:)a-d Order and hctice to Claimant, addressed to .re cla -.a as st:40^ :_.e Q p BY: PHIL Ea'CwE_OR tyrAA10&A.ZeutyI Clerk Cc.rty Av-ir•.strat:.r Cla:- to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIRANI' A. ::limos relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or tolpersonal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this f orm. RE: Claim By ) Reserved for Clerk's filing stamp D�r,•� ) : RECEIVE® A*)Tz oc. � C A c7-'-f Sv r ) Against the County of Contra Costa ) AN 3 ' or ) IM V/i4`. District) CLERK BOARD OF SUP VISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ Zg 2- 5 3 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) &g511E'[3 -X00b C147 LLA c9n CAA-SCR 4�-o40j dog' koonSLI V4C-(— aO 6�. 3. How did the damage or injury occur? (Give full details; use extra paper if, required) SES 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? �. wnat are the names of county or district officers, servants or employees causing • the damage or injury? %6 - 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) $. Names and addresses of witnesses, doctors and hospitals. 5 - -------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM. tr- r � - AMOUNT �__-':rat!► Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney AL-, t� t �. fV� Claimant's Signature Address. Telephone No. 4 Telephone No. -7-79 - a 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 ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such im-priso-went and fine. 1 3.'How did the damage or injury occur? I was driving Northbound on Vasco Road, a car was coming Southbound. The cars tire hit one of the yellow reflectors on the double yellow line in the middle of the road and it popped off. When it popped off it flipped into the air and came right through the middle of my front windshield. I was very lucky; the reflector did not hit me, or my son who was in his car seat on the passenger side. 4. What particular act or omission on the part of the county or district officers, servants, or employees caused injury or damage? The bonding adhesive that holds the reflector to the road came loose causing a dangerous object to be in the middle of the road. I do have the reflector in my possession. 5. What are the names of county or district officers, servants or employees causing the damage or injury? I believe the claim would be against the Transportation, or Roads Department. 6. What damage or injuries resulted? Damage to my front windshield. Luckily, no bodily injury was incurred. Repair bill for the windshield is attached, along with full pictures of the damage. 7. How was the amount computed? I called 3 or 4 windshield installers for the least expensive replacement. 8. Names and addresses of witnesses? There were none. Only the pictures of the damage and of the reflector I have. 9. Expenditures made on account of this accident? Date: 03/21/95 Item: Front Windshield Amount: $282.53 Dear Sirs: This claim was originally submitted to Cal-Trans after the accident happened. I later found out it was not in their jurisdiction, but the counties. I apologize for the delay. Please give me a call should you have any questions or need any additional information. Lei STATE OF CALIFORNIA•DEPARTMENT OF TRANSPORTATION CLAIM AGAINST DEPARTMENT OF TRANSPORTATION/FOR AMOUNTS $11000 OR LESS LD:0274 Page 1 of 2 Front r r PERSONAL INFORMATION NOTICE Pursuant to the Federa(Privacy Act(P.L.93-579)and:he information Practices Act of 1977(Civil Code,Sq .1 S78r,etee ;-police is hereby given for the request of personal information by this form. The requested personal information is voluntary. The principle purpose of the.volurrti3`ry"information is to-facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of perslmal information will be made unless permissible under Article 6,Section 1798.24 of the IPA of 1977. Each individual has the right upon.request and proper identification,to inspect"all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on informs YndTnfeiaance to the ansportation;Legal Unit,IPA Forms icer. This form is to be used when filing a Naim against the Department of Transportation as provided in Government Code Section 935.7. PLEASE: print or use typewriter when filling out form. CAUTION: ClafWs fir road repair(Chip Seal)damage • sign and date claim form. must be received within 30 days of the (UNSIGNED AND UNDATED FORMS WILL NOT BE PROCESSED.) incident. All others within 6 months. STATE uSE ONLY FILE NUMBER 1. NAME: LAST FIRST��`�rr tZ—" DLE M P—/ D 50 ^ �( HOME ADDRESS BUSINESS PHONE HCME PHONE (S70 ) _1'T —b79`T CITY STATE — ZIP CODE 45r[CDC-44 1 TIME OF INCICFNT J DATE OF INCIDENT 2. PUT A SPECIFIC TIME AND DATE WHEN THE DAIMAGE FIRST OCCURED i AM / PM 3 /D L�S 3. STATE THE LOCATION OF THE INCIOEI.T VJITH'N ONE-HALF MILE(CITY,COUNTYI HI 3HWAY,AlEAREST OFF-RAMP,CROSS STREET OR POST MILE). I G1T�I: a Tzc � (f rN:cin;2A '_S5 A . o : VASCO POC!-,o i•(onx-` 6)cy Y 1004'-r_W : bu was DRtJINi-bm� LO(� M son I p(r�(�-vp - 4. EXPLAIN HOW THE INJURY OR DAMAGE OCCURRED. C.q.fL 1455 - o5 Ong O1= _Tv1e Y600'0 Ili! MLAO{E Oar E a'0A-0 A-r\D I 1 1�L'z�[)._ ��nc .. T^t���-"�!�4 Mcg FfL.erti'i' c��,v�.S M�t,�z,� • c.��. c..�12.� Lvr..K c-I n �/J _ rcAme `�G wo<�(� / r _ YV1 `4L �r✓ t c�wtcX.S � —_' bAe Ctf OS L'0&4& f}cJieq- WHAT PARTICULAR ACT OR OMISSION 014 1 HE PART OF CALTRANS OR ITS CONTRACTOR CAUSED THE INJURY OR DAMAGE? /Cos �y 44 w i {n A t WHAT INJURY OR DAMAGE DO YOU CLAIM RESULTED? n � WHAT IS THE DOLLAR AMOUNT OF YOUR CLAIM FOR DAMAGES? (SUBMIT TWO ESTIMATES OR PAID RECEIPTS) 5. INSURANCE INFORMATION IS REQUIRED I NAME OF INSURER ARE YOU THE REGISTERED OWNER? YES � NO F] INSURANCE YOU SUBMITTED A CLAIM TO YOUR YES NO INSURANCE CARRIER. IF YES, WERE YOU PAID? FOR WHAT AMOUNT? $ I`•; •: :r t�: YES � NO VEHICLE INFORMATION MAKE OF VEHICLE YEAR LICENSE NO. t..f{ssprA _P t cK - vp cK-- I I 1 9 k1 S) L3 6--) I HEREBY CERTIFY UNDER PENALTY OF PERJURY, THAT THE FOPVGOlNG ACTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE OF CLAIMANT 01DATE REVERSE SIDE FOR STATE USE AND FILING INFORMATION ON CLAIMS STATE OF CALIFORNIA—BUSINESS, TRANSPORTATION AND HOUSING AGENCY PETE WILSON, Governor DEPARTMENT OF TRANSPORTATION ' BOX'23666 OAKLAND, CA 94623-0660 (510) 286-4444 TDD (510) 286-4454 May 3 , 1995 Michael Conlon 4952 Cache Peak Drive Antioch, CA 94509 Location: CC-NSH D/I 3-10-95 Regarding: Claim No. D950445 The Department of Transportation rejected the above entitled claim since the site of the alleged incident was not owned controlled or maintained by Caltrans. Our investigation shows that the location of the incident leading to your claim is the probably the responsibility of the.. County of Contra Costa or the City of Brentwood ( see attached info) . I am returning a copy of your claim and original receipts and/or estimates; I have made copies for our files. Sincerely, Y DA HENDERSON District 4 Claims Officer Attachment 05-22+95 11 :22AM POI fax transmittal State of California-DeparMent of Transportation CALTRANS District 4 CLAIMS UNIT 111 GRAND AVENU OAKLAND CALIF. r� Datc: 5 '" Total Pages Fax No. From: CAPMA BODY Telephone: (510) 286-5807 Fax No. 285-4638 Message Mailing Address: mt Office Box 23660 Oakland, CA 94623-0664 OJ-22-9J 11 ;22AM FO2 10 I 11 i 12 13 14 70 E46FNMa o•• .,.r;.� —_ �/I rancwELG ; Is.AHe % ..��ntrnrr�r�' .,�\� .....__...._._ Alameda�- ��=U f QRADfORO g and �' EmnatOAC V ntra Costa J ^• Counties SHERWAN ISLAND �"� '•+� F^ �Y/ �, ATAE1r4C7��. ".;r,urw•'h\. a ', LEGEND rryT �`'"4lrwnet �:`ii fq.uAR TA,cr F .I, .,: � p �,_ ♦4` v Bs FREEWAYS CIN WITH C.B.A.A.O°FILE st. _.. . ... s \}.._ Fri....... .. . ..� .. -.A�rr.,�s�nA.ti7t�..�.:: " alawl– a■rM EkVItHW a5WAY8 �i INTERSTATE HOA°NUMEEA �1•+: yq ` ,` �• MAIN HIGHWAVS U.S.HIGHWAY NUMBERS •• \ 'aLfNa II. pIANQ p' '�'*+y i� ARtA J ��r` OTHER PAVED ROAD STATE HIGHWAY NUMBERS nI 'Ilur. li7ltu !{'IELAwQ 4 1� )+ OWNBY II ♦ 1.1 'b`\ •�)' SURFACE NOT INDICATED � COUNTY ROAD NUMBER$ tatAUD \ .dau, L..r; gB';., \fir BAYlw=r ea•n 7nb[A E,7NETR'N • TOURIST 4TTRACTIONS,FACILITIES ,7 %"... �y,a ;frm• y.•,..z. ktft p,I". :I• i:. .,.��ll;'' e" _+yyy ` _„. F STATE ROADSIDE REST Qi COUNTY BEAT • COY WITH AWY.PATROL OF _ +t• +;•,, - •wla�=Puca � a v, {��:•' OFFICIAL SCENIC NWI'• i rD GCLF COURSE I O7VEANMEVT CAMPOI t �.•-N ,.Lee.tr = •\� 'roLLANo `Ma7'T� 4M•V IS M16ME BEIW EEN TOWNS AND JUNCTIONS 1 Ro S3� ,QBkley m .�. 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A A y �-..' j�l� 1 �I ,3e �-,J j..�,� y ��� ;''�y'fit y #:.#1_:.,�•,� � �>r > 1 _,: ,,. i irr:..� � ,. r fim`.-#..'ya Rae^. ..� „VJ _ �._._J _ - s :;. ., "3 \�� � �v.. ,✓_ �J, i 3{ 1 _ ..a 'may- �''r���x„� �� � ��.a$ 'rFJ V..,�'1 p _.-..✓- tiav i Z•f_.J:;",� ._..� ._..... .-a.. u-.r r R ^r `k 1.i_.2�'��_ � R+�a��.se''y.^ au'?:x':v"� j •Y' ��'�aC'SE i'c k�we ZZ'G y"z4S' � ' �i'a'�'�'�'-��'��'�` s ' -.cam.`:��`� '•x"a.-. =�'st,:�s i--.- i.���"�ri�i"�2�� ���.3„a, �-�i. N 4;.i�,slr r;��a���,':'�.�' �^�..�W,'.� �'d�`a'��„�,5c; ro�"���» s�s,'�''��*sa:-€�"��s�."��'�,.��`��.�,»»'v:�'�•���x�F.�"'� �:.k'�'w>�..� '::. � �4 - ' AM]MED i_ CLAIM ��.. BOARD OF SUPERVISORS CSF CONTRA COSTA COUNTY, CALIFORNIA t June 20, '.1:995 Claim Asainst the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy .of this document mailed to you is your notice of California Government Codes.. ) the action taken on your claim by the Board Of Supervisors (Paragraph IV below), given pursuant to Government Code. Amount: Unknown - ctn 913 and 915.4. Please note all "Warnings.,,. m� $ 1.0 CLAIMANT: Jacquiline Valentine JUN r595 AT TO INE Y: Hayes and Mitchell COUNTY COUNSEL c/o Debra A. Hayes MARTINEZCALnte received ACORES$ 1944 Embarcadero BY DELIVERY TO CLERK ON .Tune 1, 1995 Oakland, CA 9 +606 BY MAIL POSTMARKED: May 31, 1995. I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached i s -a copy of the :above-noted claim. 1 1995 JYAl IL BATCHELDATED: Junety COR, Clerk epu II. ffWOFW FROM: County Counsel TO: Clerk of the Boardd.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)0 ( ) Claim is not time1y filed. The Clerk should.. return claim on ground that it was filed late and seed warning of ciaimar 's right to apply for leave to present a late claim (Section 911.3). { ) Other: La to d: BY•• Deputy County Counsel a y y I11. F.;Cs : Cierk of the Board TO: County Counsel (1) County Administratpr (2) ( ) Claim was returned as untimely with notice. to claimant (Section 911.3). IV. BChR., ER: 8 unanimous vote bf the Supervisors present ✓) T+^is Claim is rejected in full. ( ) Otr:e r: I certify that this is a true and correct copy of the Boards Order entered inits minutes for this date. Dated PHIL BATCHELOR, Clerk, BYLC , Deputy Clerk WARNING (Gov. code section 913) Sutject to certain exceptions, you have only six (6).months from the date this notice was personally Served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. Y.ov r-2,v sfek tt'e adv ce cf Zr, a*, orney o; your chc ce in connection with this matter. If you want to consul+, air a 4.orney, y u At�c i'd do s i. ,te i.ateIy, For Additional Warnino See Reverse Side Of This Notice. AFFIDAvIT .OF MAILING • I ca:l awe under .'pendd t}v of per jury that I arm now, arc, at al 1 timeS herein mentioned, have been a citizen of the ::r i:ed c:a tes, over aoe 1.; and that tcday I de�osi tetd in the Ur►i ted-Stat.es Postal Service in Martinez, Ca �c•ni a pcs:ace f u y preps i d a ce- Ed .coy of th'S Board Order and Ni'ot ce to Claimant, addressed to t"e c'z'-ar: ass shown y. AAA BY: PHI! BaTCwELC►R may. Deputy Clerk r v C :.C.ar".y Com::*'CO i 'Cur;,y Admir.,stra or .V 1 DEBRA A.. 'HAYES (113141) Hayes and Mitchell RECEIVED 2 Attorneys at Law 1944 EmbarcaderO 3 Oakland, California 94606 (510) 261-8188 i 4 CLERK BOA OF SUEORS Attorneys for Claimant . SONTRA RA COSTA-CO. 5 * AMENDED' * 6 GOVERNMENTAL CLAIM FOR DAMAGES AGAINST 7 THE COUNTY OF CONTRA COSTA [Government Code, Sec. 9100et seq. ] 8 TO: Shirley Casillas', Secretary 9 Board of Supervisors County of Contra Costa 10 651 Pine Street Room 106 11 Martinez California 94553 12 CLAIMANT'S NAME: Jacquiline Valentine 13 CLAIMANT' S ADDRESS: 102 Chelsea Hills Drive Benecia, California 14 ADDRESS TO WHICH Hayes and Mitchell 15 -NOTICES ARE TO BE SENT. 1,944LEmbarcadero Oakland, California 94606 16 DATE OF ACCRUAL OF CLAIM: December 15, 1994 17 AMOUNT. Not Stated; . see, Govt, Code 18 r Sec.' 910 (f) 19 OTHER CIRCUMSTANCES RELATING TO ACCRUAL OF CLAIM: See Attachment hereto 20 NAME. OF PUBLIC EMPLOYEE(S) 21 CAUSING INJURY: MILT CAMHI, per Attachment 22 ITEMIZATION OF DAMAGES: Contract./Tort; Jurisdiction 23 over the claim would rest in the Superior Court 24 DATED: May 31, 1995 Hayes a d itchel l 25 Attorn s .at L 26 B D' RAA AYES } ATTACHMENT to Governmental Claim of Jacquiline Valentine 1 1. Claimant made application, pursuant to 2 r 3 advertisement for'' the position, about November, 19'.93 , and was hired to begin work about January 15, 1994, as a .Triage Manager 4 g 5 for the CONTRA COSTA HEALTH PLAN, a Division of CONTRA COSTA 6 HEALTH- SERVICES and/or the COUNTY OF CONTRA COSTA. Among 7 claimants-duties were to supervise all triage nursing personnel 8 in two counties, Contra Costa and Solano. .Claimant was hired 9 under a written employment agreement for the first year's 10 service. In November, 19941 claimant was given new contract to continue her position through November, 1995. 11 2 . On or about December 15, 1994, claimant was 12 13 terminated from her position without good cause in breach of 14 her employment agreement. r 3 . Claimant worked directly. for the CONTRA COSTA 15 HEALTH PLAN,. under Executive Director MILT" CAMHI. Beginning in 16 s 17 June 1994, claimant approached CAMHI about an increase in her salar after an outstanding three month review, claimant's 18 � mandator overtime for which she was denied compensation and 19 Y 20 the requirement that she remain "on call'' at all times, ncludin nights and weekends. At this time, with only claimant ., 21 g j I 22 and CAMHI present in the latter's office,, he became verbally 23 and physically enraged at c -aimant's request and blocked 24 claimant' s exit when she tried to escape f rom his of f ice. 25 4 , on or about July 30, 1994, claimant again 26 approached CAMHI about her raise in light of those factors outlined. above (mandatory uncompensated overtime and being Attachment to Governmental Claim of JACQUILINE VALENTINE 2 on-call) ,, ' 1 perpetually - ) , and was heatedly told by him In response 2 that she was "emotionally disturbed" as a result of certain 3 instances of domestic violence claimant had endured at the hand 4 of her former husband 5 5 On another two or three occasions, CAMHI again 6 reproached claimant about her physical, abuse at the hand of her 7 former husband at those times that she made further application 8 for a raise in salary due to the number of hours she was 9 required to work and the fact she was on-call seven days a 10 week, 24-hours a day. 11 6. At all times, claimant rejected CAMHI 's statements that her request for raise was a result of being the 12 g 13 victim of physical abuse by her former husband. 14 7 • In retaliation for rejecting CAMHI 's misconduct 15 in using. pla%ntf f's spousal , abuse to avoid .her -legitimate -claim for a raise, claimant was demoted from theposition for 16 17 which she was hired and her contract renewed to a lower 18 position of Advice Nurse Manager. 19 8. In further retaliation for claimants rejection 20 of that harassment by CAMHI as set forth above, claimant was 21 terminated for not responding to a request for Overtime work 22 which was not part of claimant's job description. 23 WHEREFORE, Claimant prays, as to her non statutory 24 causes of action 25 1. That rate of pay consummate with her contracts of 26 employment, within the jurisdiction of the Superior Court, exclusive of interest; Attachment to Governmental Claim of JACQUILINE -VALENTINE 3 1 2 . Damages for emotional distress as a consequence 2 of sexual harassment, defamation in being terminated not for 3 cause and interference with her contract with CONTRA COSTA 4 HEALTH PLAN, within the jurisdictional limits of the Superior 5 Court; 6 3 . Such other relief as the Board deems proper in 7 the premises. 8 Dated: May 31, 1995. HAYES & MIT ELL 9 10 By D A. YES 11 Attu neys f r Claimant 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Attachment to Governmental Claim of JACQUILINE VALENTINE 4 1 DEBRA A. HAYES (113141) Hayes and Mitchell RECEIVED REC ,E'VED Fr_� 1 2 Attorneys at Law M 1944 Embarcadero M MAY 8 1995 3 Oakland, California ,94606 C-- iA--) (510) 261-8188 CLERK 6 ft0j "D—O F�SU P E R�t V SORS COST C: 4 Attorneys for Claimant A Co. 5 6 GOVERNMENTAL CLAIM FOR DAMAGES AGAINST 7 THE COUNTY OF CONTRA COSTA [Government Code, Sea. 910, et seq. ] 8 9 TO: Shirley Casillas, Secretary Board of Supervisors County of Contra Costa 10 651 Pine Street Room 106 11 Martinez California 94553 12 CLAIMANT' S NAME: JaIc quiline Valentine 13 CLAIMANT' S ADDRESS: 102 Chelsea Hills Drive 14 -Benecia, California ADDRESS To WHICH Hayes and Mitchell. 15 NOTICES ARE TO BE SENT: 1944 Embarcadero Oakland, California 94606 16 DATE OF ACCRUAL OF CLAIM: December- 15, 1994 17 AMOUNT: Not Stated; see, Govt. Code 18 Sec.. .910 (f) 19 OTHER CIRCUMSTANCES RELATING TO ACCRUAL OF CLAIM: See Attachment hereto 20 NAME OF PUBLIC EMPLOYEE(S) 21 CAUSING INJURY: MILT CAMHI, per Attachment 22 23 ITEMIZATION OF DAMAGES: Contract/Tort; Jurisdiction over the claim would rest 24 in the superiorCourt DATED: May 5, 1995 Hayes an Mitchell 25 Attorney at L 26 y: Yv(Z ATTACHMENT to Governmental claim of Jacquiline valentine 2 1. Claimant made application, pursuant to 3 advertisement for the position, about November, 1993 , and was 4 hired to begin work about January 15 , 1994, as a Triage Manager 5 for the CONTRA COSTA HEALTH PLAN, a Division of CONTRA COSTA 6 HEALTH SERVICES. Among claimants duties were to supervise all 7 triage nursing personnel in two counties, Contra Costa and 8 Solano.' Claimant was hired , under a written employment agreement 9 for the first year' s service. In November, 1994, claimant was 10 given a new contract to continue her position through November, 11 1995 . 12 2 . On or about December 15, 1994 , claimant was 13 terminated from her position without good cause in breach of 14 her employment agreement.. 15 3 . Claimant worked directly for the CONTRA COSTA 16 HEALTH PLAN, under Executive Director- MILT CAMHI. Beginning, in 17 June, 1994 , claimant approached, CAMHI- about an increase in her 18 salary after an outstanding three month review, claimant's 19 mand'atoryoVertime for which she was denied compensation and 20 the requirement that she remain "on call,".' at all times, 21 including nights and weekends. At this time, with only claimant 22 and .CAMHI present in the latter's office, he became verbally 23 and physically enraged at claimant.' s request and blocked 24 claimant-Is exit when she tried to escape from his office. 25 4 . On or about July-, 39, 1994 , claimant again 26 approached CAMHI about her raise in light of those factors outlined above (mandatory uncompensated overtime and being Attachment to Governmental Claim of JACQUILINE VALENTINE 2 1 perpetually on-call), and, was heatedly told by him in response 2 that she was "emotionally disturbed" as a result of certain 3 instances of domestic violence claimant had .endured at the hand - 4 of her former husband. 5 5 . On another two or three occasions, CAMHI again 6 reproached claimant about her physical abuse at the hand of her 7 former husband at those times that she made further application 8 for a raise in salary due to the number of hours she was 9 required to work and the fact she was on-call seven days a 10 week, 24-hours a- day. 11 6 . At all times, claimant rejected CAMHI 's 12 statements that her request for raise was a result of being the 13 victim of physical abuse by her former husband. 14 7 . In retaliation for rejecting CAMHI ' s misconduct 15 in using plaintiff's spousal abuse to avoid her legitimate 16 claim for a raises claimant was demoted from the position for 17 whichshe was hired and her contract° renewedto a lower 18 position of Advice Nurse Manager. 19 8 . In further retaliation for claimant's rejection 20 of that harassment ,by CAMHI as set forth above, claimant was 21 terminated for not responding to a request for overtime work 22 which was not part of claimant' s job description. 23 WHEREFORE, Claimant prays, as to her non-statutory 24 causes of action: 25 1.• That rate of pay consummate with her contracts of 26 employment, within the jurisdiction of the Superior Court, exclusive of interest; Attachment to Governmental Claim of JACQUILIKE VALENTINE 3 1 2 . Damages fot emotional distress as a consequence 2 of sexual harassment, defamation in being terminated not for 3 cause and interference with her contract with CONTRA. COSTA 4 HEALTH PLAN, within the jurisdictional limits of the Superior 5 Court; 6 3 . Such other relief as the Board deems proper in 7 the premises. 8 Dated: May 5, 1995. HAYES &. MI C ELL 9 10 B f SRA A YES 11 At rneys or. Claimant ENTINE 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Attachment to Governmental Claim of JACQUILINE VALENTINE 4 HAYES AND MITCHELL ATTORNEYS AND COUNSELORS AT LAW May 31, 1995 Shirley Casillas, Secretary Board of Supervisors County of Contra Costa 651 Pine Street Room 106 Martinez CA 94553 Via FedEx Delivery Re: Valentine v. Contra Costa Health Plan, et al. Dear Ms. Casillas: Enclosed please find an original and copies of that Amended Governmental Claim pertaining to the above-captioned matter. A copy of the original claim is appended. Please endorse a copy as received by the Board and return it in the enclosed envelope. Thank u for your courtesies in this matter. Your v pry truly, A. YES nclosures cc: Client 1944 EMBARCADERO, OAKLAND, CALIFORNIA 94606-5213 TELEPHONE (510) 261-8188 • FACSIMILE (510) 261-8190 ay' yN$ /moi 0 t A cv b ca to ram" to, co O t��.S` 4 �2 j � •moi..""�Qy @�� � � & .k� �m a `�a g Q • ' o, all $.y�s,•Sc. wW OSS o'� m0 ,� S ocr Q Q W Qta 95 -'o s1 yE_ 4 m ~ S�Odw �gy �.sOJO� v Z `., gip': a� • O �n c �n �n >.$ S-" :, �WW . W s1W�' N UOj tS X p Thi yam. .4r'\ -....�..n. 7 c �.� d °°. �/ sr .d� A jrON ..a m 4 w I CLAIM • O� I BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA June 20, 1995 Claim Against the County, or District governed by) BOARD ACTION the 6oa'rd of Supervisors, Routing Endorsements, ), NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government,% Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $856.05 + Section 913 and 915.4. Please note all "Warnin " O/ CLAIMANT; Armando Hermosillo ATTGP"+EY: Steven Kroff, Esq. J U N 0 2 9995 Date received COUNTYCOUNSEI. ADDRESS: 780 Welch Rd. , Ste 103 BY DELIVERY TO CLERK ON June 1, 1995 MARTINEZ CALIF. Palo Alto, CA 94304 BY MAIL POSTMARKED: Interoffice I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IV IL June 2, 1995 BYJL BATCHELOR, Clerkepu II. 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 serd warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( } Other: Dated: —] BY; � j�`_ Deputy County Counsel Ill. FRO": Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOA;: - =ER: By unanimous vote of the Supervisors present (✓) T!is Claim is rejected in full. ( ) Otr:er: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: 9 9 PHIL BATCHELOR, Clerk, By. Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. you Fray seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, y.-u st:c�ld do s: immediately. * For Additional Warning See Reverse Side Of This Notice. AFFIDAVIT OF MAILING I ce:lare under penalty of perjury that I am now, are at all times herein mentioned, have been a citizen of t^e Urited States, over ace 1=; and that tc#ay I de:osited in the United States Postal Service in Martinez, Ca!"f:-ria, postage fully prepaid a ce-t'r'.ed ;coy of triis Board Order and Notice to Claimant, addressed to .re cla`-ar.t as show^. at:ve. J ,'S' BY: PHIL BATCH tykDj e;uty Clerk :[ y C:..rCe i County Ad�^i ni Strator 1 i RECEIVED 1 Steven Kroff, Esq. (State Bar #55818) Nancy Olsen, Esq. (State Bar #170830) 2 KROFF & ASSOCIATES 780 Welch Road, Suite 103 ,,E 3 Palo Alto, CA 94304 CLERK BOARD OF SUPERVISORS (415) 328-8435 CONTRA COSTA CO. 4 5 Attorneys for Claimants 6 NOTICE OF CLAIM AGAINST THE CONTRA COSTA COUNTY SHERIFF'S 7 DEPARTMENT (California Government Code §§ 905 and 910 8 9 In the Matter of the Claim of 10 ARMANDO HERMOSILLO, 11 Claimant, 12 v. 13 CALIFORNIA DEPARTMENT OF CORRECTIONS, MICHAEL ROBERT BOEHRER, and DOES 1 14 through 20, inclusive. 15 ARMANDO HERMOSILLO, hereby present this claim to the CONTRA COSTA COUNTY 16 RISK MANAGEMENT DIVISION, pursuant to Sections 905 and 910 of the California Government Code. 17 18 Claimants' Address: c/o KROFF & ASSOCIATES 780 Welch Rd., Ste. 103, Palo Alto, CA 94304 19 Date of Occurrence: January 3, 1995 20 Place of Occurrence: Westbound Clayton Road near its intersection with Delaware Drive in 21 the city of Clayton, County of Contra Costa, state of California. 22 Said Claim Arises From the Following Circumstances: Michael Robert Boehrer was travelling westbound on Clayton Road in the number 2 lane at approximately 25 to 40 miles 23 per hour carrying six prisoners, claimant included, from the Contra Costa County Jail. A second vehicle was also westbound on Clayton Road in the number 2 lane in front of the 24 vehicle driven by Michael Robert Boehrer. Due to the fog, the second vehicle had a hard time seeing the right turn into the entrance of 5555 Clayton Road. This caused the second 25 vehicle to start to apply brakes. Michael Robert Boehrer, seeing this looked into the number 1 lane to move left, but could not as a vehicle blocked his path, so he continued on in the 26 number 2 lane. The second vehicle made a hard right turn into the driveway of 5555 Clayton Road. Michael Robert Boehrer slammed on his brakes to keep from hitting the second 27 vehicle but was unable to stop in time, causing his front bumper to hit the rear of the second 1 , 1 vehicle. Michael Robert Boehrer contributed to the cause of this collision by being in violation of Vehicle Code Section 21703; following too close. 2 Description of Nature and Extent of Damages or Injuries: Mr. Hermosillo was injured as 3 a result of the accident. Mr. Hermosillo has been diagnosed with cervical sprain/strain and has incurred medical expenses to datetotaling $856.05, which includes an ambulance bill. 4 Mr. Hermosillo has further suffered general damages in an amount oto be determined. 5 6 May 30, 1995 7 8 9 J/ 'Stev6o 9 Attorne f r Claimant 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 2 • ,1 PROOF OF SERVICE BY MAIL - CCP 1013a, 2015.5 2 3 I declare that : 4 I am employed in the county of SANTA CLARA, California. 5 I am over the age of eighteen years and not a party to the within 6 cause; my business address is 780 Welch Road, Suite #103 , 7 Palo Alto, CA 94304 . On May 30, 1995, I served the within: 8 NOTICE OF CLAIM AGAINST THE CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT 9 on the below named, in said cause by placing a true copy thereof 10 enclosed in a sealed envelope with postage thereon fully prepaid in 11 the United States mail at Palo Alto, California, addressed as 12 follows : 13 14 Office of Risk Management Contra Costa County 15 1020 Ward Street Martinez, CA 94553 16 17 I declare under penalty of perjury that the foregoing is true and 18 correct, and that this declaration was executed on: 19 Date : May 30, 1995, at Palo Alto, California. 20 21 /] an Estacio 22 23 24 25 26 27 28 STATE OFCAUPOWSA RAFF. COLLISION REPO C RT PADS &F CNmO"'S NUMBER HIT&RUN 'rY SU,:,, DISTRICT NLOWDER twURED FELONY I I -117 14,AVO I IUMIIIII IIIT�RIIN RING DISTINCT BEAT T KILLED 0. -0;;1- 1:1 , COLLISION OCCURRED ONMo, DAY YEAR TIME(2400) NCIC♦ OFFIZERI.D. z 0 ------------------------------------ 0-7D31 tfole, MILEPOST INFORMATION DAY OF WEEK TOW AWAY, PHOTOGRAPHS BY: OF MILEPOST S M(9WTF S Ovas ONO u 0 EMAT INTERSECTION WITH STATE HWY REL OR: MEET I MILES or -Doc- 6 YES NNO 0 NONE STATE CLAS PARTY DRIVER'S LICENSE NUMBER V;. S%IXFTY VEN.YR MAKE!MODEL I COLOR LICE NUMBER STATE S CA .4 P. 64 DRIVER NAME(RRST,MIDDLE.LAST) . . . . . . PEDES STREET ADDRESS 07 5 NAME SAME AS DRIVER TRI AN El ll e0671 PARKE1 D CITY I STATE I ZIP V;1A14If OWNER 5 ADDRESS ❑ SAME AS DRIVER VEHICLE 1All-X - Z . BICY. six I HAIR "bw oWEIGHT WATHOATE RACE DISPOSITION OF VEHICLE ON ORDERS OF:. OFRCER 01 DRIVER 0 OTHERCUST I - MO. DAY Via 0 BILI ;�;JCS41 eo-NZ 12 Lo ep9 -Dgiyey AWAy OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: I NONE APPARENT REFER TO NARRATIVE C] 'V&40 CHP USE ONLY DESCRIBEVEHICLE TYPE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY mumlkot nUNK. omome MIN" F]MOD. OMAJOR TOTAL DIR.OF ON STREET OR...Al SPEED PCF occ 0 . I" e lb Aj LOOT I'm (3 ju�lad ril-4 S9 -A EL CMP 13 PARTY STATE CLASS I SAFETY VEH.YR. MAKE�MODEL/COLOR LICENSENUMBER STATE (416 1 E41P, 9 Ae D _We 2 Afo q q/ r DRIVER NAME(FIRST.MIDDLE.LAST) . . . . . . . . . . . . . . . . . . . . . . . . . . N - loq6LA IS 4U,&AJ 1�14C- R PEDES. STREET ADDRESS OWNER'S NAME SAME AS DRIVER TRIAN I 11 0 c eIr, PARKED CITY I STATE 121P OWNER'S ADDRESSS AME AS DRIVER VEHICLE PI 0 LA V —T--C sicy. -SEX HAIR t'. HEIGHT WEIGHT I Mo. BIRTHDATE DISPOSTION OF VEHICLE ON ORDERS OF: OFFICER DRIVER OTHER CLtST DAY YEAR 0 Ap . y 1�J -D R I U&Al 40 OTHER HOME PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: APPARENT It REFER TO NARRATIVE 0 0 6,79 to& CHP USE ONLY. DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSTURC WRIER POUICYNUMSER VEHICLE TYPE 0 UNK [:]NONE [:]MINOR A17-69- - -7 UMOD. 0160LIOR [:]TOTAL DIROF JONSTREET OIIHIGIIWAY S"60 PCF occ [3 TRAVEL • CMP 00 PARTY DRIVER'S LICENSE NUM ER STATE. ICLASS I SAFETY VEK YR MAKE I MODEL I COLOR LICENSE NUMBER STATE 3 foulp. DRIVER NAME(MAST,MIDDLE,LAST) • . . . . . . . . El I PEDES. STREET ADDRESS OWNER'S NAME Q SAME AS DRIVER TRI AN 11 PARKED CITYISTATEIZIP OWNER'S ADDRESS VEHICLE [j SAVE AS DRIVER alcy. SEX HAIR, EYES HEIGHT WEIGHT MO. BIRTHDATE DISPOSITION OF VEHICLE ON ORDERS OF: ❑OFFICER ❑ DRIVER ❑OTHER CLtSY DAY • YEAR OTHER HOE PHONE BUSINESS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT ❑ REFER TO NARRATIVE ❑ 0 ( I , ) i CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE UNK El NONE 11 I-NoR MOD, E]MAJOR OTOYAL OFON STREET OR HIGHWAY ---Fsp—tEo PCF KC [] —1 ' l TRAVEL t"TPUG 0 CHI, ❑ PREPPRS AME DISPATCH NOTIFIED IREVIEWER'S N Ar E TE REVIEWED t)c,;4 ice M YES 0 No 0 wA —iz—' - 7 — �2-1--r CHP 555-Page 1 (Rev.7-87)OPI 87 45344 'I RAFFIC COLLISION CODING DATE Of CO TME I asoo) "CIC NlimsEm ER 1.a WNSER MO. A DAY' YEAR /0 T OWNERS NAME I ADDRESS T_4071RED p IPROPERTY# I nYES NO DAMAGE OF_SCRPTIONON OFO A SEATING POSITION OCCUPANTS SAFETY EQUIPMENT M I C BICYCLE jjFuMFT EJECTED FROM VEH. I-DRIVER A-NONE IN VEHICLE L AIR SAG DEPLOYED o•NOT EJECTED 2 TO 6-PASSENGERS 9-UNKNOWN M AIR SAG NOT DEPLOYED DRIVER t FULLY EJECTED I-STA.WGN.REAR C-LAP:ELT USED N OTHER V-NO 2-PARTIALLY EJECTED RR.OOC.TRK_OR VAN 0:LAP ELT NOT USED P NOT REQUIRED W-YES 3,-UNKNOWN POSITION UNKNOWN E SHOULDER HARNESS USED 123 a-OTHER F-SHOULDER HARNESS NOT USED CHILD RESTRAINT PASSENGER 456 aLAP I SHOULDER HARNESS USED 0-IN VEHICLE USED X-NO H: LAP I SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES 7 J-PASSIVE RESTRAINT USED S-IN VEHICLE USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T-IN VEHICLE IMPROPER USE U-NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASTERISK SHOULD BE EXPLAINED IN THE NARRATIVE. PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES 1 13 TYPE OF VEHICLE MOVEMENT PRECEDING LIST NUMBER(#)OF PARTY AT FAULT — 3 COLLISION • A VC SECTION VIOLATED- C18YO.' A CONTROLS FUNCTIO04NG A PASSENGER CAR i STA.WON. I al V. c. - NCO B CONTROLS NOT FUNCTIONING* e PASSENGER CAR W I TRAILER A STOPPED 0 8 OTHER IMPROPER DRIVING• C CONTROLS OBSCURED C MOTORCYCLE I SCOOTER B PROCEEDING STRAIGHT NO CONTROLS PRESENT I FACTOR' D PICKUP OR PANEL TRUCK C RAN OFF ROAD COTHER THAN DRIVEfr TYPE OF COLLISION I E PICKUP I PANEL TRK.W I TLFt D MAKING RIGHT TURN UNKNOWW A—HEAD-ON F TRUCK OR TRUCK TRACTOR E MAKING LEFT TURN 0 E FELL ASLEEP' F MAKING U TURN 8 SIDESWIPE G TRK.I TRK.TRACTOR W/TLP C REAR END — H SCHOOL Bus G BACKING WEATHER(MARK I TO 2 ITEMS D BROADSIDE I OTHER BUS H SLOWING/STOPPING A CLEAR E HIT OBJECT J EMERGENCY VEHICLE I PASSING OTHER VEHICLE 8 CLOUDY F OVERTURNED K HWY.CONST.EQUIPMENT J CHANGING LANES C RAINING G VEHICLE I PEDESTRIAN L BICYCLE K PARKING MANEUVER D SNOWING H OTHER% MOTHER VEHICLE L ENTERING TRAFFIC E FOG/VISIBILITY =0 M OTHER UNSAFE TURNING FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN F OTHER% A NON-COLLISION 0 MOPED N XING INTO OPPOSING LANE G WIND B PEDESTRIAN 0 PARKED LIGHTING C OTHER MOTOR VEHICLE P MERGING A DAYLIGHT D MOTOR VER ON OTHER ROADWAY OTHER ASSOCIATED FACTOR 0 TRAVELING WRONG WAY B DUSK•DAWN E PARKED MOTOR VEHICLE 1 2 3 (MARK i TO 2 ITEMS) R OTHER:* C DARK STREET LIGHTS TRAIN A vC SECTION VIOLAnON: CITED I/C; OYES D DARK-NO STREET LIGHTS G BICYCLE HIT OBJ OVERTURNED LGVVEH 'CLI H OTHER' I E DARK- STREET LIGHTS NOT H ANIMAL: B vC sECTIDN VIOLATIONCITED FUNCTIONING* VC OYES SOBRIETY-DRUG o- ROADWAY SURFACE FIXED OBJECT: C VC SECTION VIOLATION: CITED ;12 PHYSICAL A DRY OVES 3 {MARKT TO 2 ITEMS) B WET J OTHER OBJECT: D ONO A HAD NOT BEEN DRINKING C SwWy-ICY B HBD-UNDER INFLUENCE D SLIPPERY(MUDDY.ILY:ETC. E VISION OBSCUREMENT C HBO-NOT UNDER INFLU.- F INATTENTION- D HND-IMPAIRMENT UNK* ROADWAY CONDITIONS PEDESTRIANS ACTION G STOP&GO TRAFFIC E UNDER DRUG INFLU.* (MARK I TO 2 ITEMS) A NO PEDESTRIAN INVOLVED H ENTERING I LEAVING RAMP F IMPAIRMENT-PHYSICAL' A HOLES,DEEP RUTS- I PREVIOUS COLLISION I G IMPAIRMENT NOT KNOWN B CROSSING IN CROSSWALK J UNFAMILIAR WITH ROAD jH NOT APPLICABLE LOOSE MATERIAL ON ROWY.* AT INTERSECTION K DEFECTIVE VEH.EQUIP.: CITED C OBSTRUCTION ON ROADWAY' c CROSSING IN CROSSWALK-NOT OYES SLEEPY I FATIGUED D CONSTRUCTION-REPAIR ZONE AT INTERSECTION ONO SPECIAL INFORMATION E REDUCED ROADWAY WIDTH D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE I A HAZARDOUS MATERIAL F FLOODED* E IN ROAD-INCLUDES SHOULDER M OTHER*: G OTHER*: F NOT IN ROAD N NONE APPARENT H NO UNUSUAL CONDITIONS G APPROACH i LEAVING SCHOOL BUS 0 RUNAWAY VEHICLE IIASCEI.LkNEOUS SKETCH, -PAOKW6 "1' 11 it 34 1 Y? T reA tJ -t I ri VoLve 1) NORTN O 19V cc .4y Illd KD cl STATE OF CALIFORNIA INJURED / WITNESSES / PASS ` ::.3,ERS PAGE 3 DATE OF COLLISION TIME(2400) NCIC NUMBER OFFICER I.D. NUMBER ✓• 3 (',doo7o3o Co/o S-0003 EXTENT OF INJURY( "X" ONE) INJURED WAS ( "X" ONE) WITNESS SEAT SAFETY NESS PASSENGER AGE SEI EJECTED ONLY ONLY FATAL SEVERE OTHER VISIBLE COMPLAIN NUMBER POS. EOUIP. DRIVER PASS. PED. BICYCLIST OTHER • INJURY INJURY INJURY OF PAIN ❑# 1 El 131m ❑ ❑ I ❑ ■ 1 0 10 IF11 ❑ [1 2. c r, NAME J D.O.B.i ADD=ESS �1 r a-F, TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: 1 DESC E INJURIESa 4AlmrF .o VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ aS m ❑ ❑ ❑ t■ ❑ 10 101 ❑ 11:11i 40 1 A I 0 NAM OAJA Q58 TELEPHONE e� I' PAJ (INJURED ONLY)TRANSPORTED BY: /J TAK N TO: DESCRIB INJURIES J D� 4 /.Al70 F OKLDE VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ I ❑ 1 ❑ 1 ■ 1 ❑ 10 101 ❑ 1 ❑ I z I ti 1A 1o NAMA D.O.B.I ADDRESS TELEPHONE 1U6 /1 JAR C-9k.EX_ -F7e A./ / 'pa e, In/ QNJURED LY)TRANSPORTED BV: � � TAKEN TO: n OESCPo INJURIES A/N aF f ollAl L or - ClVICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ 131 InI I ❑ 1 ❑ 1 ❑ 1 ■ I El F071:11 ❑ 11:11 -Z NAME I D.O.B.I ADDRESS TELEPHONE rA RL i -is -(v3 W,anEJ ece X67 T7a A /G/ QNJURED ONLY)TRANSPORTED BAKEN TO: 1n/ ATE T r:S? t el!^iLF / /7,77, DESCRIBE JURIES i4//1/ / ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ 1' ❑ ❑ ❑ ❑ ® ❑ 1 ❑ ❑ % 1 O NAME%D.O.B.IA DRESS TELEPHONE >9 L ar�4 I.GE B 7-(iD 1/1AP5 bE A/770 / � J'41 (INJUR##D ONLY)TRANS PORTED BY: TAKENT fnIC I /) . OUAI 7 Se O` / DESC E INJURIES ` ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑� ® � � ❑ ❑ ❑ ❑ 1 ❑ 10 ❑ 1 ❑ ❑ 2 1 7 14 1o NAME 10,0.9./ADDRESS TELEPHONE / A e IES LIN tea- 2- QNJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED [VR R'S NAME I.D.NUMBER MO. DAY YEAR REVIEWERS NAME MO. DAY YEA CDID I � CHP 555-Page 3(Rev.7-87)OR 042 87 43F17 STATE OF CALIFORNIA FACTUAL DIAGRAM PAGE { _ OAT!:OF COLLISION /y^/(/ TIME�(2�00( NCIC NUMBER OF FIC F.R I/D�. NV MBER coos 1 s / DAY 3 YR. /V �V / le,46o7c),5c �O'`� R S= coos MO, 1 ALL MEASUREMENTS ARE APPROXIMATE AND NOT TO SCALE. UNLESS STATED (SCALE _ PAR►c�NG► LOT sS55 C.[-Ay'fuN R� N oT Ta SC.A LE INDIC kTE N NOR r C' PoL6 4 lQ r`r Iq �I�rl 11 �r 2 �. ---..W.I g CCAym►.t_ �� - fZ rlB ClA-IT ION ?.D or- Nva 7/ � IS P � -DELAwAt�17, q "1�� PAINTED -ANE CENTEr- LINE- WNITE HAIN-TEU 'DotlaE Li"ES ' ,-IF_LLOK) PAWTF-D CRosSWALK L1NE5 - W A ITE PAINTED "\4E UNE- WArls © RA\SEr) CoNc.RrTE CeNTEe DEVIDE RL �] CeNf-R,ET6 Sr sssALV, Q PLANTER AREA ..AWNfY D. NVMr1ER MD. DAY YR, EVIL WER•S NOME MO. DAY YR. 1 P• 1-��sc�1�� I colo ' � S qs IR CHP 555-Page 4 (Rev II.85) OPI 042 • STATE OF %ALI.'OBNIA FACTUAL DIAGRAM C'` FACE DATE OF COLItfION TI ME� Il.00� NCIC NU�BEw .N I.O. NU"BE. • L.q • DAVL,4007550 `'OI coos ALL MEASVREMENTS ARE APPROXIMATF /1ND NOT TO SCALF. UNLESS STATED (SCALE PPRK\M(* Lo-r SSSS C•C.A,jlbN KD IV or TD SCALE St. Jo�rJ S INDIC TE UaKNew��Q CNu2Ca NON N Nu�P� G� E V-1 d' ?J- KD KD Nva 5-roP 'sem---------------.._._--_------- - rAAwAsM 516 �FI�S SCA� EV I D6N G� `D A CA IZA M /1/vv",\ ^I�A F"afZ 11'lEfISuRErriE/�I�S Tb PAc4 DwAWN B�• 1G//�• .Ej1 I.O. NVHBEw MO. OCAv Av w, wEVIC WENS NAME MO. OAV vN. CHP 555--Page 4 (Rev 1185)OPI 042 STATE OF CALIFORNA INJURED /.WITNESSES / PAS -..:.'GERS (- PAGE �. DATE OFLUSION TIME(2400) -IC NUMBER OFFICER LD, NNUMBER /- 31 9 o(oI� e4007o30 co/40 5- 40603 EXTENT OF INJURY( "X" ONE) INJURED WAS( "X" ONE)WITNESS PASSENGER PARTY SEAT SAFETY EJECTED ONLY ONLY AGE SEX NUMBER POS. EOUIP. INJURY COMPLAINT SEVERE OTHER VISIBLE COMPLAINT INJURY INJURY INJURY OF PAIN DRIVERWE CVCU5T OTHER ❑# ® 440 M? ❑ ❑ ❑ ❑ ❑ ❑ 1 -7 Q NAME 10.02.OBADD8 �/ w TELEPHONE tpA !/7/ a CA V (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES 0 VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ I ❑ lo lol ❑ I ❑ NAME I D.O.B.J ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ lo I ❑ I ❑ NAME 10-0,9.1 ADDRESS - TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME I D.O.B.I ADDRESS TELEPHONE (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED Q# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ TELEPHONE NAME 1 D.O.S.I ADDRESS (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ 07 ❑ ❑ ❑ 1 QI ❑ TELEPHONE NAME I D.O.B.I ADDRESS (INJURED ONLY)TRANSPORTED BY: TAKEN TO: DESCRIBE INJURIES VICTIM OF VIOLENT CRIME NOTIRED PREP SN,�+E I.D.NUMBER MO. pAY YEAR REVIEWER'S NAME MD. DAY YEA ` Nr1S oto 1 CHP 555-Page 3(Rev.7-87)OPI 042 87 43537 STATE OF CALIFORNIA t NARRATIVE/SUPPLEMENTAL CHP 556(Rev 7-90)OP 1042 Page DATPi OF tNCiDEA7TlOCCURRENCE TIME/7100) NCIC NUMBER OFFICER I.D.NUMBER NUMBER /- S' 9•5otol� CA,04>1e'50 Cpt 0 5- 000B 'X'ONE 'X'ONE TYPE SUPPLEMENTAL r'X-APPLCCABLE) 10 Narrative 'Collision report ❑BA update ❑Fatal ❑Hit and run update ❑Supplemental ❑Other: ❑Hazardous materials ❑School bus ❑Other: CITY/:OUNTY/JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER 7 a eNT A C o S rA /I'7T .*4611-a LOC TX) EJECT STATE HIGHWAY RELATED ATd 1�i� 7)E1-AAJA Z4f 1R . ❑Yes O No 1. 2. c, 3. C e vlcr- or- 4. f4. CAC L . AU, `2f 7-A&PCX1 6. 7. ! • e. - RIR ' ' Z" ST of - RtoLwJ A Q1J of 'T ST- CBL. 9. oF' 'DE(,AWARIS DR AND ' r' SPLAT14. OF 114e Mleat OF G, 10. 11. tiAN 0 ( r 3,r s /t 12. --2RIR : AL►' 11 of " t t 13. rr AN D n 4c & TaA1 Jac it I 14. 114' 10 IN r l 11 15. D 16. 17. 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PR RER' NAME AND I.D.NUMBER DATE REVIEWER'S NAME DATE • C01 G 1'S'q57 I _ Use previous editions until depleted. 90 57541 STATE.OF CALIFORNIA NARRATIVE/SUPPLEMENTAL G CHP.556(Rev.7-90)OPI 042 Page 1,D DATE OF INC4DENT/OCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D.NUMBER NUMBER -3-RS orJ.i� &Atoa-7o3n o10 9S- coo3 'X'ONE 'X'ONE TYPE SUPPLEMENTAL('X-APPLICABLE) ❑Narrative ❑Collision report ❑BA update ❑Fatal ❑Hit and run update ❑Supplemental ❑Other: ❑Hazardous materials ❑School bus ❑Other: CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRiCT/BEAT CITATION NUMBER LOCATION/SUBJECT STATE HIGHWAY RELATED ❑Yes ❑No i. CwAs Cb -rT 2. 15 Ale w S 011S 0 3. 1146 *7- L,.4yuF,, 1AE SAID 14. W-46 db,01, LOS 4. A cwD broler. P-1 S,410 Al "A:5 .Ste.J,,AJ 5. Tb MAY-- A �I T TaeIIJ i E •D 21 A F S rml 6. •U- -S,4/43 uS F I-We 46 r ;444!-� dJ o 7- SEf "Re 04 L 7. we CL 'A.� D 'DD VJ IJ Pef,Ily >q T,5 m A K 8. 1 16 -( S I D a G �Aucm AePUez) 5 •P�AA It It 5 9. 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PREPARM,'S NAME AND I.Q.NUMBER QATE REVIEWER'S NAME DATE Use previous editions until depleted. 90 57541 01-05-1965 @1:01PM FR ^-7267767828466 TO('_ 96721429 P.01 CONTRA COSTA COUNTY SHERIFF'S DEPARTMENT Q CU VSY ALS UM BURUlU MARSH A CRWK Qnxk� O14 FAC"" N,o�ric�i)e�rM CA 90553 C ytoa,CA 9a51.7 Plant Ge nend(910)646.1368 Planc (510)"64700 Co_ ftr(Sio)646.0713 Fina: (510)646-5718 FM (510)646.4932 Fiwx: (510)646.1392 MARTIl=V=NnON FACBM Q WEST COUNTY DEf'EN'1'ION FAauc" 1000 wwd Street 5555 Gitni Webwx Nar AW4 CA 94553 Rkboo4 CA 94806 Q BAS:Pboac (510)6464644 E3 BATS:nw wee (S10)2G-4T10 Fkm: (910)a$-LW y#= (510)2a42" Q OM-nmm (510)604493 0 OPS;rbom (SIO)?b'L4210 Fwr. (90)6464391 F (5101 Q Cl7 R; ✓ C) OTHM - - TtJ LOCATIONS- NAME: OCATION:NAME. FROM: LOCATION: M F> F DATE/TIME: 9 � L @ (IWa .+r.r MESSAGE,: NUMBER OF PANES INCLUDING COYER: + B1-05-1995 01:02PM FR(:_ 17267767828466 TO_ 96721429 P.02 • _ Warren E. RtV 8HERIFFCORONEA Sheriff-Coroner � Qordd T.010 1 1 contra Costa County ,, Aad.t.nt ShwW Detention DWMM Rodow L.Davts 1000 Wird Street Martinez,Coofomla 94663 'Q! AuNtant SMrHf co8s� (610)040-2190 To: Officer Hischier Date: January 4, 1995 Clayton P. D. From: Sgt. G. Gilbert Subj: Traffic Collision on 1-3-95 On January 3, 1995 I Conducted interviews with four inmates who were passengers on County Vehicle f 5958. The interviews were conducted between 0920 hro and 1105 hrs. Below is the statements of the inmates. SMTH—KARL (94219353) : Smith stated, in substance, that was seated in the second set of seats back from the front, on the right hand side of the vehicle. He said he was "half asleep" and did not think the deputy was driving unusual. At the time of the collision, he woke up when he heard the deputy say "oh shit! " Smith looked up, saw brake lights and 'then felt the collision. Smith said he hit his knee on the edge of the front seat in front of him. Smith stated he was examined at County Hospital and feels fine. STFVENSON, DONALb (94220316) : Stevenson stated, in substance, that he was seated in the first set of seats back from the front of the vehicle, on the right aide of the van. He was looking out through the front of the van. Stevenson said it was dark and rainy, and the deputy was driving at about 30 mph. The van was in the right lane (no. 2 wjb) and there was a blue Ford Escort traveling in front of the van, in the same lane. Stevenson said the blue Ford slowed down to about 5-10 mph in the right lane. Then the blue Ford stopped braking and continued on for a short distance. Stevenson said he noticed the blue ford was swerving a little to the left. He said all of a sudden blue Ford came to a stop in the traffic lane and the two vehicles collided. Stevenson said he did not see the blue Ford signal at any time. Stevenson said he had a complaint of pain in his neck as a result from the collision. Stevenson stated that he was examined at County Hospital and now feels fine. t.n..fi..d r. I Pt 1102 ON AN EQUAL OPPORTUNr7Y EMPLOYER . 01—€35-1995 01s03PM FIC':d7267767828466 T 96721429 P.03 HEE_MOSSTLLO., ARMANDO (94217785) :_ Hermossillo stated, in substance, that he was seated in the first compartment-back, from the front of the vehicle, on the left side of the van. Hermossillo said, he was dozing and was not aware of the collision until it occurred. " He said he had a complaint of pain to his neck area and hit his left knee on the seat in from of him. He was examined at County Hospital and now feels fine. ALLEN. MICHAEL-Dz- Allen stated, : in substance, that he was seated in the second compartment back from the front of the vehicle, on the left side of the van. Allen said his eyes were closed, because he thought the deputy was driving too fast on the road. Allen could not give as an estimate of the speed. All of a sudden he felt the van coming to a quick stop, and then felt the collision. Allen said he had a complaint of pain to his neck area and was examined at County Hospital. Neew Fore R 2/91 SON AN EQUAL OPPORTUNITY EMPLOYER •l y�. 3 tl •. , I �• • rh •�-..�{ �trr • f:•f.y.�:� • • _ 1 �.. .( ��::: ► � { .'.i., is Ti i` ,•- .yi:� •• Ii %��� ✓ .•`�•��•iF.- rV, tis. MEN MINES NO mom NNEENNINEW E ' S� �Q1► ����.1� _ �. v _- t +fir ONNESEEMINIEW0101 VlLnMAUN _ ■ ■r. . ■N■ .■C■ ..��. ■.■.■ INNOWNE •�- '-,• •• • r . - 1I % _ * .-•;a _.:.. il . itsiL r ._._. _ .•. i./•� _ •fix Y .iii:. •. _ .,., -�:.-}:..: �. .<�� .'=��.. O m x x c /\� F+ cn y T o n z o p {.1 m HD r�F. Z OX m Z 0 < 2D z co< o Cn m mm NON OC X�4b N 0 DC) OOm� m Z;O 30V N cz --177, D\ 1 .A -4 mm �"ZD 70S ZV GJ Z C;a 0r11Cn DD ONTO N ° rc mmmm j � O�Q` Z C7O a 2VN 0 nm Cpm►-+D 1 En3 7af,AW GJ m -7 DDZ11 • Ula 00700 m m ZC mor, 2 0-4 Z V! .. O C) O %0 O p r m _ CO d m 33 m } 0 a m Z N3 v z r D m N 0 1 ZnN 1 O o 0;0.. - o vmm 0 •0: W � cn O Q mtZI:5 � m m r N DDDR n m D D d0000 . n T) D 1-4 G vW(4W si a O0000 ®` myon ........ tnmz 0 n 3 -n - m _ - � \ ' m N -I r �D m cncn►�N NVNf.J WNO]T z 0 UD m moat/ m mo 0 r � ` S N D Om D rr_-m N zm r m o d n n �0 D� C cn w 1 u�t -ic°n o o_� mN �N C,o p mm m a rn� xD m Qb rr n {"1 ani o n 3 Pb m Cl)N v r D ma C Nr °m �p 1 to ZZ m m p� m <T T O O C 3-n m- o m� ..1 m0 a 0 am 03 O 07 m 14 z 0> 4 CV nm �N DO (�� _ UI p'� Z 'ry Q' 4 nD Oz QA r\ N Z m ain r.Q 0� a c M z0 W C 0 0Z O 'o ' '� m� N o mcg CA �A �� o a � Cl) O nz D w n �� mz < m �z co I MD M 0 cn ID: PA1180-00 MERRITHEW MEMORIAL HOSPITAL DATE: 05/03/95 USER: PA. LEE1 Combined Transaction Detail TIME: 10:53:30 -------------------------------------------------------------------------------- Pat#: 7147530-5 Name : HERMOSELLO. ARMANDO MR#: 4181053-02-0003 L Cyc Sry—Date Itm Code Description Post Dte Ptch# Oty Amount L 1 1/03/95 45323094 UC LIMITED VISIT 4/4/95 , 8390 1 50. 00 L 1 1/03/95 45300001 TREATMENT ROOM 4/24/95 38390 1 60. 00 TOTAL. . . . . . . . . . 110. 00 ---------------------------------------------------------------=---------------- AR7. 4. 4 i . I,tE'I.IVING I,IT�t CONTRA COSTA COUNTY P E-HOSPITAL CARE FORM FIELD BASE p/ / /'AGENCY^ry,lf2- RADIO IF AUTM.i� .L.___RESPONSE• TM f AOEZ{,� CAE RE C CAU as E«+w rs, oN su r. u»r.c� r k C, •�,."� NAME / �y� 7 LOCATION/FOUND 7. # Spam � ETA � (GI (A CHIEF C4MPLAiNT LEVEL OF DISTRESS. NAA MILD MOD SfY TRAUMA CRIT Y N r � _ ��► ���n s1,ty f t� A' '� TtL4ur,+A pE.gT r N PMH �--- i11a.f i. ✓at✓rr� t*t trc>tM�. TI.tE_ - T.G BYPASS Y N VZOICATIONS _ �J2 utt r/�I4E' pyl V%AC"s Tia CRAMs ALLERGIES.Dt _ GCS _ 6 N+E� Lbs 11tTltS atPliP P R —CAP/REFILL-` p t t V Y SIAfa.) l QUAUT ,���, ) t rj�� EKG RHYTHM FO �.�ZZA L' MCAT FACT•Y 10 11 t2 t)t4 i�'FIT LOC:ALERT X �L RESP TO t31 LOSS OF CON Y u tY TO tt »` 77 :A ...,4 . . HOTSKIN:49WPHO3C COOL aEAgE2Wu5 w+rEEO r C a Fuisi+E0 PALE CYANOTIC » .=.r. HE —,._J7&ZY1()U; w1{����I ,) AF court t UMATIC MIJURY' utaraD`"A`T AINVtEY LEAK/OU NOISY FOREIG 80DY �++� /�� PUPI UNEQUAL RT LT OTHERt��c —1'' Crd L -�-- FAuasca4aaEta FLUILT NOS <e- Q � • ,°'' NE .� NTENDER NDER H. ,}.,�_CHE .NONTENDE TEN R FyXA1N E tf LUNG UNEO� ;FILES RNCN{ M?12E .�--- tR,c ABCK) WENDER TENDER (f AGO .DIST AI _ /e777. ��lyM��• r k SACNTENDE TE `` ti. L J "/ Arm. EITRICATiON IME _ EXTREMITIES.PULSE EDEMZ NJURYM/S �y¢y�A( 13 S GENERAL ASSESSMENT: klt-CA'l t lI �] �yT-r EBL r.i �^ ♦; (� i } �" WEIGHT 11b*4 EKG STRIP Y MCP EXAM BY'-.S A S 71 t t C> •4 "•` '' r„t TIME ' ' t CONTINUATION FRM Y�I ','•• POSED TO OLS: —� 1 t :.� t..r, MANAGEMENT: Time Done Mit Response T B/P P R / l / I REASON FOR PROLONGED SCENE A_ - y PRIOR MOVEMENT OR TREATMENT ✓►+t3jyA st r_1•l 0 "1r L i. CODE TO SCENE � SCENE ASSIST 4'647k) 4)[.dIt�F ASSISTANCE ENROUTE W A L TRANS.TO Atrt$.�. `r k tvt./—CODE T INCIDENT LOCAnom/CRY(mop coor./pp.) �f.9.;/%1: -- N INFUSED ccs CC'S PVT.MD SAM HOSPITAL/MICN — PT PE �!`��t L t� RAO/DRIVER INTERN SIGN S�r CERT.IF SIGN CERT.a SIGN I RELEASE FROM MEDICAL RESPONSIBILITIES: I refuse medical care and transportation offered to me by American Medical Response Wasf In so dolnp relieve them, COITtra Costa County, and the Ad!�Pnced Life Support t Base Hospital and physician of ' further responsibility.Sgnaturw� / IFr Ar 11.W.r r►Art Witness Dater O refused to sign If Patient Unable to Sign State Reason: ..� REAMONFOR PT/FAMILY REO CLOSEST tNOESrONATCD REMX/tE pf CE RANO t1pSEMTAL/M D HOSfMTAL BELECtION MD RIG SMCIAL KPVICES TWItW CENTER O714rf1 �LrZSl CI" �iNoc� 1'72q - 733 PATIENT ADOUSs IC" "40K DDB ss. INSUPAWA*3 INDUSTRIA .r Y N EMPLOYER RESPONSIBLE PARTY MILEAGE I COMMENTS' BEGIN AGGRESS END ND�F M y TRW NUMBER CONTRA COSTA COUNTY HEALTH,SE-R.VICES PATIENT REGISTRATION Financial Class Code J,, J p Med.Serv. Patent a E 111,11 4181053-02-0003 Work Related? N Dr's 1st Patcom Type Voluntary ClerkiCon Medicare? N St Facts? 071475305 E ADM.ROBEP7 Insurance? N H Plan? N PATIENTS NAME Medi-Cal? N Vel? HE S,F.0SELL0 ARMANDO S'D? M Y;$ Previous Change Race Coverage## INTERD£PT JAIL HISPANIC. Policy# Sex D.O.B. Age Information I D J O M 1/17/1968 026 Coverage#2 Soc.Sec.8 I.D. M.Status Policy It 547-19-6243 S SINGLI Information Maiden Name Mother's Maiden Name Coverage#3 MARTINEZ 0 Policy A Information Language How Arrived ENGLISH . Other Insurance Address:Phone Note: DETENTION FACILITY Patient's Mailing Address MARTINEZ CA 1425 BELDEN COURT PINOLE _ CA 94$64 Pt Employer Day Phone Night Phone Occupation (5101724-7330 HM ; Local Address ®Employer's Address 1000 WARD ST,MARTINEZ RESPONSIBLE PARTY HERMOSELLO ARMANDO Resp.Party's Employer D.O.B. Relabon Sex UNEMPLOYED SE — SEL Resp.Party's Employer's Address Soc.Sec.# I.D. 547-19-6243 00000 R.P.Address �Subscnber 1425 BELDEN COURT i"Soc.Sec.II Employer P I HOLE CA 94564 r. •,—r,n_n r n,i EMERGENCY CONTACT rnNR A COSTA JAIL Day Phone Night Phone HERMOSELLO PRIMARY CARE PROVIDER&CLINIC Relationship MO — MOTHE MART Day Phone Night Phone Admit Date Tune Pre-Admit E.D.A. 724-7330 HM 1/03/95 07: 42 Address 92 — SE'LP—RE'ER 7 : 35 ' 425 FELDEN COURT 5 — NO ADVANCE -"'' C- CA g45F,4 NEXT OF KIN Relationship Room Bed Med Sery Acc.Cd. Day Phone Night Phone Smoke Religion Inquiry Address Last Admd Date Place OTES R�nl Unawe to SEgn Consent S , ce L 1j Consent to Service on file Consent to Servo Signed dated - ------- �i f V Discharge Date T„-;r ►iERI,C '':CLL0 APMA1.00 CONTRA COSTA COUNTY HEACYf+-4RVICES tt Iw A, T `, l O 724-11`330 J D CONSENT TO SERVICES AND CONDITION4 - 3 0114 IS" OF SERVICES AND OF ADMISSION I f 02 iia , P�t�Et MEDICAL/SURGICAL TREATMENT CONSENT: The undersigned consents to any medical treatment, including but not limited to x-ray examinations, laboratory procedures, medical/surgical procedures, injections, and blood transfusions, considered advisable or necessary by the attending physician or by other of the hospital's medical staff, including physician residents and independent contract physicians; and further agrees to the provisions expressed on the reverse side of this form. TEACHING PROGRAM: The undersigned understands that Contra Costa County Health Services, Merrithew Memorial Hospital and Clinics. is a teaching institution and that residents, inters. and health care students, under the supervision of professional staff,may be involved In providing medical and/or health care. CONSENT TO RELEASE MEDT-CAL LABELS: The undersigned authorizes the Contra Costa County Department of Social Services to release information concerning the status of the patient's Medi-Cal application, and to send the patient's Medi-Cal labels to the Contra Costa County Health Services Department. FINANCIAL AGREEMENT: The undersigned promises to reimburse the County of Contra Costa for any hospital care and/or medical services provided to the patient at any time within 365 days of the date indicated below, which services are not covered by Medicare, Medi-Cal, insurance or any other health care compensation carrier, at the rates established by the Contra Costa County Board of Supervisors. The undersigned further agrees to use any damages or indemnity paid to or on behalf of the patient as a result of the injury or illness which necessitated this care to reimburse the county up to the amount billed,but not to exceed the rates set by the Board of Supervisors, The undersigned waives the statute of limitations on this matter fora period of 1Q years. This agreement and waiver is binding on the undersigned.his or her heirs,assigns,administrators,and executors. ASSIGNMENT OF BENEFITS: The undersigned authorizes, whether he/she signs as agent or as patient, direct payment to Contra Costa County of any insurance benefits otherwise payable to or on behalf of the patient for this hospitalization and/or these outpatient services, including emergency services if rendered, in an amount not to exceed the County's regular charges. A photocopy of this authorization shall be considered as effective and valid as the original. _ The undersigned authorizes and directs the attorney, claims adjustor, insurance company and any person(s), company or corporation who may effect a settlement or payment of any claim for damages or indemnity that the patient may have arising from the injury or illness which necessitated this hospital care and/or outpatient services, to deduct the amount of the charges of these services from any sum due the patient and to pay that amount directly to Contra Costa County and the undersigned hereby assigns that amount to Contra Costa County. RELEASE OF INFORMATION FOR REIMBURSEMENT: The undersigned agrees that, to the extent necessary to determine liability for payment and to obtain reimbursement, Contra Costa County may disclose portions of the patient's Awbk record, including his/her medical and psychiatric records, to any person or corporation which is or may be liable for all or any portion of the charges, including but not limited to insurance companies, health care service plans, workers' compensation carriers, Social Security Administration,and peer review organizations. The undersigned certifies that fie/she has read both sides of this document, received a copy thereof, and is the patient, the patient's legal representative, or is duly authorized by the patien as the patient's general agent to execute this document and accept its terms. j 2—a - 72--- pg7E SIGNATURE OF PATEN OR PA 'S REPRESENATWE F PATIENTS REPRESENTATIVE, _ pEEATK)NS14P Tp PATENT WITNESS E If patient unable to sign.STATE REASON: Date: BY MEDICARE PATIENT STATEMENT OF FACTS o Patient is years of age. C This visit is not the result of any kind of accident. ❑ Patient is not employed. Cj No other Individual is responsible for the patient's medical bills. 7 Patient's space Is not employed _ INPATIENT.I have received the Medrare Notification entitled Patent Is not covered by voorker's Compensation.The Black Luny .AN IMPORTANT 161ESSAGE FROM MEDICARE Program or a large group health plan 1 certify that all of the above statements are true. DA-� Sr...'aAt lN7E LY r'AtANT rJH f'�rif N15IICf9�E::f•i.A.^.! IF W IF k" N{/v7E',A V IA71A Wiu, ORIGINAL—C tiAliI �COI'Y I—FINANCIAUPATIENT ACCTG COPY?—PATIENT _ e _ JF CONTRA COSTA COUNTY HEALTH SERVICES HfpnOSELLO ARMAN-DO N MART SIO 724-7330 JO errithew 004 1 � 1 CS 3 011'i 1 S 3 0 S- emorial 1 i l 7/196 8 rh �cl!3° • E 1 iO3/95 Qq op EMERGENCY DEPARTMENT S PHYSICIAN ASSESSMENT DATE ` ,; 5 TIME '�p�.... 1R1 ALLERGIES-SEE NURSING RECORD. ORDERS _ wed % Q CSTn-A 1 J►T�C� - w � � i C�•�.+1..w �JL�- o. � -,- � � � .AVL- L�.,v�•� � � �a!t�-�C" � . - IAB AND X-RAY RESULTS: DISCHARGE DIAGNOSES .. CONDO UN ON Ni{l ASF �A►^� I�--ln.� - M.D. . C30'L�� } _ - 4 -. 't Contra Cotta Coin- :lealth Services '+ ^` -- r• .. Merrithew Memorial Ifospital EMERGENCY DEPARTMENT— NURSIN(P RECORD ' MERMOSELLO ARMANDO DATE /- "y3 ____ ALLERGIES M MART 510 724-7330 JO TRIAGE STATUS { 041 "1 a5- 3 01141S30S. - ( /17/1968 CURRENT MEDS PAST MEDICAL HX • � Pfient Id/03/9S ISUAL LAST TETANUS � 4 +. vCUITY` WEIGHT ;- \\ LMP: OS/,W ❑ CORRECTED CONTRACEPTION ODUNCORRECTED TO EMERGENCY ROOM VIA WRING ❑CARRIED ❑W C ❑AMBULANCE ❑POLICE ❑ 5150 ❑OTHER ..::; TIME NURSES'NOTES TIME INT! TYPE BP P R T• ;y • TRIAGE—(CC:HPI) 00 -- cf 9Z R iG� o----- t., i - ADDITIONAL NOTES ❑ MEDICATIONS AND IV SOLUTIONS SE GIVEN TIME I MEDICATION OR SOLUTION(IV solution bag#and rate) AMT INFUSED ROUTE RESPONSE ! INT. INTAKE PO I IVh DISPOSITION. ❑MHS Al `-ADMIT — ❑OTHER I [/f ^-' i HOW DISCHARGED /I WALKING WC GURNEY rjOTHER ._ OUTPUT NOTIFICATION i DISCHAR BY I DISCHARGE TIME- URINE EMESIS NGT : OTH ;POLICE JCORONE /��. .! ._.:CPS _'OTHER - C) �,-� SIGNATURES .—.. ------- ------- - --- ---- -- ----- w u d s 1 2 it, 90) wna Ctw� rNaw: Mrc -sup. 4 PATIENT NAME GATE . e- ADDRESS I _ ..; Mrs "OSELLO A A M A N 0 C Aa ► C, 10 724-7330 JG or,L: i _ 1 :: _ 3 �1141S3C+5- r //p t�PATIENT 10 M�r+H Mea m,m taaG "c,x�rs W r PHS m �, �.� �, �c. 1417— H x 41,S ) uwr COSTa¢L N DEA 100, amoncolm M.D. 0 EMERGENCY DEPARTMENT / PATIENT NAME V - DATE / _ ADDRESS - - - .-.. --- _ R / :4 •a - 4rt \ .. g ` - PATIENT 10,0 0 4 Amu Inst be readade on all 417— 0 _ AxeI UKT -0cosr r z ^ , No Refilts ��L ? QGENEFPEFAWTV0 WA 55E"- DOE OC WLWALENT M.D. EMERGENCY DEPARTMENT OTHER RICs DISCHARGE INSTRUCTIONS It is important for you to have a follow-up appointment in (type clinic)at Martinez Pittsburg Richmond Concord Brentwood (circle one) in days weeks [] Appointment arranged for (date/time). ❑ You will be called for appointment If you do not receive a phone ❑ Patient desires to call for appointment call within two working days of your Emergency visit,call for an E] BRENTWOOD CLINIC ONLY:Call 634-1102 for appointment appointment at the number listed above. NURSING INITIALS 2 WlGtJ c vim_ sy o`�ec_L� e-� c, ❑ Given preprinted I HA REI+ 9ND UNDERST ESE OkSTA TIONS (Pa S9 el instructions for:t — - X , _. DATE LL1 / Q1 S _ NURSE S SIGNATURE ;TIME TED off,IMO in' PHYyC1AN}S1CiNATU I CHART