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MINUTES - 06161998 - C11
... ......... ......... ......... ......... ......... ......... ....... .. _ .... ........... .......-__.. ......... ......... .....__.. .._....... ......... ......... ......... ............._._.. _ _ _. _ . _......._ ......... . ........ ......... CLAIMd 1 BOARD OF SUPERVISORS Of COMM COSTA COUNTYAL IFORNIA ROAD ACTItfE ' Claim Against the County, or District Governed by the Board of Supervisors, Routing Endorsements, 1 NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your California Government Codes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV belov4, Oven pursuant to Government Code Section 913 and 915.4. Please note all "Warnings" AMOUNT: Unknown RJEC11377TJ) CLAIMANT: Glenda Ellyn Edwards MAY 18 1998 ATTORNEY: DATE RECEIVED: CM RT N COUNSEL ATTORNEY: ADDRESS: 2520 Ryan Road #85 BY DELIVERY TO CLERIC. ON: Concord CA 94518 BY MAIL POSTMARKED: May 14, 1998 L FROM- Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATC LOR, Clerk Dated: May 18, 1998 By: Deputy IL FROM County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.$). (, 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: ctu,rkt,,moo u^-v "r) t9�Z.►' t''U �! 1�5"� �% — �,,rr.7it!,r-c-�- L' •r�c.t, w Dated: Deputy County Counsel III.,,FROM Clerk of the Board TO: County Counsel (1) County Administrator (2) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( Other: I certify t at this is a true and correct copy of the Board's Order en ered in its minutes for this date. Dated: ,r' '' PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning 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 Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: , '" By: PHIL BATCHELOR By `- ,,.� v Deputy Clerk � tr CC: County Counsel County Administrator The Board of Supervisors Contra. C**Of 00 Dow Casty Courcy Administration Suiiding 651 Pine Street,RWM 1C* )W or Mtaar&w,CWoml Your only recourse at this time is to apply without delay for leave to present a late claim. (See Government Code sections 911.4 to 912.2 and 946.6) Under some circumstances leave to present a late claim will be granted. (See Government Code section 91'1.6) You may seek the advice of an attorney of your choice in connection with this matter. If you desire to consult an attorney, you should do so immediately. PHIL BATCHELOR, Clerk of the Board of Supervisors and County Administrator By: ZDe p u—ty Clerk Dated: Enclosure Affidavit of Mailing I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18, and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid, a copy of the above Notice to Claimant (of Late Submitted Claim), addressed to the claimant as shown above. Date: f4KBy Phil Batchelor by `� ~ Deputy Clerk H:\GROUPS\TORT\RIsx-MGT\CLAIMS\TATE\Edwrds2.wpa claim to:, BOARD Of SUPZRVISORS CF CONTRA COSTA COUNTY r/ A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the .100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Gov't Code 911.3. ) 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, Kartinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. FrAud,,. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. w�•trer+t+��e#�r�s�r�+�aee�re+��er���a,��er�errr�r��►rer#a��+�r�r��rt�rrrr��r�:a,�+�t�e#+���t�+r�er�+�: RE: Claim By Reserved for Clerk's filing stamp } Against the County of Contra Costa} MAY 15 r i or } _District) (Fill in name) } . .......-............... _......._,:-...._ } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named 'District in the sum of 7\, and in support of this claim represents as follows: 1. when did the damage or injury occur? (Give exact date and hour)' A 2. where di the damage r injury occur? (Include city and county) Y + � 0,9 ULC1AA14Z�AkA/-Q Ce!a L 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 distri* officers, servants or employees caused the injury or damage? (over) 5. what are the names of county or district officers, servants or ,°� employees causing the damage or injury? 6. what damage or inu ies do you claim resulted? (Gi a full extent of injuries or damages claiioaed. Attach two estibates for auto damage. }� 7. How was the aviount claimed above computed? (Include thsoostimated amount of any prospective injury or damage. ) . 5 s. Names and addresse f witnes,"a, doc or and gteZ. Anl V Ansz. Ak, 9. List the expenditures you made on account of this accident or injury. AMOUNT } Gov. Code Sec. 910.2 provides } "The claim must be signed by the } claimant or by some person on his behalf," Name and Address of Attorney } } (Claimant's Signature) } ::� � ) } (Address) ? i c-A Asi Telephone No �`t } Telephone ���r�►�r�atr��r*�s`,��►:�r,��r��:�*���+�,����*+�ar�r:����+�#��►��� ��+������t�*+�#��er�r�� 310TICS Section 72 of the Penal Code provides; Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not +exceeding one thousand ($1,000) , or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. na � C� p a j di ''I'll'-,......................................................................................................................................................................................... .. ..................................................................................................... CLAIM BOARD OF SUPERVISOR: OF CONTRA COSTA COUNn, CALXEQRNIA 8=13 ACTI Jum 16, 1998 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 you is your California Government Codes. notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given pursuant to Goveramnt Code Section 913 and 915.4. Please note all AMOUNT: 5598.29 MAY Z I 1,-Iq CLAIMANT: Jim Petropoulos COUNTY COUNSEL ATTORNEY: DATE RECEIVED: MARTINEZOALIF, ADDRESS: 2063 Pacheco Street BY DELIVERY TO CLERK ON: May 19, 1998 Concord CA 94520 BY MAIL POSTMARKED: L FRONE Clerk of the Board of Supervisors TO. County Counsel Attached is a copy of the above-noted claim. PHIL BATC LOR, Clerk Dated: May 20, 1998 By: Deputy IL FRON1 County Counsel TO: Clerk of the Board orSupervisors (%0 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: lit By: aAd�iC,l�._ Deputy County Counsel UL FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER- By unanimous vote of the Supervisors present: This Claim is rejected in full. Other: I certify at this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFMAVff OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By: PHIL BATCHELOR R /Z_." Z,���eputy Clerk CC: County Counsel County Administrator Claim to-. BOARD OF SUPERVISORS OF CONTRA COSTA OMM INSTRUCTIONS TO CLAD A. Claims relating to 'causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later .than the 100th day after the accrual of the cause of action. Claims relating to causes of action for 4eath or for injury to person or to personal property, or grouting crops and which accrue on or after January 1, 1988, must bepresented 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 the one year after the accrual of the,oause of action. (Govt. Code §911.2.) B. Claims mast 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 RE: Claim By ) Reserved for Clerk's filing stamp ------ RECEIVED Igainst the County of Contra Costa or ) f8 District) CLERKovtsat3 trffl in Tlr1i{le CONTRA COSTA,CO, The undersigned cls t hereby makes claim inst the County of Centra Costa or the above-named' et in the sum of $ p�1 L2. and in support of this claim represents as .follows: 1. When did the damage or injury occur? (Give exact date and hour) PRIL ;242�� 7A tA IY. �s�MilMiWfawMiria�i'sr+�Yf� N1Ya.Y.r a+Yra�aaMa�'Wi'�'�M Ya�ifYaaa 2. Where did~this damage or injury occur? (include city and county) vosi:,"08, BAVf—IDI MT 3. How did the damage or injury occur? (Give full details; use extra paper if required) �u � , WAT s� 6ttekkl P E-4k"S .._..a_..a.......,,......ia.. .�....___ F. �.�...a.�...�._a....,...______. � 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damageTIC ? fW '- - K1hf � L �hJ RC1 jD/ $ (ov X1) 1 -L)C> 62S� E # � � 1 41 wr►at are the names of county or district officers, servants or employees causing the damage or injury?,-SW A" ......_...._...,.....a...._...._...._,.............. ___�.,.__�......�._,._.�_...._a___..__._a_.......__�___----___- 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damageslaimed. Attach two esti tes f auto e. .- - - - . 7�fI'!s 7 s cis EJb 4- �W'. fiYsrYi+ya.l�YaM�aM_a_aaa_arNa_Yi.iMi���`i���'wYN� � � • • 1� t^�~`- �+.w 7. How was the amount claimed above computed? (Include the estimated unto of any ros (c ive injury or damage.) r IT5W A, 6., Namesand ,addresses of witnesses; doctors and hospitals. + �f 00Cr P:_ VSs PP407" 9. List the expenditures you made on account of this accideta n ury: DATE ITEM AMOUNT Gov. Corte Sec. 910.2 provides "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or son on hi behalf." Name and Address of Attorney Clai t s Signature Address 45 Telephone No. Telephone No.n' -s-.2 N 0 T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison,- by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. - --------- And the t ... ............... ,l i,d at � a �y'4h ri .he III g ve )u T 11V GR€8 ST OHM rla MICKEY LEE of gay Point cradles his dog,Mishka,whose leg was broken by a bullet during a raid by the Contra Costa Sheriff's Office, Po em were searching for Lee's brother.They encountered his dogs instead, one of which they killed. Mishka's veterinary bill is$3,500. 00C S t art A Bay Point resIc ntloses idence. of it until I heard a pop, pop,pop." The Los Angeles District Attor cys Seconds later,two bursts of semi- The Contra Costa County Sher- Office, however, has chosen r pet to police ;E�e iter a automatic gunfire were heard com- iff's Office SWAT team served a file a murder charge against 1: 3n SWAX team,looking for a ing from the master bedroom at the search warrant at Lee's Marys Av- Lee for lack of sufficient evide back of the house. enue home early in the morning of Mickey Lee said the death c murder suspect,meets up Instead of finding the murder sus- April 24 in an attempt to apprehend dog has deeply saddened his fa s' With two pit bulls instead pect they sought,SWAT team mem- Lee's younger brother, Walter Lee. especially his daughter, who bers shot Lee's two pit bulls,killing Walter Lee, 26, was wanted on sus- with Gracie, the 3-year-old pit By Ryan Kim one and breaking the leg of the other. picion of slaying an acquaintance in He said the pain could have TIMLS STAFF WRrrra Lee,28,feels it didn't have to go the San Fernando Valley in August avoided. ex- BAY"POINT--After the tear gas down this way. in what Los Angeles police investi- "Four to five times,I begged settled, SWAT team members en I kept telling them, Please dont gators call a drug dispute. `Please, don't gO its there and l€red M okov l t-'s;homo tlwo!wh 111t> 170 4n My house. of my i�.•>i�,r t , . _.,. ,.a t.,, . ,;,_,. FROM PUS CONSTRUCTION PHONE No. 510 674 8811 May. 19 1998 12:29PM P1 173 i I3k1is Al Al I I Ccrncora C&94520 Crett Lona.l iomw#738563 polf . : may 19, 1948 107 Marys Av. Bay Point,Ca, Dear inn The undersigned proposes to furnish all material and perform all labor on the above dei l)ed real property necessary to complete the follrswing work do to a polio raid on above described property. 4COP'E OFVYEM Remove and replace fYont door. $412.00 Replace kitchen c e;ling. $725.00 Replace 89 squ.Yrt.of carpet do to blood and smoke bomb damage. S t555.00 Replace 2 fence posts and xeattaEch existing fbnce S168.00 General cleaning of blood,glass etc. S374.00 Replace 4 screens $ 196.00 All of the above work to be eompleaod in a smbstantial and worknuanlilce manner according to standard practice,for the sum of Three thousand fear hundred and thirty Dollars (S 3430.00). AcceptanCe The above proposal is hereby accepted according to terms thereof,and the owner agrees to pay the amount mentioned in said proposal. ZP.W.S.Constructio Client- . lient- -- _____....____...... - `qty, . ��r�f'.�.�'.',�.''r`� �e,S"'g3°''� � Sx { Y•r^ � �#. �i r . . . • • r • • r • a . • r L� b:--4 a "1' `l. lt'��c ,f3 .. ..:/r'AS ', �.. ' 4it•.3 Rauft To: 1214 W.W N'E`ON AVE. Contractor No. 592542 -WAFAM —1-OA— HAYWARU, CA 94545 Sar Na. AS 15200 rr S Co. iNc. R•pri ro , o s • s�rc s M: 1-800-233-9443 t ,xv-k CDV-ct dm�, MIS JIM PET-ROPOULO i4- 4-19 1 W#r?`tf*ni 3 110 gt<,9¢!!>t:astAYL1P SAit'J+r EXEm"AtG ,t,$':r„a29"t:CEttn;.SAX'�tmU Avv Cid 'SALL'SMA3t 1-p, tlletb£A SAR et tSY �i$TAtLELy B\` _ Ss RD IN BILL'TO. JIM PET ROPOULOU5 SOLD=o. 107 MARYS AVE HAY POINT, CA �k t51i�888--0;�b8 fNURAN(E C6. POLICY NO. INSURANCE CO CLAIM WO. j(PHONE NO. }POLXY mwe L�iOCA7tOPt { AGENT WW - -- VERACIED 8Y AGENT"ONE OATS OF LOSS DEDUCTIBLE Ir • Gtr y De sr-v- pt i an -- j 1 32 x 24 -- 1./8 P-516 OBSCURE GLASS Ot Desr i tion 1 c� 34 X 7 + 5/8 OA CL.. OVER CL I LABOR **** 1 LABOR TO INSTALL, PATIO DOOR** Coaments ****INSTALL 2 WINDOWS AND BOARD UP ON OVERTIME .INS'T'ALL ON REGULAR TIME AUTHORIZATION TO PAY I t',gr1�tlY dcethbri2i Arco .:rt?a3»'sr uta :ibavw.+bsev,?d 'rtts,rtanoe campAny W tray IN$ intrpiCc in ivti tstder�+r. sat:SracGOn and d4ch6(gt U( A loss.UnCW Ink: ebOVe poliCy U000 Such ¢tlytrgnt. 8d 69hu 1 may tiave tar Cta"m Glass disc 15. 00-A 8. 3e And J*ft*,*0 for Iris asci 4L9tMIspe ciazc+uatl 4Wvt 49aimoi $10 abu++e named ;ns.r corcmany snax be tr&*w Subtotal 655. Of t00c vs0 aacisargo0(, In tsae euenl mat trur 8 3ays ,ssmed ,nsur nct eomaany 00" not mskt (ionAty andw ry,,11 S.?—S% T elk X 13. 21 paymi*n# of t111; ;nvCiCe 4$6COttittig 10 ;ts t6rm8. i hgnr +y aceapt teaponswity (tv such payment " agree So pay ail Chbrr fes rea fac on mia it+voia- la '1'w above naawl plass aompilly A-04001 to and 30;ording W 811 (0049 40d LcIlt wd oma 0A Inis.;nvdlce. ��t T+Char ,___ _ jr$MS-NEy 30 t3RY&SaRvteA CRAN34F OF t`h".i.PER MOW"j18%DER ANNUWd Wtt.L.$f:C ,t!ON OVESStXife ACCC%3riTS. r ... _.. . .... ».».5«.�,.,� ZZN»»tl..kRk+'.I�fJ.44k�!u�A �l �, �x•ff tN } ' lrf::f.�n4• } t f {OWIMM St+.....::.sn ...i:. }: } r .. ..•... 4{ iw ......... ......... ......... ........._...__. .. _ . ..............._........._.. ......... ......... ......... _........ ......... ......... ......... ......... ......... ......... ............................................... - {Y y+:�yC% M {fi�• OL•�f?+fn[ N ..E...~{:�.+�k,6 :'T4'j:..vn `� f lh �4 44 3{r 3•;�+i?}.: .. 3 a {' .. {�i:•ri:'N�`Y},R�;.. ? f r i ;s'N ism '1y', '9 ...... . hti,•�' y' ':.: . 1� �4 yfCO�L x fi .y, t Y \r f yi. 7. ..;... ... ✓ar N4.c,ct'y+�c ttt. :.f i fi.e; G } +j:�, F h� .... .Y:A1. I •meq G { t :�.`tY.ErlMen'•w. :yp7aGl�tit<n ..x .............. --. x ::}': .. ------------------- :y ,lir - ... '• r is } 7 sc F 40 }l L.:. 'tit.-Lv'2? 5� A r s$�a�>_ .: i •: _: '. tFz z`{52` +SSL���iS'�dnK-'- . < }�£•'�f C� 'F F.,y•<L H , } }°�c°< d,9}'�}zs ;sd a# f {,oj3 t ._. _._... ......... ......... ......... ......... ......... ......_. . . .. ............ .............. ......... ......... ......... ........... ......... ......... ......... ......... ......... ......... _ _.. . .................... ... .v::. .•pkv.�., •Yv` w•:M{��: ice' y S ya94:tF �� �r ufav?.<'KR 6 } F 3 ..0 yff`;..:.�•w �: {,x� SSS S: � <�3< { a { � y ' •�•:bfy,,y,. � �a4,kM1L$i{k`{�./vy4ys� $w}F �* ' �.�„�,; �5 L2yiF6�r•�'L f > aj� 9�a{i� ,fr. } r,3 L � �y, `ve>,%��`'2�S.asa spa S s ; ( �{ �cyFC•,F,� �� dc%.,i:. 'xY of r 3 •' ?. a 5�.; - S-.. � # sit �. `L.•:{�}:. � L- Y•£%?.�.<. %;.:. +�kkeseoiEfts.'i�i�'+.^+._..:ri. :. '. C: mar •,. s�`s� ° .�? f•. f; `,�f {± ,Qvc°c< s?Ir..asDa Lr :tri 4f Ly f' iL .X U : . •". if f{ flUfv ,ry/i♦ ff" f; ,S.L i.r ,{ { .c•{ rl f7,J r r f AM f x�2 } xrf{nti y'r.ryr F L •Y � � w ft ?' s• '? F { u %ff'. O'd {•�} ttC f°t'':�{ •9•b. ,+ts'm' ,c.�s>wii rr r .... f :4 f f $ r. .'....::: .:'+i: fcY }y�'rt'CR•k. if }. { }Y y4't4 .+dt-� } f 3 }^ { ...., ... .......{:. :.,::.a:r:::..:......:: x f ....... ; } k •a:tt .L+2 ��.7 j.>� •/�}:,ti+C»k;},•i>i?..' :µ3:'j''i:;:v:::j'I.'`j S %}' i•>:v> 21 }ki G . xm— �'+ f r . .r� k \ f bf }�� f� ti •LaY Y i ,F.. t: '9s t IIl t 4 tX. r k' f: r:"•j L } f. > x v r ' r 1� } CLAIM BOARD OF SUPERVISORS OF IRA COSTA COUNIL -CALIFORNIA BOARD A June 16 1998 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 you is your California Government Codes. } notice of the actiontaken on your claim by the Board of Supervisors. (Paragraph IV below), Oven pursuant to Government Code Section 913 and 915.4. Please note'all "Warnings". AMOUNT: $ within jurisdiction lE317 JE CLAIMANT: Erma Rapp MAY l 1 18 COONTY COUNSEL. ATTORNEY: Dorothy D. Guillory DATE RECEIVED: MARTINEZ CALIF. ADDRESS: 314 27th Street BY DELIVERY TO CLERK. ON: Oakland CA 94612 BY MAIL POSTMARKED: May 19, 1998 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHE OR, Clerk Dated: May 20, 1998 By: Deputy IL FRONL County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. { ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed', late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: -'( ( By: ds t�v Deputy County Counsel M. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order en eyed in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By puty Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAH ING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated l 'r By: PHIL BATCHELOR By ti-Lri %, � Deputy Clerk CC: County Counsel County Administrator R E " M UAV Ay 2 0 1909 CLAIM AGAINST GOVERNMENTAL ENTITY l CONTRA COSTA COUNTY f FOAM CONT 100-A RESERVE FOR FTI..TtiG iTAMP CLAIM FOR DAMAGES CLAIM NO TO PERSON OR PROPERTY f�� ORIGINAL FCA FILE Ii4�STRUC711ONS 1. Claims for death, injury to person or to personal property must be filed not later than six months after the occurence.(Gov. Code Sec.911.2) 2. Claims for damages relating; to any other type of occurrvnvte must be tiled not later than one year after the occurrence. (Gov. Code Sec. 911.2) 3. Read entire claim before filing. 4. See Page'.? fur diagram upon which to locate place of accident. 5. This claim form must be signed on Page 2 at bottom. ti. Attach separate sheets,ifnocess ary,to give full detoails.SIGN EACH SHEET. ". Claim must be Cited with CITY CLERK. (Gov. Code Suc. 915a) Board of upervisors - CONTRA COSTA COUNTY ;lame of Claimant Age of Claatu.ant __.�._E�2MA_RAPP_-_ ._. _.._ _ ..__ ...._._._____ 52' Hume address of C;lairnant City and State H,uttae Telephone Nuwnbrr _ 534 __-__s So. 21st._Street Richmond, CA (.5] � _237-58` 6 I3add- _ . .. us;nes_ s addrestef Claim;,nt City artd State Liustness Telephone Num.-e.. 151 Linus Pauling Drive Hercules, CA 94547-1822 (510) 262--5228 ''ive address to which you dc-,ire noti,:es or cummuuic.ations to be sent regarding; this claim: Dorothy D. Guillory, Attorney at Law, 314 - 27th Street', Oakland, CA 94612 ,Jw did DAMAGE or I,JURY occur? Please include as much detail as possible. On March 25, 1998, Social Work Supervisor Savannah MacKenzie maliciously falsified statements and information concerning Erma Rapp's handling of an alleged physical abuse case (Scott Bremer) , causing Ms. Rapp to be subjected to unwarrantet disciplinary action for alleged insubordination and untruthfulness' MacKenzie's superiors, Ray Merritt, Dana Fabella and John Cullen acquiesced in and ratified } e co duct> (see attached sheet '�" es, d`id A MA6E or VNJ U RY o c:ur:' Plea,v titcludc the LiatIa acid trait :f the Llaniat;e or injury .March 25, 1998, and continuing 1Y'herc drd I AiY1.Y(:-k or IN,] °RYovc;ur' Plv:cye deo cnbe fully, and locate on the diagram on the reverse sine of tl~..s st~.,tz:_ Where appruprtate, piva.ae give;street names and addresses or rnea,urernems fr in specific: landmarks: Carquinez Middle School, Crockett, California 151. Linus Pauling Drive, Hercules, CA What parti urar A("I' s,r (3N1ISS10N ds, you c�lairn tuse�l tFrr it}rue} 0__ clariat;e•' Please pve the:names of City emp.o:,ers causing the injury or damage and i•lentity any vehicles involved fay license plate number, if known. Same information as above. Please list the name. s nand address of Witnesses, Doctors and Huspitals:Robert Bremer, Rose Mellow Scott Bremer, Savannah MacKenzie, Ray Merj�ittj Dana Fabella,John Cullen 'A hat DAM AGE or INJURIES do you claire resulted? Please give full extent of injuries or damages claimed: Injury to reputation, emotional distress; loss of pay, benefits 4Wil,at is the AMOU—N.-I'of yr,ur claim? Please itemize your damages: Amount is within the jurisdictional limit of the Superior Court If you have received any insurance payments,please give the navies of the insurance companies: - Nobe For all accidents claims pleaseplace on the foll,,win� diagram the names of the streets'where the accident i and the neareht cross,-btrev". indicate the place of the accident by an -V and by showing the nearest addr:ss and d.star-: s to street corners. Please indicate where North is an the diagram. Nutt: If the diagram do" not fit the situation, please attach your own diagram. LL SIDEWALK CURB-7 FEAR K WAY SIDEWALK rF 11 rF Si`=nature of C'lai ant t I rson Pilin Typed Name:_ b or. claimant's behalf giving relationship to claimant: Erma Rapp May 19f 1998 MacKenzie acted in complicity with Deputy Sheriff Carl Fabbri and Carquinez Middle School Vice Principal Linda Steensrud in maliciously and intentionally defaming Erma Rapp, interfering with Erma Rapp's ability to do her job, and setting Ms. Rapp up for wrongful discipline. MacKenzie, Sheriff Carl Fabbri and Linda Steensrud wrongfidly fabricated statements and information concerning Ms. Rapp's handling of the Scott Bremer case because of her race and in retaliation against Ms. Rapp,because she would not carry out a personal vendetta which Sheriff Fabbri had against Scott Bremer. MacKenzie, Sheriff Fabbri and Linda Steensrud have not treated other Child Protective Service workers, non-Black, in a similar fashion. ..''..-,............................................................................................................................................................................................... .................................................................................... CILAIM 19-r>1eovol5iD BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY* CALROMIA BOARD ACT] June t4 1998 ., 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 you is your California Government Codes. notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: Undetermined 170=19rIVNE) CLAIMANT: Cynthia Walker JUN U 1998 UL ATTORNEY: Michael F. Wohlstadter DATE RECEIVED: IMOAURITTI NY E Z cO0 A U FNSE Attorney at Law ADDRESS: 488 Seventh Street BY DELIVERY TO CLERK ON: —June 10, 1998 Oakland CA 94607 BY MAIL POSTMARKED: L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELf'20, Clerk Dated: June 10, 1998 By: Deputy EL FRON1 County Counsel TO. Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). Claim is not timely filed, The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). Other: Dated: By: Deputy County Counsel HL FRON1- Clerk of the Board TO. County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER- By unanimous vote of the Supervisors present: This Claim is rejected in full. Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By Deputy Cie.At WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF NIA]UNG I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. A Dated: By: PHIL BATCHELOR By Deputy Clerk CC: County Counsel County Administrator eld v TRECEIVED MICHAEL F. WOHLSTADTERAttorney at Law .::...; 488 Seventh Street Oakland, CA 94607 CLER BOARD(?oSt PERVISORS Tel. No. (510) 839-1612 COWRA f-MTA C£). Fax No. (510) 839-4250 Attorney for Claimant AMENDED CLAIM FOR DAMAGES AGAINST COUNTY OF CONTRA COSTA 1. Name and Address of Claimant. Cynthia Walker, 1516 Bissell, Richmond, CA. 2. Name and Address of Person to whom Notices are to be sent Michael F. Wohlstadter, 488 Seventh Street, Oakland, CA 94607; telephone no. 510/835-1612. 3. Hate, glace and circumstances of occurrence giving rise to claim On January 7, 1998 between 1:30 and 2:30 p.m. at the Department of Social Services, 1305 Macdonald Avenue, Richmond, California, in the GAIN Instruction Room, claimant slipped on oil or water on the floor, and fell forward on her knees to the floor, sustaining injury. Claimant's knees were wet with the fall to the floor. It is known that adults and children frequent this area and bring food and drink to the area. The area is maintained in an untidy fashion. Chandra Williams, believed to be a DSS employee, came to claimant's aid, spoke with witnesses, and offered a statement (statement was attached to claim submitted May 22, 1998) . Claimant informed security of the incident, and a report was taken by a male Asian security guard. Mrs. Vann of the Department of Social Services later contacted the claimant. Claimant maintains that the premises of the incident was in a dangerous condition and that the County or its employees had notice of and should have remedied the condition. 4. Description of iniuries sustained. Claimant sustained injuries to the knees, low back, neck and shoulders. Claimant was treated at Kaiser, Richmond, and by Dr. Jonathan Francis, EMC Medical Group, San Pablo, CA. 5. Names of public employees causing damages in occurrence Unknown at this time. 6. Amount claimed as of date of presentation of claim together with basis of computation. Plaintiff claims Municipal Court jurisdiction at this time. "Copies of medical records of Kaiser Permanente Hospital were attached to the claim submitted May 22, 1998. Billing of Kaiser and fur er m ical records and bills will be submitted. Dated: June 8, 1998 MICLSTADTER Atto ey laimant I PROOF OF SERVICE 2 in re Claim of Cynthia Walker 3 The undersigned declares that he is over the age of eighteen, not a party to the 4 within action, a citizen of the United States andemployedat 488 Seventh Street, 5 Oakland, California 94607. That on /! ^f the 6 undersigned served true copies of Amended Claim of Cynthia Walker on the parties 7 by 8 first class mail in a sealed envelope, postage prepaid, deposited with the 9 United States Post Office in Oakland, California, addressed as follows, or xxx 10 personal delivery to the address set forth below: 11 Clerk of the Hoard of Supervisors County of Contra Costa 12 651 Pine Street Martinez, CA 94553 13 I declare under penalty of perjury that the foregoing is true and correct 14 and that this declaration was executed in Oakland, California on 15 16 17 18 MARKIWI 19 20 21 22 23 24 25 26 27 28 F ZKBOAR—CDOOFF-S-UPERVI EIVED MICHAEL, F. WOHLSTADTER JUIN! d lcl�Q Attorney at Law 488 Seventh Street Oakland, CA 94607 SORSTel. No. (510) 839-1612 :COsTA CO.Fax No. (510) 839-4250 GSE Attorney for Claimant AMENDED CLAIM FOR. DAMAGES AGAINST COUNTY OF CONTRA COSTA 1. N-ame and Address of Claimant. Cynthia Walker, 1516 Bissell, Richmond, CA. 2. Name and Address of Person to whom Notices are to be sent Michael F. Wohlstadter, 488 Seventh Street, Oakland, CA 94607; telephone no. 510/839-1612. 3. Date place and circumstances of occurrence giving rise to claim On January 7, 1998 between 1:30 and 2:30 p.m. at the Department of Social Services, 1305 Macdonald Avenue, Richmond, California, in the GAIN Instruction Room, claimant slipped on oil or water on the floor, and fell forward on her knees to the floor, sustaining injury. Claimant's knees were wet with the fall to the floor. It is known that adults and children frequent this area and bring food and drink to the area. The area is maintained in an untidy fashion. Chandra Williams, believed to be a DSS employee, came to claimant's aid, spoke with witnesses, and offered a statement (statement was attached to claim submitted May 22, 1598) . Claimant informed security of the incident, and a report was taken by a male Asian security guard. Mrs. Vann of the Department of Social Services later contacted the claimant. Claimant maintains that the premises of the incident was in a dangerous condition and that the County or its employees had notice of and should have remedied the condition. 4. Description of injuries sustained Claimant sustained injuries to the knees, low back, neck and shoulders. Claimant was treated at Kaiser, Richmond, and by Dr. Jonathan Francis, EMC Medical Group, San Pablo, CA. 5. Names of public employees causing damages in occurrence. Unknown at this time. 6. Amount claim aa of -date of Presentation of claim,_ together with -basis of comoutat:ioa. Plaintiff claims Municipal Court jurisdiction at this time. Copies of medical records of Kaiser Permanente Hospital were attached to the claim submitted May 22, 1998. Billing of Kaiser and fur er ieal records and bills will be submitted. Dated: June 8, 1998 let MI STADTER Atto y laimant I PROOF OF SERVICE 2 Tz re Claim of Cynthia Walker 3 The undersigned declares that he is over the age of eighteen, not a party to the 4 within action, a citizen of the United states andj employed at 488 Seventh Street, 5 Oakland, California 94607. That on �,/l �(� the 6 undersigned served true copies of Amended Claim of CynthiWalker on the parties 7 by 8 ,,,_,,, first class mail in a sealed envelope, postage prepaid, deposited with the 9 United States Post Office in Oakland, California, addressed as follows, or xxx 10 personal, delivery to the address set forth below. 11 Clerk of the Board of Supervisors County of Contra Costa 12 651 Pine Street Martinez, CA 94553 13 I declare under penalty of perjury that the foregoing is true and correct 14 and that this declaration was executed in Oakland, California on 16 17 18 MARK 19 20 21 22 23 24 25 26 27 28 AM BOARD QE SU ORS OF CONTRA COSTA CD-UNMsL MMIA RM A00 JUNE 16, 1998: 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 you is your California Government Codes. I notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given pursuant to Government Code Section 913 and 915.4. Please note all "Warning". AMOUNT: Municipal Court Jurisdiction CLAIMANT: Cynthia Walker MAY 2 6 1998 EL ATTORNEY: Michael F. Wohlstadter DATE RECEIVED: MARTINEZ CALIF. Attorney At Law ADDRESS: 488 Seventh Street BY DELIVERY TO CLERK ON: May 22, 1998 Oakland CA 94607 BY MAIL POSTMARKED: L FROM: Clerk of the Beard of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHEL/_"z Clerk Dated: May 22, 1998 By; Deputy IL FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. This claire 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: 6 I+ By: Deputy County Counsel M. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: ,,' PHIL BATCHELOR, Clerk, By ; Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning 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 Martinez, California, postage fully prepaid a ertified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By: PHIL BATCHELOR By - ?� Deputy Clerk CC: County Counsel County Administrator ......... ......... ................11.11 -- _. .. _. ........... ......_.. ......... .......... ........ ......... ........ ......... ......... ......... ..............._... __. ......... ......... . ........ ......... �, 11 RE EIVED MICHAEL F. WOHLSTADTER Attorney at Law EAY 488 Seventh Street Oakland, CA 94607 Tel . No. (510) 839-1612 CLC-ftK BOARD OF Fax No. (51.0) 839-4250 CL?Irafa3 t :. Attorney for Claimant CLAIM FOR DAMAGES AGAINST COUNTY OF CONTRA COSTA 1 . Name and Address of Claimant . Cynthia Walker, 1.516 Bissell, Richmond, CA. 2 . Name and Address of Person to whom Notices are to be sent . Michael F. Wohlstadter, 488 Seventh Street, Oakland, CA 94607; telephone no. 510/839-1612 . 3 . Date, place and circumstances of occurrence giving rise to claim. On January 7, 1998 between 1 :30 and 2 .30 p.m. at the Department of Social Services in Richmond, in the GAIN Instruction Room, claimant slipped on oil or water on the floor, and fell forward on her knees to the floor, sustaining injure. Claimant' s knees were wet with the fall to the floor. It is known that adults and children frequent this area and bring food and drink to the area. The area is maintained in an untidy fashion. Chandra Williams, believed to be a DSS employee, came to claimant' s aid, spoke with witnesses, and offered a statement (statement is attached) . Claimant informed security of the incident, and a report was taken by a male Asian security guard. Mrs . Vann of the Department of Social Services later contacted the claimant . Claimant maintains that the premises of the incident was in a dangerous condition and that the County or its employees had notice of and should have remedied the condition. 4 Description of injuries sustained. Claimant sustained injuries to the knees, low back, neck and shoulders. Claimant was treated at Kaiser, Richmond:, and by Dr. Jonathan Francis', EMC Medical Group, San Pablo, CA. 5 . Names of bublic employees causing damages in occurrence Unknown at this time. 6 . Amount claimed as of date of presentation of claim, together with basis of_ computation. Plaintiff claims Municipal Court jurisdiction at this time, and attaches copies of medical records of Kaiser Permanente Hospital . Billing of Kaiser and further medical records and bills will be submitp.- , s� f Dated: May 21, 1998 � 5� MICFZMIJ F LSTADTER. Attorney o Claimant _. _...... ......... ......... ......... ......... ......... ......... ......... - .. _..... ............ ..._......... ......... ........ ......_.... .._...... ......... ......... ......... ......... ......... _. _..__..._ . ........ ......... . ........ ......... f j C c�Yl + -4 6 fir- C km �i Ty\tqA uj�cc+ ka Alr -e r S (ct t t 6'' cx wcx P 4�D •tiJ/` TIS .. `f e f ve 3, 1 k/eA-A-4 e f C �aAASiW ((pj Va 1'.J '-V THE PERMANENTE MEDICAL:GROUP,INC, 1 KAISER FOUNDATION HOSPITALS EMERGENCY Rt3C3M RECORD ROOM dR BED NO. V DRUG T$MPERATURE o BLOOD PRESSURE i L TIME d A,M. S-DRUG: PULSE RESPMATIC 1 SEEN i THE UNDERSIGNED CONSENTS TO THE EXAMINATION OF THE PATIENT AND TO THE PERFORMANCE BY MEDICAL GROUP PHYSICIANS,THEIR ASSISTANTS,AND HOSPITAL ASSISTANTS,AND HOSPITAL PERSONNEL,OF SUCH DIAGNOSTIC AND MEDICAL PROCEDURES AS ARE CONSIDERED NECESSARY OR DESIlIA13LE IN THE CARE OF THE PATIENT,INCLUDING INSECTIONS,ADMINISTRATION OF ESTHETICS AND REMOVAL OF TISSUE.NO ASSURANCES HAVE BEEN MADE AS TO ANY RESULTS OR CURE. SIGN UAE(OR OTHER WITNESS) DAT RECEP WIT SS x __ZU CHF C _ PROBABLE E BY DIAGNOSIS _...., -�7- - Seen ID LaSt 7 days _ _ .. _ _..0 Emergency Department13 fiJ - _ ° _.__..x #inks Departses �No ID Sham Yes , l -— -------------- I(yy Arr o t✓ 3s tNJ IAf //-� tt ' SCA SUBTOTAL 94 r-d TOTALS SMALNUMBSIM 'siCR(a)tfi+EiTIAYE111 . LAPf!OAM�f. • SPdSIT1dN REGULAR MD? CONSUL ANT TIME ,M, ADMITTED ® DECEASED CODES tr '� i 2••j 3•,OUT M. I NOT ADMITTED 0 AMBULANCE E INSTRUCTIONS TO PA ENT L , APPOINTMENT WITH(Dr.,Clinic;Cate) REFERRED TO(Clinic and Data) - TRANSFERRED TO(e.g..Service.Floor,Countyl i 1, the undersigned, acknowledge receipt of a copy of these instructions together with any of the special instructions noted. PATIENT OR OTHER RESPONSIBLE PERSON EMERGENCY ROOM PHYS 1.L ft-.4'r A * KAISER* MSE/ PERlvw4E[4TE , r _ TRIAGE TIMEIDATE Medical Screening Exam/Triage SWAMP 'J EMERGE Y oF-Fr. FL HEET f ACE. SEX: M f 1 866 7 GURNEY -RAY IN C•SPINE PRECAUTIONS 1 2 3 4 5 6 7 8 9 TIME v"URSE INITIALS Pupil Gauge(mm) METHOD OF ARRIVAL LF EMT UNIT EMT,P OTHER OB.IECTIVI`DATA CC: /f GLASGOW COMA SCALE EYE OPENING VERBAL RESPONSE M R RESPONSE SUBJECTIVE TRIAGE DATA SPONTANEOUS 4 OMENT€D 5 OBEYS COMMANDS 8 TO VOICE 3 CONFUSED 4 LOCALIZES PAIN 5 TO PAIN 2 INAPPROPRIATE WORDS 3 WITHDRAWS TO PAIN 4 /� /� m NONE 1 INCOMPREHENSIBLE WORDS 2 FLEXION TO PAIN 3 NONE I EXTENSION TO PAIL! 2 NONE 1 E%PLA ATION - r SKIN SKIN CAPILLARY 8 THiNG4 SKIN COLOR PUPILS PERTINENT MEDICAL HISTORY MOIST TEMP REFILL ORMAL NORMAL Y "DRY WARM _ MAL RL CARDIAC/ _ SEIZURE _ HTN SHALLOW PALE _ MOIST COLD <2 SECS PINPOINT RETRACTING ASHEN COOL _ DELAYED DILATED ASTHMA/EMPHYSEMA CVA PSYCH ABSENT FLUSHED HOT >25EC5 REACTIVE DIABETES SUBSTANCE A8U5£! - CYANOTIC TURGOR ABSENT NON REACT. RAPID JAUNDICED GOOD R>L LMP G --_ P AB _ LABORED _ POOR L>R OTHER SIZE VITAL GNS PEDIATRIC a PROBLEM PROBLEM ASSESSMENT(Detail of+rat 1 $P P r R ) T WT NEURO _ _.....� t 2 t+v».arcs.rwiy MEICATItNS HEAD/FACE 3 CURRENT MEDS: ' 9( NECK 4 CHEST 5 ALLERGIES: LUNGS — - -- - - — .K 6 LAST TETANUS TOX: ABDOMEN 7 TRIAGE INTERVENTION aACK.SPINE a EXAM FIM 3MMED. ELEV. SPLINT/SLING ICE PELVIS DRY STERILE DRSG. XRAY ORDERED 9 EXTREMITI€S r TRIAGE DISPOSITION: PROTOCOL I PBTIATED RESOLVED ADmrr DAITEITIME DATEITWE f DATEI7ME ELI: fl£D BLUE RSEN OW CONSULT _.r AMSUL.ATORY SERVICES: MEDICAL(PERSONAL PHYSICIAN) SURGERY 64115 ORTHOPEDICS 1155 EYE 1240 OB/GYN IOW PEDIATRICS(PERSONAL PHYIAN) OTHER CALL DR. OCC MED 1244 MEDICAL APPOINTMENT 7D _ NO APPOINTMENTS Acuity: I 11 ![! V V VI Triage Nurse Signature Nurse 04984(RFV.10-981 O;STRIBUTION: WHITE=MEDICAL RECORD•-CANARY a CLINIC CERED f T119 I INIT X-RAYSMISC. ! T INIT CXR I MISC.X-RAYSN 1 � WALKER j C SPINE CLEARED MD, EKG Ga . C 1 - J E1 ABG E ! SITE j { IMPRtNT AREA CHART INDUST. Page Of SP I P j R j TPUPILS--j GCS uR I PROGRESS MATES Ark Vtl 4 1 1 ! 1 I j1 f t i I II 1 PARENTERAL FLUIDS I AMOUNT RN TIME/ NURSE AMT TYPE GAUGE! SITE 1A8sorb";INITIALS DATE MEDICATIONS DISE I ROUTE SITE � MlttfALS 1 1 I I TYPE AMOUNT TIME 'TYPE AMOUNT I I INITIAL SIGNATURE INITIAL SIGNATURE STAKE TOTAL OUTPUT ......... ......... ......... ......... ......... ......._. ... _ _ ....................._. ......... ......... ......... ......... ._....... ......... ......... ......... ......... ............. _ _.. ..... ......... ...........,1........ ......... JAI ��1'F�S C THE PERMANENTS MEDICAL GROUP,INC. - KAISER FOUNDATION HOSPITALS CYNTHIA u A'L K E R ___. . ...._. _ * - { ( EMERGENCY 00M RECORD RCYOM OE6 O. i NO TE TUR BLOOD PRESS''R3 i '~r ''✓ I — 1 _. .. _ DRUG E I_.. N ICA L SENSITIVITY ° \14 TIME /0 A.M. I YES—DRUG: PULSE RESPI ION Si EN ? PM I THE UADERSIGNED CONSENTSTO TH6 EXAMINATION Of-THE PATIENT AND TO THE PERFORMANCE BY MEDICAL GROUP PHYS►OIAHS.THEIR ASSISTANT$,AND HOSPITAL ASSISTANTS,AND HOSPITAL PERSONNEL,OF SUCH DIAGNOSTIC AND MEDICALPROCEDURES AS ARE CONSIDERED NECESSARY OR DESIRABLE IN THE CARE OF THE PATIENT,INCLUDING OWEC'IIONS,ADMINISTRATION OF ANESTHETICS,AND REMOVAL OF TISSUE.NO ASSURANCES HAVE BEEN MADE AS TO ANY RESULTS OR CURE. SIGNAT (OR OTHER WITNESS) j>7AT£ REPT. LYfTNES +r CHIEF C PLAF © PROBABLE E BY DIAGNOSIS Seen In Last 7 days --------_-._ p Emergency Gep rtments _Yes..t3. -- _ .. ._.. ... 'r .. .__. ._ oe7_ _: _. w C[in ics Nparts .- .... -Yes.D_. . -_.. -aD Si A`-rG Y7 C { t._ _�__.. a ttw 1u, ell �jo _ ... S ------ ----------- 73F ._Z..U , 2�r,r: z.l.. . CSCR i SUBTOTAL' 93 94 's TOTALS r' j_ AES NU"EAC� 2- , * ,IME Q A M }DISPOSITION REGULAR MD? CONSULTANT +� ---}t©ADMITTED © DECEASED � �� CODES 1-1 01 �,� 3— OUT i. PMI ADMITTED 0 AMBULANCE I { INSTRUCTIONS TO PATIENT APPOINTMENT WITH(Dr.,Clin;c,Data} REFEfRED TD(Clinic and Date) TRANSFERRED TO(e.g..Setvice.Floor,County) f,the undersigned, acknowledge receipt of a copy of these instructions to ether with any of the special instructions noted. PATIENT OR OTHER RESPONSIBLE PERSON EMER N R f P M CIAN • m MSE/ 1 /11 pE t!>c�1;0E rE TRIAGE Medio Sereening Exam/Triage .93 AN 7 ;'2 :LY g TIME/DATE EMERGENCY DEPT. FLOW SHEET STAMP7 7 } 7 AGE: 2, SEX: MAF k LOBBY GURNEY _ X-RAY IN C-SPINE PRECAUTIONS 1 2 3 4 5 6 7 8 9 RODM TIME NURSE IN Pupa Gauge(mm) METHOD OF ARRIVAL $ELF EMT UNIT EMT P, OrfHOR OBJECTIVE DATA GLASGOW COMA SCALE CC: YE OPENING VERBAL RESPONSE MOTOR RESPONSE_ SUSJECTty�TRIAGE DATA ,z SPONTANEOUS 4 ORIs J TO VOICE 3 f CONFUSED 4 LOCALIZES PAIN 5 TO PAIN 2 INAPPROPRIATE WORDS 3 WITHDRAWS TO PAIN 4 NONE I INCOMPREHENSIBLE WORDS 2 V FLEXION TO PAIN 3 NONE I EXTENSION TO PAIN 2 _ NONE 1 EXPLANATION SKIN SKIN CAPILLARY PERTINENT MEDICAL HISTORY BREATHING SKIN COLOR PUPILS MOIST 7 TEMP f3EE iAt NORMAL AfkM _AN RMAL :Y PERL SHA CARDIAC/ SEIZURE HTN LLOW PALE MOIST _ COLD <2 SECS RIIN INT _ RETRACTING ASHEN _ COOL _ DELAYED ^" TR✓ ASTHMA/EMPHYSEMA CVA PSYCH a ASSENT L FLUSHED < 1idT >2SECS REA VE .m DIABETES SUBSTANCE ABUSE/ _ - CYANOTIC TURGOR ABSENT NON RCA RAPID - JAUNDICED — 0000 0000 r R>L LMP G P AS — LABORED POOR L>R OTHER SIZE s PROBLEM PROBLEM ASSESSMENT(Dotaii of♦u VITAL S IGNr !! PEDIATR y $P �—i P ( , , R }�T . �.��✓,-, NEURO \ 2 MEDICATIONS HEADlFACE 3 ! CURRENT MEDS: , NECK CHEST 5 J ALLERGIES: �" ��"-�' Ir LUNGS i 8 { LAST TETANUS TOX: ti ABDOMEN t� 7 TRIAGE INTERVENTION BACK-SPINE t 8 EXAM RM tMMED. d ELEV. SPLINT/SLING _ ICE PELVIS / n DRY STERILE DRSG. X-RAY ORDERED EXTREMITIES TRIAGE KDISPOSITI N: PROTOCOL I INITIATED RESOLVED comm t7ATEMIME DATE.MME DATEMME Ed: RED BLUE BEEN YELLOW CONSULT AMBULATORY SERVICES: MEDICAL(PERSONAL PHYSICIAN) SURGERY 6405 ORTHOPEDICS 1155 EYE 1240 OSIGYN 1080 i PEDIATRICS(PERSONAL PHYSICIAN) _ OTHER CALL DR. _ ( CC MEd 1244 ! MEDICAL APPOINTMENT 2070 LOAPPOINTMENTS FN��' cuity: ! t! iii) 1V V!, VI Triage Nurse Signature urse 04984(REV.10.98) DISTRIBUTION: WHITE.MEDICAL RECORD•CANARY.CLINIC __...._. ......... ......... ......... ......... ......... . ......... ........... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... _. _. _ ......... . ........ ......... C-sl ORDERED 1 '11ME INIT X-RAYS/MISC. TIME INIT 1 '" i - MISC.X-RAYS C SPINE CLEARED MD g # ASG { SITE IMPRINT AREA u CHART INDUST. Page of SP P R ? GCS PUPI # PROGRESS NOTES 1 1 c_ 5 r I I i I 1 I I i I I I i i PARENTERAJ,P Ulos AMOUNT RN TIME/ NURSE # MEDICATIONS DOSE ROUTE SITE AMT I TYPE GAUdE SITE AeswwdltNkTFAtS DATE INITIALSi i i i 1 � I j i a AMOUNT TIME TYPE AMOUNT 7 CL �' INITMAL SI TURF INITIAL SIGNATURE 3 �LINTAKE TOTAL OUTPUT ........ ......... ......... ......... ......... ......... ......._. 1111 ...... _.._._.... ......... ......... ......... ......... ._....... ......... ......... ......... ......... ................_.. _ _ _.. _ ......... ......... . ........ ......... THE PEIRMANENTE MEDICAL GROW INC. _ KAISERFOUNDATION HOSPITALS EMERGENCY ROOM' RECORD CYPITHIA' WALKER ROOM OR BED N& i NO DRUG ERAT.URE i BL`a PRESSUPE 3 ty;� 3 L �.. .� SENSITIVITY If- ©' ! +� TIME YES DRUG: 1 PULSE RESPIRATION r ; ; SEEN PM— THE UNDERSIGNED CONSENTS TO THE EXAMINATION OF THE PATIENT AND TO THE PERFORMANCE BY MEDICAL GROUP PHYSICIANS,THEIR ASSISTANTS,AND HOSPITAL ASSISTANTS,AND HOSPITAL PERSONNEL,OF SUCH DIAGNOSTIC AND MEDICAL PAOCEOUII ES AS ARE CONSIDERED NECESSARY OR DESIRABLE IN THE CARE OF THE PATIENT,INCLUDING INJECTIONS,ADMINISTRATION OF ANESTHETICS,AND REMOVAL OF TISSUE.NO ASSURANCES HAVE BEEN MADE AS TO ANY RESULTS OR CUBE. SIGRE(OR THEP WITNE S) DATfE RECEPT. WrTNESS X7(�;i i f x � ` s err CHIEF COMPPINT Seen in tast ® PROBABLE E BY DIAGNOSIS mergency Departmmnts Yes_C3-71 O oZ Clinics Departs _._._Yes ❑ n N .-.___... . ..JD Shown Yes _ ..ftE r._.__.. �- __ ,. ,�•. ,� � ���Ic�rlrsys ANG Iw IOC __._----- ___....__.____...____..___.__...__.___.--_11___11...__ "�r. ..._ 7._ -.— ......__... '-__..__._....._.--_1_111,.,.__....._..__-.... .,.._..................�_..._._,.__..........__.._._.._,.__..W.__.- _.__... 1111 __.. f art)j ... 1111.._ __...._..._..._ _.._.. _,..._..... w�t. iNd IMM <Z' �s.�- ,:�.,�r-_111.1(.�..��►�. � ._ __���--3`t�a _._.�,,,�,.� c.,,,.�,,�,�• �- L1*� 1 " - ►+w 1111.. S _ .. .. .__. ..._._.._.. _. SUBI TAIL c..�',S`� iI.1►--'1� `G..��L.IS'•� ��,1.�+�J"`4._. _ 93 fls — c fI -'u�Dw' r TOTALS � act" T DISPOSITION REGULAR MO? CONSULTANT TIME DISPOSITION "' ,r..1,ADDMITTED O DECEASED CODES 1-1 x- s» OUT ty P.M. l L.crrs9J NOT ADMITTED 0 AMBULANCE I ) INSZ'MCTIOM TO PATIENT APPOINTMENT WITH(Dr.,Clinic.Date) REFERRED TO(Clinic and Date) TRANSFERRED TO(e.g.,Service,Floor.County) 1, the undersigned, acknowledge receipt of a copy of these instructions together with any of the special instructions noted. PATIENT OR OTHER RESPONSIBLE PERSON EMERGENCY ROOM PHYSICIA ......... ......... ......... ......... ......_.. - ......... ......... ......... ........_....1.1_1.1 - - - _ ...._ ........ ..._........ .._...... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... _. __. _. .. ......... ......... . ........ ......... �m MSEJ ,/ U-LieL#d PEM,VLt4NElti M TRIAGE * ' - 7 TIME/DATE Medica{Screening Exam/Trfg` I w;i#': : Lr STAMP EMERGENCY [SEPT.FLOW SHEET ell 11 AGE: 1 SEX. M IF OSBY ❑ GURNEY X-RAY _ IN C-SPINE PRECAUTIONS 1 2 3 4 5 6 7 8 9 ROOM -nmE t NURSE INITIALS Pupit Gauge(mm) Ij ( ,., , . • i METHOD Of ARRIVXL 'SELF a EMT UNIT EMT P OTHER OBJECTIVE DATA CC: 1 GLASGOW COMA SCALE t"sY�0#�14NINGi SAL RESPONSIE MOT GN88 SUWECTIVE'TRtA4E DATA PONTA75OUS 4 ..J ORIENTED) 5 '�S COMMANDS 6 TO VOICE 3 CONFUSED 4 LOCALIZES PAIN 5 e- LL f TO PAIN 2 INAPPROPMATE'V ORDS 3 WITHDRAWS TO PAIN 4 NONE 1 INCOMPREHENSIBLE WORDS 2 FLEXION TO PAIN 3 ''2 NONE 1 EXTENSION TO PAIN`` 2 _ L NONE 1 L t"C i'Ll s 77 EXPLANATION �•-� ,- EATHtNiii SI(IN COLOR3KIN SKIN CAPILLARY PUPILS PERTINENT MEDICAL HISTORY MOIST TEMP REFILL Z,46SMAL G''yNORMAI. -1�10RY :,-WARM NORMAL tRL CARDIAC! SEIZURE HTN SHALLOW - PALE MOIST COLD <2 SEC$ PINPOINT _ RETRACTING - ASHEN COOL DELAYED DILATED ASTHMAIEM:PHYSEMA — CVA PSYCH ABB€NT FLUSHED HOT >2 SECS C REACTIVE _ CYANOTIC TURGOR ASSENT NON REACT. DIABETES SUBSTANCE ABUSE) RAPID JAUNDICED G000 :21 R>L LMP G P A9 Y LABORED POOR Z L>R Y OTHER SIZE VITAL SJIChtS r PEDIATRIC ✓ s paa t rn i PROBLEM ASSESSMENT(D+�ta)L of Ns BP �s'- P R T=L_ WT NEURO 2 t"."ft.how y MEDICATIONS HEAD/FACE 3 CURRENT MEDS:A7 NECK CHEST ALLERGIES' LUNGS '' 6 LAST TETANUS TOX: ABDOMEN -I 7 TRIAGE INTERVENTION BACK-SPINE _ 8 , EXAM RM IMMED. ❑ ELEV. SPLINTJSLING ICE PELVIS — DRY STERILE DRSG. '-7 X-RAY ORDERED a i EXTREMITIES TRIAGE DISPOSITION: PROTOCOL INITIATED ! RESOLVED ADMIT DATEmmE 1 DATEJIm DATErnum ED: ::1 RED 7 BLUE GREEN YELLOW i CONSULT AMBULATORY SERVICES: u MEDICAL(PERSONAL PHYSICIAN) SURGERY 6405 ORTHOPEDICS 1155 EYE 1240 OWGYN 1080 I PEDIATRICS(PERSONAL PHYSICIAN) OTHER CALL DR. OCC MED 1244 E r MEDICAL APPOINTMENT 70 NO APPOINTME S ; ' :, Acuity: N !N IV v VI _...._. ......... ......... ......... ......... ......... ......... ......... ......... .. . .. .............. ......._. ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... _. ........_ ......... ......... . ........ ......... ,F.RF-J 1 TIME 1NIT X-RAYSIMISC, TIME 0112 q 8 cxR Mi C.X-RAYS , �" ' NTHIA W INL C SPE CLEARED , o: 0°9EX G7 j ABCs E —,1 SITE w IMPRINT AREA i I I u CHART of INDUST. Page op i P R T GCS j PUPILS ' PROGRESS NOTES UR G .- I AJ I t j II ; IIS f s j k j � 4 PA ENTERAL FLUID AMOUNT] RN TIME/ MEDICATIONS t�ClSE I ROUTE SITE NUR AMT TYPE i CrAUGE St IAb-b"1.tWTfALS DA lNtTIALS j r i i f k 1 � I P I AMOUNT TIME TYPE AMOUNT v INITIAL I SI TUBE INITIAL SIGI+IATURE G I I I INTAKE TE)TAL OUTPUT KAMER PERIV AiVENM PLEASE IMPRINT OR PRINT flA38 LSF t3trRViCBLOCATION STATION PATIENT PROGRESS'RECORD _ '�j _v , �'�., �.�- _ PATIENTS NAME(LAST,FIRST,MIDDLE) tA5' N "raAM� u�ttAt ADDRESS WOTHOATS HEA,TH iSt.F 4.123 F W f A MCI 0A.V, ............ .................... ...... ....._. ................�.�.�__ _._.... _...._..... CITY MWI AL RECORD NWlark C?Ifcx DIG;T 0 117 70 BIRTH OA PHONE f GROUP <,rEx.cov- Q-F ^ROUP NUMBER ACCOUNT NUFAIN:A I sun Wour DATE TIME Y /Z- AP n � � -- �) Lu �.� I ? C-e �.-.... ef i..� ------------------- r . -- nn597 tRC�� i.n,^, KAISER0 MSE/ ,�,E _ TRIAGE -76 Aedica3 Screening ExamlTriage *9~ l` f? ;% STATIMEM?PATE � 0� G STAM EMERG Y DEPT.F SHEET ROE: SEX: LOBBY GURNEY W X-RAY IN C`SP#NE PRECAUTIONS 1 2 3 4 5 6 7 $ 9 ?OOM TIME NURSE ftdtTiAtS Pupil Gauge(mm) AETPOO OF >RRIVAL SELF ! EMT UNIT _ EMT P OTHER OBJECTIVE DATA JC. GLASGOW COMA SCALE EY P-SMING RBAL RESPONSE MDtOR RESPONSE 3U9!£CT1VE TRIAGE DATA ^ PONTAN€OUS 4 ORIENTED OBEYS COMMANDS d TO VOICE 3 CONFUSED LGCALVAS PAIN 3 TO PAIN 2 INAPPROPRIATE WORDS 3 WITHDRAWS TO PAIN 4 NONE 1 _ INCOMPREHENSIBLE WORDS 2 FLEXION TO PAIN 3 NONE 1 EXTENSION TO PAIN 2 NONE i EXPLANATION SKIN SKIN CAPILLARY PERTINENT MEDICAL HISTORY SRI A G SKIN COLORmow R PUPIL NORMAL MAL DRY 0 WARM _ NORMAL 216!L CRRD#ACI SEIZURE vHIN SHALLOW PALE MOIST COLD c2 SECS PINPOINT RETRACTING _ ASHEN COOL DELAYED DILATED ASTHMA/EMPHYSEMA CV PSYCH = ABSENT FLUSHED HOT >2 SECS y REACTIVE _ e CYANOTIC T GOR _ ABSENT NON REACT. DIABETES SUBSTANCE ABUSE! a RAPID :JAUNDICED GOOD y R>L IMP G P AB — LABORED POOR L>R OTHER SIZE it PROBLEM =I PROBLEM ASSYISSME14T(Detail of*v V! AL SIGNS PE ATR# , BP P NEURO 2 ("..m.no..) . MEDICATION t HEAD/FACE _ 3 CURRENT MEDS: NECK d CHEST 5 ALLERGIES: LUNGS s I LAST TETANUS TOX; ABDOMEN ' _. TRIAGE INTERVENTION SACK-SPINE 8 EXAM RM 1MMED. = ELEV. SPL#NTISLING ICE PELVIS DRY STERILE DRSG. X-RAY ORDERED e EXTREMITIES PROTOCOL INITIATED RESOLVED ADMIT TRI S'5010 DATEMME DATFMME i DATEMME ED: RED 7CEBLUE N YELL CONSULT Y Tt3R I MEDICAL(PERSONAL PHYSICIAN) SURGERY 8405 1 ORTHOPEDICS 1155 EYE 1240 OB/GYN 1080 i V PEDIATRICS(PERSONAL PHYSICIANS _ OTHER - CALL DR, OCC MED 1244 MEDICAL APPOINTMENT 2070 ❑ NO APPOINTMENTS Acuity1 III IV V V} Triage Nurse Signature Ad=- A -7' Nurse a98d tpEV.to-9s1 QISTRmUTION WHITE-MEDICAL RECORD •CANARY=CLINIC c At ADULT pRIMARY CARE. 1997 APRT JULIE PAISST, M.D BONNIE STEUBLE, M.D. RtNDR��, HOBAAT .0. BR1Git7 M' Last V.-sit And rPezent Labs Reviewed y Weight: l . i ar;t t °rR: C General:l: «.i.. l�`i --SID fr:A :pm Itt HE EN T: CAB: Heart: Vulva: - 0 NL 0A3: { NL i"A3: Lungs: Vagina: ONL 0A3: ,. ' Breasts: _Cervi;: NL Abdomen: U.erTuS R Adnrp. _ NL L7 TREATMENT<' FOLLOW U? PIT LABS COUNSELING Cho-LH:)L ?aP S:n!3r 71 Z Smoking :1 Al:zhoi Use Safety -3 Safer Sex 1 Birth Can=l _1111. ......... ......... ......... ......... ......... ......... ......... ......... ......... 11.11. __ _ ...... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... ......... _ _ ...................... . ........ ......... THE PERMANENTS MEDICAL GROUP,INC. C Y N T 111 A W A L K E Ft KAISER FOUNOATiON HOSPITALS pq7 EMERG 'NCY ROOM''RECORD ROOM OR 8 O NO. ,NO T RE !BL ES DRUG I SENSITIVITY TIME CAM 3 E -DRUG P �AE$PIAATON 21'� SEEM Pm,❑ l THE UNDERSIGNED CONSENTS TO THE EXAMINATION OF THE PATIENT AND TO THE PERFORMANCE BY MEDICAL GROUP PHYSICIANS,THEM ASSISTANTS,AND HOSPITAL ASSISTANTS,AND HOSPITAL PERSONNEL,OF SUCH DIAGNOSTIC AND MEDICAL PROCEDURES AS ARE CONSIDERED NECESSARY OR DESIRABLE IN THE CARE Of TH9 0 PATIENT,INCLUDING INJECTIONS,ADMINISTRATION OF ANESTHETICS,AND REMOVAL OF TISSUE.NO ASSURANCE$HAVE BEEN MADE AS TO ANY RESULTS OR CURE: SIGE7 {OR OTHER fTNE$S) DATE RECEPT. WITNESS c —�'6 N CHIEF COMPL.#INT I, BAL3LE E BY DIAGNOSIS Seen-In East.7 days v Emergency-Departments .._:Yes E3 -__ No-13- - Q j3_ 111.1_.._ _ _.ales_12._._._ R6[3___U ID Shown Yes d No 13 ..__.__._.._.._..__._... o,.._P _..__..____._..___.�_.._.__.___�_ __._.___..___._ .' IEDIGATIOr S AND__. .fECfIONS _._.___._ r. l ._ _�__.. .. _ _ _., ..._. .___....._....,....___...._ 111_1 ..- _.t,,, std01!.`{1NJ RAIIA ..._-._._.._.__....._._.. .............__._ _........ _1111__-1111 ..._.._.._.. 1111_ ......... ... k .............._. ....�1111..._.__.._..._..._... .. .......-__........_........._....._.._....._.............._...._ ._..._............ _..._..111___1.;-._...,.__:_....,_�.._ I .._ ._.. .... _.___ .. _.. . _.__.. -:_1111._'_._..___1.11.....1 . ..........._..._..._- _1111... _ ` i 1111.._..._ .. _.._.__. ....,.__._.._.._.._....._._........111...._ .......... .._.r .. _11__11 ............._.. .,.._....... ._._ .,.._1111. ........ _._......._. _. __ .. __ 11_11. _.. _.. ... r ..___._....__. .__... . f 1111.. -_. ._ 111__1_..._ `_1111..___. ................ ..._.... _.......__..... ....._.......... r ..._........__......_...........__ ........111__1_.. ........... .............. ....._......_. ..—.1111._ f 1111 1111 _.. _. 1111 ... - ... .. 111_1... ...11_11.. 1111. 11_11._.. ..-__..__.._ 1111 1111._...... ._. _ .•_ . a.. . - ............ SCR t _ _._.....__. . ..._ _.__.. ._....__..__ .._....... .. ..__._.. _. .__.......__ ._ _ _.._ .-............_.._._. ........ .... .. 1111_.._». _... __._.._ SUBTOTAL: 93 $4 TOTALS TIME A.M. DISPOSITION REGULAR MO? CONSULTANT n )� C ADMITTED Il DECEASED CODES t-. V� � 2-1i 3-1 1 OUT P.M.® © (H)NOT ADMITTED C AMBULANCE I INSTRUCTIONS TO PATIENT APPOINTMENT WITH(Dr.,Clinic,Date) ;REFERRED TO(Clinic and bate) TRANSFERRED TO(e.g.,Service,Floor,County) f 1, the undersigned, acknowledge receipt of a copy of these instructions together with any of the special instructions noted. PATIENT OR OTHER RESPONSIBLE PERSON EMERGENCY ROOM PHYSICIAN ^-Ili)IPPV •-na,a:=VFPSE Pccca-SP.?Ar _........ ......... ......... ...........__-... .... ......... ......... ......... ......... ......... ......... ......... ............._. ... . ... .................................................................................................................................. _ ............................. Ater � pEj�llv usAN9N1't» F{I Medical Screening Exam/Triage TIME/DATE STAMP EMERGENCY DEPT. FL�W E'ET � t)afk'y AGE: SEX: M' 0 ,9q 3 1. 0 LOBBY GURNEY ` -RAY iN C-SPINE PRECAUTIONS 3 2 3 4 5 & 7 $ $ ROO :000 NURMS Pupli Gauge(mm) • * MEtH00' ARRIVAL EMT UNIT EMT P OTHER 08JECTIVE DATA GLAS92IN COMA SCALE E PENING gAL RESPONSE MO ESPONSE SUBJECTIVE TRIAGE DATA � ,/° ` �" SPONTANEOUS 4 Of ORIENTED 5 �08EYS COMMANDS 5 w TO VOICE 3 CONFUSED 4 LOCALIZES PAIN // 40 7 _ TO PAIN 2 w INAPPROPRIATE WORDS 3 WITHDRAWS TO PAIN d = NONE i INCOMPREHENSIBLE WORDS 2 FLEXION TO PAIN 3 NONE I EXTENSION TO PAIN 2 = NONE 1 EXPLANATION M SKIN SKIN CAPILLARY PERTINENT MEDICAL HISTORY /7 f'p., BREATH"- � SKIN R TEMP —REFILL PUPIL$. _ _ CSRMALORMAL --- DRY WARM MAL L CARDIAC/ _ SEIZURE HTN _ SHALLOW PALE _ MOIST COLD <2 SECS PINPOINT RETRACTING — ASHEN COOL DELAYED DILATED ASTHMA/EMPMYSEMA _ CVA _ PSYCH p ASSENT _ FLUSHED HOT >2 SECS REACTIVE _ DIABETES SUBSTANCE ABUSE/ CYANOTIC TUR ABSENT m NON REAC'. RAPID _ JAUNDICED CIOOD e R>L IMP G P AS — L.AaOAED POOR e L>R OTHER SIZE s PROBLEM = PROBLEM ASSESSMENT Detail of#a 7 VITAJLSIGNS PEDIATRIC , BP P R �G"_T-� WTNEURO 2 (syw,we.now I MEDICATIONS HEADIFACE 3 i CURRENT MEDS: '� NECK 4 CHEST 5 ALLERGIES: v . LUNGS f LAST TE'T'ANUS TOX: ABDOMEN _ 7 +L- TRIAGE INTERVENTION BACK•SPME j s _ EXAM RM IMMED. _ ELEV. r SPLINTISLING _ ICE PELVIS DRY STERILE DRSG. X-RAY ORDERED s EXTREMITIES TRIAGE DISPOSITION' PROTOCOL INITIATED RESOLVED ADMIT �. DATE/TIME DATEMME DATEMME ED: RED BLUE :'_ GRNYELLOW CONSULT AMBULATORY SERVICES: j MEDICAL(PERSONAL PHYSICIAN) SURGERY 6405 ORTHOPEDICS 1155 EYE 1240 OBIGYN 1480 4 PEDIATRICS(PERSONAL PHYSICIAN) OTHER CALL DR. OCC MED 1244 MEDICAL APPOINTMENT 2070 NO APPOINTMENTS Acuity: i ! il( IV V V! r d-er Triage Nurse Signature Nurse .;.,. �_.. .„ �, ^IC76i1p,1_JTtf1y. �A;wiTC „--,ria oC^^exn r,..nAv—ry•.,at .ABS ORpERED j` TIME INIT X-RAYSIMISG. 1 TIME INIT crdst I CXA ,A-6 MISC.X-AAYS 'YLASE 41 ,�EAT, a SPINE CLEARED ,PTT MD: EK LTURES ABC,' j SITE "HER J IMPRINT AREA CYlART .INDUST. � Page of PEJRr, i TIME $P P E3 T GCS PUPILS j PROGRESS NOTES LJR � . i ' I ' I 1 f f I j 1 1 i I I f ItT 41 INITIALS DATE ---- START PARENTERAL FLUIDS AMOUNT j RN NURSE TIME) Abtarb*d I MEDICATIONS DOSE ROUTE SITE 04MALS TIME AMT 3 TYPE 6iAUt31 SITE I I I I � TIME TYPE AMOUNT TIME TYPE i AMOUNT 1 INITIAL ( SIGNAT E INITIAL SIGNATURE t t S PAL INTAKE rTAL'OUTPUT y PLEASE IMPRINT OR PRINT hRTE 3E'2 iC R STATION PATIENT PROGRESS RECORD _.` ._.. _..t. _�... " J... . PATIENT'S NAME(LAST,FIRST,MIDDLE, h� ADDRESS CITY ......................_................_.._........_...._........_........_.................._ . ._ .._.__.. _........_._ ....... ..._. ._.S5+Z3::«:L Af:f;'3HJ?dVStiti::f�t �L`ttLGK Ciz3t". BIRTHrDAjE PHONECtJb f GROUP ;rY r,'. cllr%l p vV?i "Flt ACCOUNT hUld8f.t `stat QRMU; 44JJ��77 41 �"�(�(j( -Jl /fes J J, TOBACCOW r nZINES NO )MEDICAL CLINIC FEB 12 1998 APPTREQ_...,_, . .00 ► , KAISER PENIANEN E N //� }}}��►► PLEASE IMPRINT OR PRINT - �1t i it DATE Of SERVICE 'LOCA -STAT NOMEPATIENT PROGRESS RECORD r--� PATIENT$NAME(LAST.FIRST,MIDDLEI "If wine k2f NAME INITIAL 1 th ADDRESS N gTHDA fE HEALTH INEEMANCiM,nnA NUMBER DAY 'mAn cliY MEDICAL RE00140 NUbY N CHECK DIGIT BIRTH DAT PHONE7coos GROUP 7Ex coven) :ACCOUKTNUMBOR :$usGROUP Al tN TOBACCO US ZfIES �in fly 3 1998 1v'-t Ka , c- Ac-PT E rIEG Al C6 All 7" z" Fe-s 7(p E_2�� yj r\, C, 1 - i vu I 12 S- s � 90537(REV.1-92) _ _. .. ......... ......... ......... ......... ......... ......... ......... .._...... _ _ ....... ......_.... ......... ......... .. ....... ......... ......... ......... ......... ......... ......... ......... .......... _ _ _ ......_.. ......... . ........ ......... t� I# "SER PETWANENTE PLEASE IMPRINT OR PRINT PATIENT PROGRESS RECORCt -cq C/ff- fil F>10 PATIENTS NAME(LAST,FIRST,MIDDLE) �("' - J ADDRESS NON-MEMBER f jJei 11) �1�fjslt` OIT3/ 70 BIRT DAT PfiONEi Rt7UP r r MEDICAL CLINIC P 1931't�; 10 1928 ;PPT REG ML srt 90537(REV.1-92) • r Y Kgi5GR > w crrr PLEASE IMPRINT OR PRINT '—V CATE OF SuvwtC8 i LOCAll STATION PATIENT PROGRESS RECORD PATIENT'S NAME(LAST,FIRST,MIDDLE) AR NAME NfTYJtL ADDRESS REATH E KSALTITAOCF CLA04 NUbtititR CITY 1tl O7CAt NtiUUHfI NtTtfBEH fj'I� ON@CK CIQlT BIRTH DATE PHONE Cwt GROUP sxx a sWup mlNaw A000UNT NU."SA SUB GROUP -S2 , DATE � TIME cl OVEDICAIL CLINK; iklA #fir. �t� t;�-vt.ez. d '. 111 i i f 90537iA�V !•9�I �• �li/#iSEtZ PLEASE IMPRINT OR PRINT PATIENT PROGRESS RECORD PATIENT'S NAME(LAST.FIRST,AttDBt.3=J ,- ,. _ .> 'n i�..17{Al Q ADDRESS CITY c R C}tbiF BERTH DATE PHONE CODE GROttP .ar.� _,:z,N N1.=�jZ TOBACCO USE =YES== NO MIEDICAL CLINIC COUNSELED Q APR 161998 APRT REG.�....�. OJT, __21! ,, AC e_/ -� �A. �t �e W�tjU 1 } (NIca C u OA 11 c4z- 90537IREV. 1-923 ................................. C . I PROOF OF SERVICE 2 In re Claim of Cynthia Walker 3 The undersigned declares that he is over the age of eighteen, not 4 a party to the within action, a citizen of the United States and 5 employed at 488 Seventh Street, Oakland, California 94607. That on 6 the undersigned served true copies 7 of Claim of Cynthia Walker - on the parties by 8 first class mail in a sealed envelope, postage prepaid, 9 deposited with the United States Post Office in Oakland, 10 California, addressed as follows, or xxx personal delivery to the 11 address set forth below: 12 Clerk of the Board of Supervisors County of Contra Costa 13 651 Pine Street Martinez, CA 94553 14 I declare under penalty of perjury that the foregoing is true 151 and correct and that this declaration was executed in Oakland, 161 California on 17 18 19 M —KUW. EL 20 21 22 23 24 25 26 27 28 ..........................................................