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MINUTES - 07141998 - C33
Jr3 CLAIM BOARD OF SUPERVISORS OF CMTRA,COSTA COUNTY, CSA ,IFORNLA MUM= July 14, 1998 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 below), given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: no less that $10,000 RMCMUVT 10 CLAIMANT: Bonnie Jacobs JUN 2 3 1998 ATTORNEY: DATE RECEIVED: COUNTY COUNSEL MARTINEZ CALIF. ADDRESS: 3205 Northwood Drive #360-1 BY DELIVERY TO CLERK ON: Concord CA 94520-4565 BY MAIL POSTMARKED: June 20, 1998 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHEL , Clerk Dated: June 23, 1998 By: Deputy IL FR01VE• County Counsel TO: Clerk of the Board of Super sors (><) 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: a ,�,/,�, ,+c.. "1"y7� 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 th this is a true and correct copy of the Board's OrdAentd in its minutes for this date. Dated PHIL BATCHELOR, Clerk, B e uty 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. AFFIDAVff 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 rtified copy of this Board Order and Notice to ClaiAantassed tothe claimant as shown above. Dated: v� — By: PHIL BATCHELOR Beputy Clerk ZZ CC: County Counsel County Administrator - Claim to: f BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLA31OM 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 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 ether cause of action must be presented not later than one year after the accrual of the cause of actio. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. 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 gust be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal,, Code Sec. 72 at the end of this Form. RE: Claim By Reserved for Clerk's filing stamp ss a Against the Mnty of Lantra costa2 2 R98 . or ) r 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 $ and in support of this claim represents as follows: 1. When slid the damage-or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required.) 4. What particular act or emission on the part of county or district officers, servants or .employees caused. the.injury or-damage's {over} �. Wriat are the names of county or district officers, servants or employees causing the da..-_�ge or inJury? --------------—--- _....._----_..___ --.._......__.. --------- 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. ...._....s..-__.._......�.w..___....._______ How was the amount claimed above computed? (Include the estimated amount of any 7• prospective injury or damage.; 8. -Names and addresses of witnesses, doctors and hospitals. g. List theexpendituresyou made on account of this accident or inJury DATE ITEM AMUNT � � � � � � � � * .� � � � � � � � � -� �.� � �► � � * � X10:2 provides: Gov' Code See. 9 "The claim must be signed by the claimant SEND NQTICFS T4: (Attorne } or some erson on his.behalf." Name and Address of Attorney , N , Claimant's Signature Address 1F Y"j4i� Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for or to any county, city or district board or payment to any state board or officer, officer, authorized to allow or pay the same if .genuine, any false or fraudulent is punishable either by imprisonment in claim, bill, account, voucihoe�rof noor t�moregthan one.year`* by a fine of not exceeding the county jail-for a perfne-q, Or by one thousand ($1,000}, or by boand th such imprisonmenh ten usandidollars ($14,OOO,no nby n the state prison, by a fine of not exceeding both such imprisonment and fine. Bonnie Jacobs 3205 Northwood Drive#360-1 Concord,CA 94520 925/680-6714 June 21, 1998 ADDENDUM TO JUNE 20, 1998 Documents (copy enclosed) Ms Andrea Cassidy Clerk of the Board of Supervisors of Contra Costa County 651 Pine Street Rm# 106 County Administration Bldg. Martinez,CA 94553 Claim by: Ms.Bonnie Jacobs Against the County of Contra Costa or Contra Costa County Sheriff s Dept. The undersigned Claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of no less than$10,000 and in support of this claim represents as follows: IThe following are the answers to the questions on the claim form.} 1. Dec.21, 1997 after 8:45pm - before and during arrest and until released on Dec.22 1997 after 12:00 pm. 2. The public parking lot of the Oakley Veterinary and Bird Hospital(which faces Main St.)-3807 Main Street, Oakley,CA 94561. And the Martinez Detention Facility, 1000 Ward Street,Martinez,CA 94553. Both locations are in Contra Costa County. 3. Sitting in my car,which was parked in the public parking lot outside the Oakley Veterinary Hospital, because I was seeking treatment for an injured bird. I was accosted by two(2)Contra Costa County Sheriff s Deputies,who beat me without cause and incarcerated without reason. I suffered physical and emotional injuries. 4. False arrest,assault and battery,sexual battery,unlawful detainment overnight,violated State,Federal and Constitutional Rights,failure to identify themselves,failure to read my Rights,failure to tell me that I was under arrest,and Contra Costa County Sheriffs Dept.engaged in negligent hiring,retention, supervision,and training of employees. This resulted in extreme emotional distress and physical injuries. 5. Sheriff Deputy Richard Jensen-assault and battery,&sexual battery. Sheriff Deputy George Smith- accomplice to the crime. Sgt.Phil White-supervisor of Deputies Jensen&Smith. 6. Extreme emotional distress and physical injury. Possible future medical bills. Amount unknown. Special damages incurred includes but not limited to: $100.00 to retrieve my car,$55.00 to retrieve my bird,$135.00 emergency room visit,$250.00 Bail,financial hardship,Etc. 7. Amount Claimed is based upon compensation for physical injuries,which are on going,emotional distress,out of pocket expenses,and punitive damages. 8. Hospital: Contra Costa County Health Services, 595 Center Ave. Ste.#300,Martinez,CA 94553 - Dr.Pilcher. Sheriff Deputy George Smith,Martinez Detention Facility Employees-Dec.21, 1997 after 11:00 pm. 9. DATE ITEM AMOUNT Dec.22, 1997 Bail $250.00 Dec.22, 1997 Animal Control $ 55.00 Dec.22, 1997 Oakley Veterinary Hospital $ 63.56 Dec.22, 1997 BJ's Tow $100.00 Dec.24, 1997 Emergency Room $135.00 Dec.24, 1997 Film $ 9.18 Jan. 05, 1997 Film $ 23.80 Jan. 06. 1997 Therapist $ 30.00 After: June 21, 1997 Further Therapy Amount unknown After: June 21, 1997 Possible Future Medical Expense/Bills Amount unknown Ms Bonnie Jacobs - June 21, 1998 Bonnie Jacobs 3205 Northwood Drive#360-1 Concord,CA 94520 925/680-6714 June 20, 1998 Clerk of the Board of Supervisors of Contra Costa County 651 Pine Street Rm# 106 County Administration Bldg. Martinez,CA 94553 Claim by: Ms.Bonnie Jacobs Against the County of Contra Costa or Contra Costa County Sheriff's Dept. The undersigned Claimant hereby makes claim against the County of Contra-Costa or the above-named District in the sum of no less than$10,000 and in support of this elai • 11 resents as Yellows: (The following are the answers to the questions on thi,claimlform.} {'` X11 � 1. Dec.21, 1997 - before and during arrest and 4intil�eleas orfrD c.22;J 997 ager 12:00 pm. 'A" 1` 4b It 2. Oakley Veterinary and Bird Hospital - 3 0 Main S;�tre�t, Oakley tuA 94 1 3. Sitting outside the Veterinarianital beeiust was seeking treatm�ert or an injured bird. I was accosted by two(2)Contra Cos �ty Sh ri"f''s Deputies,who b at me without cause and incarcerated without reason. I�fferetl�hysi'eal aiid emotional ries. 4. False arrest,sassaul nd battery,sexual a# ry,AlawfW detainment overnight,violated State,Federal and Constitutional hts,failure 6,idontif themseeves. allure to read my Rights,failure to tell me that I was u4der arres and Contra Costa - ounty Shep'NI:Jept.engaged in negligent hiring,retention, supervision,`and training of employees. This resuld in extreme emotional distress and physical injuries. �' 5. Sheriff y. DeP Y, chard Jensen-assault and battery,&sexual battery.Sherif Deputy George Smith- b accomplice to tl e.crime. Sgt., hil White-�6pervisor of Deputies Jensen&Smith. 6. Extreme emotional distress and physical injury. Possible fixture medical bills. Amount unknown. Special damages incurred includes but not limited to: $100.00 to retrieve my car,$55.00 to retrieve my bird,$135.00 emergency room visit,$25.0.00 Bail,financial hardship,Etc. 7. Amount Claimed is based upon compensation for physical injuries which are on going,emotional distress,out of pocket expenses,and punitive damages. 8. hospital: Contra Costa County Health Services, 595 Center Ave.Ste.#300,Martinez,CA 94553- Dr.Pilcher. Sheriff Deputy George Smith,Martinez Detention Facility Employees-Dec.21, 1997 after 11:00 pm. 9. Please See Answer to#6. e2�%. ,-•c� ss�c�r � Ms Bonnie Jaco s - June 20, 1998 CONTRA COSTA COUNTY �r TO �oC✓' _"`>` DATE_._, ��..��` { FROAA r } � � �'�--�- `-•'yam �h'' � ,,,,y � Gyc.�' t rtE....• � ' PLEASE REPLY HERE TO DATE :t t 1 ri SM)NIE? 'iSMUC3 OM-fill IN TOP PORTIOK KMO—E D1 MACA,TE MOM AND fWWARD IWAPON G, ►ARTS.TO My.PILL IN LOWER PWICNd,RETAIN TMICATE(MNK)AND RETURN ORIGINAL. #00A#AM _ t' r t ' A` � l ; 3 .... ... . w. CN sir _:k 4• a}. �. Tt k 3tN Claim to: BOARD OF SUPERVISM OF CONTRA 0OSrA COOT TY INSMUCTIONS TO CLAIMANT 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, roust be presented not later than the loath 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 rause of action must be presented not later than one year after the accrual of the cause of actio. (Govt. Code 591.1.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 551 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 form. RE: Claim By ) Reserved for Clerk's filing stamp ) Against thety of Contra Costa >> or ) District) in name The undersigned claimant hereby crakes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows.- 1. follows:1. When did the damage.or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use !extra paper if required) 4. What particular act or omission on the part of county or district officers, servants or.employees caused. the injury or-damage? (over) Wnat are the names of county or district officers, servants or employees causing the damage or inSury? 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. 9. List the expenditures you made on account of this accident or injury: DATA' ITEM AMOMT Gov. Code Sec. '9M2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) --- or soave erson on his.behalf." Name and Address of Attorney Clai is Signature Address LtSta " Telephone No. I Telephone No 5) " 1 ee 911 * * 1 N0T' ICE Section 72 of the renal 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 ($11000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not +exceeding ten thousand dollars ($10,0009 or by. both such imprisonment and fine. Bonnie Jacobs 3205 Northwood Drive#360-1 Concord,CA 94520 925/680-6714 June 20, 1998 Clerk of the Board of Supervisors of Contra Costa County 651 Pine Street Rm# 106 County Administration Bldg. Martinez,CA 94553 Claim by: Ms.Bonnie Jacobs Against the County of Contra Costa or Contra Costa County Sheriff s Dept. The undersigned Claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of no less than$10,000 and in support of this claim represents as follows: (The following are the answers to the questions on the claim form.) 1. Dec.21, 1997 - before and during arrest and until released on Dec. 22, 1997 after 12:00 pm. 2. Oakley Veterinary and Bird Hospital - 3807 Main Street, Oakley,CA 94561 3. Sitting outside the Veterinarian Hospital because I was seeking treatment for an injured bird. I was accosted by two(2)Contra Costa County Sheriff's Deputies,who beat me without cause and incarcerated without reason. I suffered physical and emotional injuries. 4. False arrest,assault and battery,sexual battery,unlawful detainment overnight,violated State,Federal and Constitutional Rights,failure to identify themselves,failure to read my Rights,failure to tell me that I was under arrest,and Contra Costa County Sheriff's Dept.engaged in negligent hiring,retention, supervision,and training of employees. This resulted in extreme emotional distress and physical injuries. 5. Sheriff Deputy Richard Jensen-assault and battery,&sexual battery.Sheriff Deputy George Smith- accomplice to the crime. Sgt.Phil White-supervisor of Deputies Jensen&Smith. 6. Extreme emotional distress and physical injury. Possible future medical bills. Amount unknown. Special damages incurred includes but not limited to: $100.00 to retrieve my car,$55.00 to retrieve my bird,$135.00 emergency room visit,$250.00 Bail,financial hardship,Etc. 7. Amount Claimed is based upon compensation for physical injuries which are on going,emotional distress,out of pocket expenses,and punitive damages. 8. Hospital: Contra Costa County Health Services, 595 Center Ave.Ste.#300,Martinez,CA 94553- Dr.Pilcher. Sheriff Deputy George Smith,Martinez Detention Facility Employees-Dec. 21, 1997 after 11:00 pm. 9. Please See Answer to#6. Ms Bonnie�Jacobs� - June 20, 1998 ,-r 0 o � i y� 1x M �y (A Al d S r 7C4, C v is 4 Alu Ww A' f CLAIM 6, CA EDENI BWD AMS July 14, 1898 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, NOTICE TO CLAIMANT and Beard 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 RMC1111WIM Board of Supervisors. {Paragraph IV below}, given pursuant to Government Code Section 913 and J U N 18 1998 915.4. Please note all "Wamings" AMOUNT: $250 COUNTY couNSEl. MARTINEZ CAUF. CLAIMANT: Eugene Green ATTORNEY: DATE RECEIVED: ADDRESS: Martinez Detention Facility BY DELIVERY TO CLERK ON: 901 Court Street Martinez CA 94553 BY MAIL POSTMARKED: June',16, 1998 L FROM: Clerk of the Beard of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOR, Jerk Dated: June 1.8, 1998 By: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. ( } This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( } Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of s claimant's righttoapply for leave to present a late claim (Section 911.3). Other: /r r l9"t Dated: By: !f 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 his is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: ,�',.�'' . PHIL BATCHELOR, Clerk, By duty 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 MAHING 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: ,.2 ., By: PHIL BATCHELOR By puty Clerk i a Claim `to; BOARD OF SUPER ORS OF COIT RA COSTA COUNTY IHMMONS TO CLAD4W A. Claims relating to causes of action for death or for injury to person or to per- sonal Property or grouting 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 tbrinjury to person or to personal property or growing drops and uhieh ague on or after January 1, 19889 must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action not be presented not later than we year atter the accrual of the cause of action. (Govt. Code 5911.2.) B. Claims mu3t be filed with the Clark of the Boned of ftpervis rs at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim i3 against a district governed by the Brest of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than cne public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code See. 72 at the end of this * * * eeeefee • e * ee * ee * seeeeeeee * efesteeee * ee * ee RE; Claim By } 'Reserved for Clerk's filing stamp n-ainsE ER Mo=—ty of tea stn ) .N CLERK,SOARC NsLwE soF t, District) CONTRA O `; > F inname)-..Clk$o�4— 'tie undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the s= of $ 150, ' .: and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact elate and hour) 1 41- : ... 2. Where did the damage or injury occur? (Include city and ocw ty) -14 3. How did the damage or injury occur? (Give full details; use extra ;*per if required -_--- r�r+rrrrrrrrYrr�r�wrr 4. What particular sect or emission on the part of county or district officers, servants or eMloyees caused the injury or damage? (over) aerMt3 or employees causing 5, -What are the rAmes of county or district offioers, the die or in�u}•y't ►+ Uhat damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates fta* auto ►$eef * f a SM segs the amount claimed above imputed? (Include the eStiIDatCd aunt Of any prospective injury or damages) �� .�'` ,3 � � � .: �� h: 9; i B. names and addresses of writnesses, doctors and hospitals. IV 9. List the expenditures you made on account of this accident or injury: mM DAZE IT ` a.Z : Gov. Code Sea. 910 provides: claimant "The claim must be signed by I CES To-. (Attorney or some son � his beh�].f." Name and Address of Attorney �f z F .'... li S tore Teiephcne No. Telephone No. a a e * * * * * * , W * * * * * * i * * # * i * ! N0TICE Section 72 of the Penal Code provides% "Every parson moo, with intent to defraud, presents for a"llowanoe or for am ny state board or officer, or-to any county, city or district board or Pto allover or pay the same if genuine, any false or fraudulent Officer, authorized claim, bill, aE3 Mt, vouch+ "', or siting, is punishable either by imprint in the county foss a period of not more than one years by a fine of not exceeding one thousand ($10000)9 or by both such �r� and ]1 ��� by imp��nmeornbY3si or the state prison,, by a fine of nota n8 ton both such imprisonment and fine. Claim ''to: BOARD OF SUPERYLIROM OF CONTRA COSTA COMM n07R iC IONS TO CLAIMMMAN"!' A. Claims relating to causes of action for death or for- injury to person or to per- scsna,l property or growing crops and uWch accrue c n or before December 31, 1987, must be presented not later than the 10th day after the accrual. of the cause of action. Claims relating to caws of action for death or for injury to person or to personal property or gror4ng crops and %hieh accrue on or after January 1„ 1988, must be prevented not later than six months after the accaruel of the cause Of action. Claims relating to say other cause of action must be presented not later than One Year after the accrual of the cause of action. (00vt. Code S911.2.) B. Claims Mwt be filed with the Clerk of the Board of _�isom at its office in Room 106, Coocnty Administrat1en Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governedthe Beard of Supervisors, rather than the County, the name of the District should be tilled in. D. If the claim is against acre than one public entity, separate ol.sims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this s e e e a a e a * e e e * e e e a a * +� a e ct a e +� a �► a �► e e se * e * s e a * e RE: Claim By } Reserved for Clerk t ss filing stamp lgi } nst W Mu—n-ty BY Coders sea } Q .k: > "'. i - District) n haw } The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the avm of $ _ ��, ��.�,..e� and in support of this claim represents as follows: 1. When did the die or injury occur? (Give exact date and hour) rte. 2. inhere did the damage or injury occur? (Include city and county) 4YA C ofs I i� ■r -- r rFr rrr rr w w+r�rr� 3. Now did the damage or injury occur? Give fun details; use extm paper if required) 5y„ f 4. What particular act or +csmission on the part of county or district officers, servants Cr employees caused the injury or damage? l7 . f .:. Y€ ..k ! • ,. ._ Vis,- '"y,.'°-'iai <.^.p. { .r, <.. (over) • 'wtiat are the names of county or district OffiOers, berMts or employ , es Oausfng t{ -the damage or injury? b. i&at dame or injuries do you claim Z*mAted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. f'4 n wa" the amount above e�omputed? (Include the estimated amount of any How �`}v•�Y^ �pps lL.''i. 'Fy}���', �t�i S,C�j^''t i�.. ,� d j �p�rfive �� offdamage.) •:dp<i . ` %.>'i¢tJ �f{T ,�.i?;:•. F i S. des and addresses of witnesses, dootora and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE IM Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NMCES TO: torne ) or by some son_on his behalf." mE and Address Of _Attorney sig_.. s. .. _..,. &; . LYS .A ss S 1 � Telephone No. Telephone No. e e e p0TICE Section 72 of the Penal Code provides: +fiery person uto, with intent to defraud, presents for allowance or for faTmmt to any state board or officer, or to any county, city or district board or Officer, authorized to allow Or pay the tame if genuine, any Mae or fraudulent *.Ulm, bilk, account, voudher, or writing, is punishable either by impr aonment in the county jail for a period of not mwe than erre year, by a fine of not exceeding one thousand ($10000)9 or by bath such imprisonment and fine, or by imprisormnt in the state prison, by a fine of not exceeding ten thousand dollars 010r000: or by both such imprisonment and fine. e.. x N Q .:. {YY ": �1 F >ya �.j�gjf tett to CH I�.i4.� ..5 `$J' ��.. ...;� i•Rp ...+4..� �O s �{+� .�Z t' `$V wn n �4Y ...... ni', k 2. f 1. Y'j4�3�..i.�.-.:7 ^�' <.>j+•"}k"#'� .� �.. w, .h y'•.�:J TO Of fk a 151 f1swic iris ikeH 04t� C4,AFf IV f : ` 14 "P.- A-7 RACE ,,q fV 7,,W,- A 10. ��f T, Y11 y i:1,1- .5fkl ki „;l 9 € y ARM N,t�, v A.w PwC 0 IWA tj -f IS eum. 1ruct me 1 Ica CBS:& mHOVE, As :1 -M, evl P��0 < b4)q : ` x `.C. i + '•.f' 3! L P� k Z cg�s�,S f}V th 't+i, t L y.{, f ?3.91 ff E MJ Ph :.. v S w, BE � 3s<�-N C,`�� 14�'�C,x-. 01, .� �� '��e� € �µv� � < T fB r �} gyp. q�^o' qj^` $ £ Y )p$ g�'•' �"¢¢$ (�j^4..nti,.;. ��: 39 8�3 � ��s. �i•.�'� '� Z`v� �:�• �+�.••:� �: � LD i a°r-3E � �1�4,.� Y i�.> : 39:. .;`•.,F :. S f S '+,::,. $ F f'^. Act PO F i Y Vic$ ., g^^ 7$ HA 'r§+Y..:,? • t r r ill An I fled- wi-ei) J ' .ate. � : �w .' -ro 1 i:C.J1w f � x � .f <. k 1' 4.. k � 1 Pat I 1 ' f H � f� .> � f-0 Vie x �o :3 Ay �j' j�"' .Y.;.. � 5 3: r. "'-0f •F t 3�;, �'` .8 y„r'•p<:E 5'^f S Y� C 7�$ . . . s- C .fie . - i r z 3f��.V. N�� talc!lut � (? -c w +r, • '.. cis, „ . . ......................... 53 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA CUA: AL•I_FORNIA BOARD AM July 14, 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 RISM11111 TED Board of Supervisors. (Paragraph IV below), Oven pursuant to Government Code Section 913 and J U N 19 1998 915.4. Please note all "Warnings". AMOUNT: $47,000GCUNT'!COUNSEL MARTINEZ BALI . CLAIMANT: Teresa Hernandez ATTORNEY: DATE RECEIVED: ADDRESS: 103 Manor Drive BY DELIVERY TO CLERK ON: Bay Point CA 94565 BY MAIL POSTMARKED: ,June 18, 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: June 19, 1998 By: Deputy p H. FROM: County Counsel TO: Clerk of the Board of S46ervisors } 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 91.1.3). { ) Other: Dated: � By: mkt 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 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 prepaida rtified copy of this Board Order and Notice to Claimant, dressed to the claimant as shown above. Dated: �, .e By: PHIL BATCHELOR B�4Deputy Clerk CC: County Counsel County Administrator ev Clain to: BOARD OF SUPERVISORS OF OONTRA COSTA COMM INSTMMONS TO CLADOM 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. Clam 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 591.1.2.) H. G a ins must be ed with the Clerk of the B mrd o>f' Supervisors at its off ice in Room. 106, County Administration Building, 651 Pine street, Martinez, CA 94553. C. If claim is against a district governed by the Beard 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. RE: Claim By ) Reserved for Clerk's filing stamp vLy? A--- S i 1 RECEIVED Against the County of M tra tosta or IJ U District) 1C K MOARD-SUPERVISORS M n name ) T The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the stmt of ' `x f. and in support of this claim represents as follows: w.r+w.�+r.r+r+.+r.�.rww.w r"+..:s F+f:t. . �'�.:.�.:.�.ar �sr`,2`.w y t � ,•;,r .� E:i s '�.. ,P �C��"i 1. When did the damage or injury occur? (Give exact date and hours '# i �ri..1YYMYtiMli�iY1M�M1YrfYil��Hpl�wlFnilrYlOMY+YI�MYii�i Y+YiYs.Mi�MM�F+1I�ioiMi YI+MiiM►+�wiwaW.Mi�'.w�4 2. Where did the damage or injury occur? (Include city and county) , 9 F f� }fyfP, tJfS s /` <,'% •?r'i '" f r... Y J,., 2 r:� { 3'�... 1,.. 1.. s.w«ww.rww.l. ..+w..rw+r..www+rsr warwJs+r.+r.r�r+.1r.srw�.+rrw,�rrr.. J 3. How did the damage or injury occur? (Give full details; use extra paper if required) �_ � ^- "t 4) '"�Ci t !� j 1F f; .3,0 Fii r0..-. P-r p ty n L L...:4 A4'/i t� :}if L`F7 t.C. %.`� .- ;`h err'! ,•••,. 4. What particular act or omission on the part of county or district officers, servants or:employees caused the injury or damage? 0 ,j.f 4 ??E3 s? r C'K" P.'A"#1 i�t�..:"1 k �.�r« F. '? -t f 1'? ; r/ t � >' n (over) 5. what are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim resulted?(Give full extent of injuries or r- damages claimed. Attach two estimates for auto damage. r _ r C'�z.s..�....r. ' A e- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 01 '7lks � f ..4b,G° f .a 4.rac:.; .,,sf wv� 7f-;r� j/lt d >=.r+' '�3..T/ (.JJ7" �Yd.;:d`;ii sisC`.i.{-t,.i"j3... v., 's".f" ✓-ark, ae ....._.._..__..___, -.�._.._ ................._�_.._. .._� __�..____....�___._..,.� ....�«......_.._.. y _ .� -10- rs. Name s and`acicir�sses of wft\��ss}c.),; dve vors �� �;*.a?s v ��{11 6—, '..`}..- „,.�� �J � o ��3`� / ,�",l�''}�.... �,,,•t�,%/!1'sFy ,f,'.d°'"""� r I i✓ 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT i Gov. Code Seo. 910:2 provides: "The claim must be signed by the claimant SEND NOTI ,TO. : ttor } or someerson on hisbehalf.r" Name and-Add- ess-af Attorney --- . -� G C2 ti f Fes'., a{.° _. V0 L, . �c s �� � ��``~ Claimants Si t 0 k LiF`1 sj ,Fc �' (Address) Teephne No. 3 Telephone Na. � , f ' v NOTICE tiv a.� ~ r-->Section 72 of the Penal Code provides: M � "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 y cz 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. CLAIM BOARD OF S p'F,R) MOR_OF CONTRA COSTA N CAIE.EE(MNIA BM A00 ,illy 14, 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. �t3C notice of the action taken on your claim by the Board of Supervisors. (Paragraph 1V blow), given a UlV 1 5 1998 pursuant ur nt to Government all°{Iltde Section 913 and 9 MTZCLAMOUNT: $10,000 ARNEAL-%OUNCYCO !FL I CLAIMANT: Raina Houbenova on behalf of Emily V. Houbenov ATTORNEY: Alexandar Houbenov DATE RECEIVED: ADDRESS: 1600 Broadway Street #1 BY DELIVERY TO CLERK ON: June 15, 1998 Concord CA 94520 BY MAIL POSTMARKED: L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCHELOClerk Dated: June 15, 1998 By: Deputy P 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 910.8). ( ) 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: ,/'/sO 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). 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"inutes for this date. Dated: PHIL BATCHELOR, Clerk, By �G,.icputy 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. LOR B Dated: B PHIL BATCHELOR y y Clerk CC: County Counsel County Administrator N aim to: BOARD or SUMMISO OF CONTRA COSTA COUNTY INATRUMM 22 CLAIM= A ; Claims relating to causes of action for death or for injury� ry to person or to personal property or growing crops and which accrue on or before December 31, 1967, 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 Tanualry 1, 19ss, 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. (Govtt Code 911.3. ) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Roam 106,. County Administration Building, 651 Pine Street, Kartinez, CA 94553. C. If claim is against a district governed by the: Boardof 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. JrAg . See penalty for fraudulent claims, penal Code Sec. 73 at the end of this form. e+�,�#e�,�r,��r+��r�r,�e�a,��*+��*�r�fe�+err+��e�r�r�r�e�,r*r�►�r��ee�r�r,r�+�,reere#r�r�r+��t,�,�+�+�#�r� RE: claim By Reserved for Clerk:-Is filing stamp' r (/ "/VV VRECEIVFD Against the County of Contra Costa) or } l 5 1998 ok �}y}�� District} �{� {_ �}1,�[� . n a.itiA} G.IXh. 6X 'w"PERV IS HS. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $„ '`t ” and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 3. When di , the damage or in u +� � �� ry : cur? (, ne ud city, ,and county) h [jy y j �J t�' "` � 3. Now did the damage or injuty occur? (Give full details use extr paper if required) t a 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? (over) S. what are t�e names of county or district of iners, servants or C" employees 4usitq the damage or injury? A -i , A 'C� F'94 NO. 6. what damage or, injuries do you claim resulted? {Give full extent of injuries or' dazages claimed. Attach two estimates for auto damage. } ' irk p 1+ ' 7. Ra� was the amount claimed above computed? (include the estimated avount of any prospective injury or damage. ) Z4;e-- 8. Names and addresses of witne'raes, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury. �rrs�se��f�+���rts��r,�,��*:�*,��er�*s:�*r�trr,ea�����r,��rrrertr�a�e���,�e,�r►#�►��r+�e�t� } Gov. Code Seo. 9I0«2 provides } "The claim must be signed by the } claimant or by some person on his SENA H02:ICES .• (Attornevi Name and Add ress .of Attorney 6, % / i (Address) r ' y Telephone No,lti ,mac Telephone No r+�rrrr+���:�t,��cr�*rr�rr►err,tr,�,r�t�r*Rf•r�►e*�rtte������*+�,��•cr•*�►rr+t�rt►,�r♦�r+►* 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 01#000) ,. or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($lo,Doo, or by bath such imprisonment and fine. CLArM Y3 BOARBOARID OF SUPERYISOM OF CONMA COST O NT CALEMNIA BUARII ACTIM Julr1A 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 1V below), given pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: EXCEEDS $ 10,000 �1CtI CLAIMANT: David Pereda l 1998 COUNTY COUNSEL ATTORNEY: James B. Chanin, Julie M. Houk DATE RECEIVED: MARTINEZ CALIF. Law Offices of James B. Chanin ADDRESS: 3050 Shattuck Avenue BY DELIVERY TO CLERK ON: June 12, 1998 Berkeley CA 94705 BY MAIL POSTMARKED: L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCI�ELOR, Clerk Dated: June 12, 1998 By: Deputy � 1c ._ - f H. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies substantially with Sections 910 and 910.2. This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 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). BOARD ORDER: By unanimous vote of the Supervisors present: This Claim is rejected in full. ( ) Other: I certify th this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: / , ' ' PHIL BATCHELOR, Clerk, By ;-qty 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 Claiman t #dressed to the claimant as shown above. Dated: By: PHIL BATCHELOR B ' Deputy Clerk CC: County Counsel County Administrator RECEIVED 1 JAMES B. CHANIN (SBN# 76043 ) JULIE M. HOUK (SBN# 114968 ) 2 Law Offices of James B. Chanin '� 3050 Shattuck Avenue 3 Berkeley, California 94705 CI.�RKBt7�Rt�€iFBtJP ># 0A$ 510/848-4752 GZTRAgQSTAQ Attorneys for Claimant 5 6 CLAIM AGAINST THE COUNTY OF CONTRA COSTA 7 DAVID PEREDA, ) 8 ) Claimant, ) GOVERNMENT TORT CLAIM 9 ) (Cal . Govt. Code 5810, et seq) VS . ) 10 ) COUNTY OF CONTRA COSTA, ) 11 ) 12 1 13 CLAIMANT'S NAME: DAVID PEREDA 14 CLAIMANT'S ADDRESS: 2204 Greenridge Drive, Richmond, CA. 94$03 15 CLAIMANT'S TELEPHONE NUMBER: (510 ) 222-3096 16 ADDRESS TO WHICH NOTICES ARE TO BE SENT: 17 JAMES B. CHANIN, JULIE M. HOUK, LAW OFFICES OF JAMES B. 1$ CHANIN, 3050 SHATTUCK AVENUE, BERKELEY, CALIFORNIA 95705 . DATE OF THE INCIDENT: 19 20 Beginning on or about December 17 , 1997 . SUMMARY OF THE FACTS SUPPORTING THE CLAIM: 21 On or about September 27, 1997 , the Claimant, David Pereda 22 (hereinafter, Claimant) , was involved in a miner motor vehicle accident. At the time of the collision, the Claimant was unaware 23 he was involved in an accident and thought he hit a pot hale rather than another vehicle. Subsequently, the Claimant was 24 stopped by members of the City of Richmond Police Department . Although the Claimant attempted to explain to the officers that 25 he did not knew at the time he had been involved in an accident,, he was detained and given a citation for leaving, the scene of an 26 accident and for a Lane violation. The citation had an 27 appearance date of November 13 , 1997 , in the Bay Municipal Court. On or about October 2, 1997, the Claimant, along with his 28 parents, met with Officer Miner of the City of Richmond Police 1 �73 1 Department concerning the September 27 , 1997 , accident. The Claimant reiterated that he was unaware at the time of the 2 collision that he had actually been involved in an accident with another vehicle. officer Miner contacted the District Attorney's 3 office and was advised that they did not believe the case warranted the filing of a criminal complaint. Thereafter, 4 Officer Miner assured the Claimant and his parents that the matter had been resolved and that no criminal complaint would 5 issue. A copy of Officer Miner' s supplemental report confirming that the District Attorney' s office did not believe the case 6 warranted the filing of a criminal complaint is attached and incorporated herein by reference as Exhibit 1 . 7 Thereafter, despite Officer Miner's representations to the 8 Claimant and to his parents, and despite Officer Miner's October 21 1997 ,, supplemental report, Claimant is informed and believes 9 and thereon alleges that D. MAPLES and/or DOES 1_,5 of the City of Richmond Police Department swore out a criminal complaint against 10 the Claimant on or about October 15, 1997 . Claimant is further informed and believes and thereon alleges that said Complaint was 11 filed in the Bay Municipal Court and the November 13, 1997 , appearance date remained on the Court's calendar despite the 12 representations of Officer Miner to the Claimant and to his parents . Based on Officer Miner' s representations that no 13 criminal complaint would be filed, the Claimant did not appear in Court on November 13, 1997, believing that the 'matter had been 14 resolved. 15 As a, result, Claimant is informed and believes and thereon alleges that on or about November 13, 1997 , the Say Municipal. 16 Court issued a $10,000.00 bench warrant for the Claimant. Claimant received no notice of the .issuance of the bench warrant. 17 Thereafter, on or about December 17 , 1997 , while the 18 Claimant was driving in El Cerrito, he was stopped by members of the El Cerrito Police Department (DOES 6-10) and arrested on the 19 aforementioned bench warrant. 20 Although the Claimant repeatedly told the El Cerrito Police Officers (DOES 6-10) about Officer Miner's representations and 21 requested that they contact Officer Miner, the Claimant was nevertheless arrested on the bench warrant. The Claimant was 22 held for a prolonged period of time in the police vehicle while the officers arrested a woman and placed her in the rear of the 23 patrol car with the Claimant. The woman urinated on herself and on the seat of the patrol car. The Claimant was then taken to 24 the El Cerrito Police Department and held there for a prolonged period of time. 25 Although the El Cerrito Police Department (DOES 6-10) 26 advised the Claimant's mother that they would hold him at El Cerrito until his mother could post bail, the Claimant was 27 nevertheless transferred to the Contra Costa ; County ,jail in Martinez . When the Claimant's mother arrived at the El Cerrito 28 1 Police Department with a cashier's check made payable to the City 2 1 of El Cerrito Police Department for her son's bail, as she had been .instructed to do by the El Cerrito Police Department (DOES 2 6-10) she was told that her son had been transferred to the County Jail in Martinez . 3 Despite the fact that the Claimant told 'members of the 4 Contra Costa County Sheriff 's Department at the County Jail (DOES 11--15 ) about Officer Miner's representations that the case was 5 resolved, they nevertheless continued to held the Claimant in custody in the County Jail for a protracted period of time. The 6 Claimant was booked and processed at the County Jail . When the Claimant's mother attempted to bail him out of the County Jail, 7 the cashier' s check for the bail was not accepted because it had been made payable to the City of El Cerrito as the Claimant's 8 mother had been instructed by the El Cerrito Police .Department (DOES 6-10 ) . Thereafter, at approximately 4:00 a.m. , the 9 Claimant was subjected to a strip search at the County Jail. 10 Thereafter, on or about December 18, 1997 , the Claimant was taken to the Bay Municipal Court for a 9. 00 a.m. court 11 appearance . After a prolonged period of time,, he appeared in Court and the case was dismissed on the motion of the district 12 attorney. Despite the fact that the case had been dismissed, the Claimant remained in custody on December 18, 1997 , until, 13 approximately 5:00 p.m. when he was finally released. 14 Claimant is informed and believes and thereon alleges that the foregoing incidents and his damages were caused as a result 15 of negligence and/or deliberate indifference in the training, supervision, hiring and/or discipline of law enforcement officers 16 by the City of Richmond, City of El Cerrito and/or the County of Contra Costa. 17 Claimant is further informed and believes and thereon 18 alleges that the foregoing incidents and his damages were caused as a result of customs, policies, or practicesof the City of 19 Richmond, City of El Cerrito and/or the County of Contra Costa . 20 Claimant is further informed and believes and thereon alleges that the foregoing incidents and his damages were caused 21 as a result of the conscious or reckless disregard for his safety, welfare and/or constitutional rights by members of the 22 City of Richmond Police Department, El Cerrito Police Department. 23 and/or the County of Contra Costa Sheriff 's Department. Discovery continuing. 24 DESCRIBE INJURY OR DAMAGE: 25 As a result of the aforesaid incidents, Claimant sustained 26 damages, including, but not limited to, emotional distress, fear, embarrassment, humiliation, pain and suffering, wage loss, 27 medical and related expenses, attorneys ' fees and costs all in amounts to be determined according to proof . Claimant is also 28 entitled to an award of punitive damages and/or statutory damages 3 1 under California Civil Code §52 in amounts to be determined according to proof . Discovery continuing. 2 The Claimant has or may have claims based on theories which 3 include, but are not limited to, false arrest, false imprisonment, denial of liberty, violation of rights under the 4 United. States and California Constitutions , including, but .not limited to, the right to be free from unreasonable searches and 5 seizures, and the right to be free from arrest without probable cause; California Civil Code SS51 . 7 , and/or 52 . 1, infliction of 6 emotional distress, misrepresentation, negligence, negligent supervision, training, hiring and/or discipline, and/or other 7 claims to be determined. Discovery continuing. ' 8 NAME OF PUBLIC EMPLOYEE(S) BELIED TO HAVE CAUSED INJURY OR DAMAGE 9 10 Does 11-15 , Discovery continuing. DEMAND FOR PRESERVATION OF EVIDENCE: 11 Claimant does hereby demand that the County of Contra Costa, 12 including its employees, agents, servants and./or attorneys, maintain and preserve all evidence, documents and tangible 13 materials which is and/or may be relevant to the subject matter of this Claim during the pendency of this matter, including until 14 the completion of any and all civil and/or criminal litigation arising from the events which are the subjectmatter of this 15 Claim. This demand for preservation of evidence includes, but is not limited to, a demand that all police department and/or other 16 public safety communications tapes be preserved until the completion of any and all civil and criminal litigation arising 17 from the subject matter of the events which are the subject matter of this Claim. 18 AMOUNT OF CLAIM: Claim is in excess of $10,000 . 00 . Jurisdiction 19 is in the Superior Court of the State of California for the County of Contra Costa and/or United States District Court for 20 the Northern District of California. 21 22 DATED: June 10, 1998 OFFICES OF JAMES CHANIN 23 Z' J L I E M. HOUK 24 ttorneys, for Claimant 25 26 27 28 4 313 1 PROOF OF SERVICE 2 1 am a citizen of the United States and employed in the 3 County of Alameda, California . I am over the age of 18 years 4 and not a party to this action. My business address is the LAW 5 OFFICES OF JAMES B. CHMIN, 3050 Shattuck Avenue, Berkeley, CA 6 94705 . 7 On the date set forth below, I caused the within 8 GOVERNMENT TORT CLAIM 9 to be served by having it personally delivered to the following 10 address: 11 Clerk of the Contra Costa County Board of Supervisors 12 651 Pine Street Martinez, CA. 94553 13 14 1 certify under penalty of perjury that the foregoing is true and correct. 15 Executed on June 12, 1998, at Berkeley, California. 16 17 . t IULIE M. HOUK 18 19 20 21 22 23 24 25 26 27 28 CLAIM BOARD QE SUPERYLSOM_OI`_ TRA COSTA COUNT', CALIFORNIA BARD ACHE .filly 14, 1G 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 Odes. 1 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: $140,000 RJECIEaWMID) CLAIMANT: Clayton B. Thomas JUN I Z 1998 couNTY cOUNSEL ATTORNEY: DATE RECEIVED: MARTINEZ GAUF. ADDRESS: 159-B Madoline Street BY DELIVERY TO CLERK ON: Pittsburg CA 94565 BY MAIL POSTMARKED: June 11, 1998 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. PHIL BATCf OR, Clerk Dated: June 12, 1998 By: Deputy ''' y" y IL FRO1Y• County Counsel TO: Clerk of the Board of Supervi rs X) 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: 1 By: / 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 that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: ,t%� PHIL BATCHELOR, Clerk, By ",G -IIepty 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, ddressed to the claimant as shown above. Dated: , . By: PHIL BATCHELOR B Clerk CC: County Counsel County Administrator Claim for BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CL.ADWTr 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 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. (Govt. Code §911.2.) B. Claims must be filed with the Cleric of the Board of Supervisors at its .office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this form. RE: Claim By } deserved for Clerk's filing stamp Against the County of Contra Costa } +N 12 1998 or ) District) M11 in name The undersigned claimant hereby makes cla. } • Inst t County of Contra Costa or the above-named District in the sum of $ 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) �c- t 3. How did the damage or injury occur? (Give fu13. details; use extra paper if required) vJC;�� ?\CkL{-.4__� 011 01.- Y— �Z_a +CCb L.UL'1-.;0�.1++ 4. What particular acct or omission on the part of county or district officers, /1,- servants or .employees caused. the injury or damage? �-' y C e, J c yrJ 0 WGI t ✓e n S-e /'Z* ueE �-4-tartyy (D eA_. 'n r�'� -`- CV or`�ht �J (over) �. Wnat are the names of county or district officers, servants or employees causing the damage or injury? 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. _ oL ck YOCU, ,� 0-t t11 n, I f-, C1 !L . 7. How was the amount cla med above computed? (include the estimated amount of any prospective injury or damage.) Ity 8. Names and addresses of wi�sses, doctors and hospitals. �wri�rri�+ r��+i M��wia+iiMwr�Yiiii iirW iiiiy'iiiriiriias+l►+riiiatia 1. List the exp4nditures you made on account of this accident or injury: DA'L'E ITEM AMOUNT Gov. Code Sec. 110:2 provides: "The claim must be signed by the claimant SEND NOTICES T0: (Attorney or some person on his.behalf." Name and Address of Attorney 9 Claimants Signature Address Telephone No. Telephone No. N 0 T ICE 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 fins of not exceeding one thousand ($11000), or by both such' imorisonment and fine i. or by imprisonment in the state prison, by a fine of not exceeding ten thousand .dollars ($1000000 or by. both such imprisonment and fine. STOP ! The following pages are medical records. Do not print or distribute without written consent from County Counsel. ION R. CONTRA COSTA REGIONAL MEDICAL CENTER& :< CONTRA COSTA HEALTH CENTEFL5 DISCHARGE INSTRUCTIONS T d M A S CLAYTON M PITT 925 432' 1`96 CU , ^'Li9381 - . 00 3 MD 22/ I963 AIKEN . J . 5/27/98 ADM. GE', al HOME MEDICATIONS DOSE!ROUSE!FREQUENCY/ SOICIAL INSTRUCTIONS (food/drugeons) 0 t t�fven to ptitternl� Y.. A W IV -4-a4j 0 ! 42 114 L �k. DIET INSTRUCTION__ ACTWITY LEVEL INSTRUCTIONS SPECIAL INSTRUCTIONS RELATED TO HOSPITALIZATION PROBLEMy,��t�,�-Q SUPPLIES I QUANTITY/ EQUIPMENT 0 See attached Education Discharge Summary If applicable i N CASE OF PROBLEM: Contact 24 Hoar Advice Nurse at 313-6W or I-800-524-2247 IN CASE OF EMERGENCY; Call lIl 1 X; fOLLOW-UP APPOINTMENTS C1ppointments 646-4715) Q Nirclf�#tyaiciari +t .1 -Date 4,Time #ocstion • �'� Vinic/physician Date Time Location f utpatient Educator IO N/A) Bate Tune location f` Horria Health Referral made © Yes.. . C! Copy of Discharge InsttucUons sant 0 N/A b lktherippoin#merit(i a.,Tab,stray) flute Liana Location ROWMIS I UNDERSTAND THE ABOVE INSTRUCTIONS Sptrtwe of tiarN/peUerK s fegaf n Eve If signed by o0w turn patient,indicate relationship a Date � si�nsw►e.Title in nef: Medical Record K> MR37&7 7) VY 0V Aatientkere6iver ink: ginic/providor DISCHARGE INSTRUCTIONS a PLEASEAETUM TO FOR A RECHECK IF NOT MUCH BETTER IN T EXT DAYS,AND RECHECK AT ONCE F YOU ARE GETTING WORSE. t' USE THE EMERGENCY ROOM IF YOUR DOCTOR OR CLINIC IS NOT ILABLE.WE ARE OPEN 24 HOURS A DAY. ;r towing are specific instructions whim you should follow: ------------ 6L0, 4 r ' r D HEAD INJURY LJ WOUND CARE(cuts,abrasions,burns eta.) A Notify doctor If the following symptoms occur keep the dressing or wound dean and dry. 1.Unconsciousness Elevate the wound to help relieve soreness and help speed wound 2.Confusion healing. 3.Unusual sleepinessn Use antibiotic ointment dal to wound. 4:Vomiting moreorethan once lY 5.Slurred or double vision Despite the greatest care,any wound can be infarcted.if your wound 6.incroasing dizziness becomes red,swollen,shows pus or red streaks,or feel more sore ?.,Fever over 1W F. instead of Was sore as days goo by you must report to your doctor 8.inability to move arms or lags right away,or rmturn to emergency room. 9.Convulsions,fits or seizures Have sutures removed in s.Recheck if worse_ - 10.Colorless fluid or bleeding from ears or nose. �Y S.Awaken patient every hours the first 18 hours after the Injury to check for these signs and make sure he/she knows their ❑ SPRAIN S FRACTURE,SEVERE BRUISES name,the date,and where they ars. 1. Elevate the injured part to lessen awaiting.This may be comfortably done with pillows,blankets,eta. [j BACK NECK INJURY INSTRUCTIONS2. toe packs also help prevent swelling,especially during the fist 48 hours. Place ice in a plastic or rubber bag,with a doth cover. 1. Use heat or cold on the injured area,whichever seams to help the most. 3. g the part swells or gets cold,blue or numb,or if pain increases Be careful not to hum yourself. markedly,have it checked promptly by physician. 2. Avoid activity causing pain. 4. If you have an elastic bandage,rewrap it.if too tight or loose.loosen for f- 3. You generally feel worse in W48 hours after the injury,then 30 minutes at least every eight hours. improvement should definitely begin if you aro not aggravating the injury and are following instructions.If not,contact your doctor. ❑ UTI INSTRUCTIONS v 4. If you develop numbness and or weakness in arms or legs rafter A. Empty your bladder aftr: ' ematgancy treatment notify physician. 1.intercourse(sex) 3.Bicycle tiding 2.Hottub 4.Bubble bath Physician,, rime s I hereby of the instructions vs.I undorstand that 1 have had irsahtrer►t and that I may be released before all my medical problems are known and trealsOMwi8 a arrarge for follow-up rare as fttrucW above. PrOprir W AfBeroata Instructions s R other than alloys. YES ® O 10599660 06/01/9$ 0028 2 Sutter Z�elta Medical meter rI-arse ,CLAYTON 39ot LONE TRIM WAY -AWK)CFI,CA 94WO 08/22/63 34 8 M En/34 EMERGENCY DEPARTMENT GUYER,LARRY, . �� AFTERCARE INSTRUCTIONS k x ao5 ttit t$lWHrM-Chmrt YEUMW-hat `` 11, ;. t. NURSING CARE Z(a Thus hospital Pnavideecmi5r _ ;/ *+trnlse�•uPan orders ofpaUgM ":3`,7 asas to Head the ssrvtoe Of a s Padernt's Physicianthe to to d the o the tune and 3sduty nurse,ft is agreed tiler such must be arranged by the patient or his/her Provided more Inbtgal repreas,*dIve.rrThe nursing COW If the pstlenft fin le st>e� hereby rsieraw�d from any and all ltabN!!y sing tom the asst that said patlsrrt t Tars hotpiEal shah in no way be responsibis for X MEDICAL AND SMGICAL CONSENT Provided with Stich additional cars. t The undef*Qrdd consemts to the basic cwe andMay i be w ll be carried out upon the order'of the Physician and the,agreement ta!the�during this hoePltWkMtlan or on an out-patient basis. Spectat treatm or au tarocredtirts.X-ray examinatlons,madlptl or sunpigi treatment, treatrnara Or Swvkft which may penerat and tp lru�trul irftudiOnS of limited utas surgeon. Ufa,will be rer ,p�+tits Patient under,the areii the Padents;PhYSidsn or # & RELEASE OF INFORMATlpN :V To the eertertt Y Y Person rare fib determine liability for Payment and ha obtain imbursement,the hoepw, � ' div be flats,far as or any P +of the hosP1W ge may d portion,of the Xk$dfiV but OM Wr PettiOrts.reocfq,�,} Ow� } or 3t of tray medical pre,f aartttartse rrtauuss dftd ,to 4- PERSONAL VALUAIM Prim"me PhYS101an.And/w Miming physician, and agreed that the hu3epditd rtratt lrm a safe for tine a int of Horsy and vrtuabNss,avid the IlOapltat Shall not be tlalbi6 far the toes or money, ProP",unless deposited with the uta pi o articles of unusual value and stmtl oompw unles, cwt no for taws he drrr>wgs oo any + Wilted for_t�afekesping, Personal a. FACIAL AGREEMEtIT r. J The undwaignod agrees,wt f;wlatnr aiSrte%sa agent or as patient toIf I (( ifierselt to Pay rite acooturt of the �n of the services sc be rendered d She urderapned shill Pay actual attorney's ode coils t ance"��o�»y nlwa and terms W the hospital. Shacdd the account be Patient, hereby ��oon�sctian tt,s �Pten*and make deHrnqueau au5caurnis Shari bear k0*4w K at the MY option,I s ar the first PsYmwft of the amouft owed In morality Imo, � rnt Pian a�a unto, 4subject. tow y his the Hoeg wa Tre}emed included On t ���bj w Plan. An aacourt d(sdceurn dasmftV the ramie and conditions of tt+e'Pneferrtd p �s�f writ be opened upon receipt ae and when due,the unpaid balancsassigns� Mom t will also recslve a eWwr ent of billing rights undsr the Fair Credit fsd PEliffin�� on i"uestand is obligntian._ ` d for aoilecllon. I agree to psy all collection costa,court c els,and neCrediedale ��inp"anis not madnt of e a. ASSIGNMENT OF INSURANCE BENEFITS The undersigned ate,whether he/she signs 88 agent ar es Patient,direct rendered e a rate not to SXtsssd the regular charges, tt is agreed Payment to ys tmenio the hospttSt of any tnsurancs taeneNls Otherwise Payable to the undersigned c0mPany Of"and so obogaarns under a poky to the extent of such 'Pursuwrrt to this atrifinrattzatian,by am insurance torr for the cares this a0+prnerti. Payment. ft Is understood by the undersigned that he/she b financial res Pony shalt discharge raid Insurance h+ Ponslbts for charges not covered by 7. AUTHORIZATION FOR REL EASE OF MEDICAL,INFORMATION STATE LAW PROVID"THAT UPON AN INQUIRY AS TO THE OTt#6=RYViSE RELtUESTED!'ry THE PATIENT,NEXT OF ItTN OR PROVIDER OF HEItLT 1>PRESENCE OR GENERAL Dq OF THE PATIENT,DELTA MEMORIAL t1LiSPITAt MAY,UNLESS HtFORMATFON' TtfE PATIENTS NAME,ADDRESS,AGE AND 8E AT ITS DISCRETION NONE,PART OR ALL OF THE FOLLOWING PATIENT. G RFJ18pN FOR ADMISSION,GENERAL NATURE OF INJURIES,OR THE GENERAL CONOCnON OF THE E ANCED DiRECTIYE ton Sine;(chore one) Pa dent Spoaae t?Itrair(who) ftnt have Advanced Dlrective? ❑ Yes a No copy M record? Yes t_l No No(WN*Instructed to provtds) oahura given? L' Yes L1 NO(►assort achy nor) ed/recorddtt ray:AdrMtting Rsgbftsr �� - S. Advanced nced Dlrective r*Sdndad by p8deft ft""P voiced _ t'�aNe - Tha undersigned caWMes that he/she has rSad the above adept its tarts.. ung,receiving a aaP!'#WW,and ti the patient,or is du y auttwrtasd by the Pert as{zttirrrd�s execute the .- r- _ 1han ) Y, r t by Penner CMter anon lite laf riR - M►the�paww and to scow the soma fr �y��of -Ttrtae a w.. S� • •. G - jF „ .. ..... � � � +r utter ter 3001 L TREE WY AWMN,t3ntNeop CONDITIONS OF AM lIISSION I REGISTRATION . .3_s d PLEASE RETURN TO a FOR A RECHECK IF NOT MUCH BETTER IN THE NEXT DAYS,AND RECHECK AT ONCE F YOU ARE GETTING WORSE. USE THE EMERGENCY ROOM IF YOUR DOCTOR OR CLINIC IS NOT AVAILABLE.WE ARE OPEN 24 HOURS A DAY. -[j The following are specific instructions which you should JI PI - _ HEAD INJURY #.,-.-- Armor x �.1,,,�,_ 0 WOU RE(cuts,abrasions,burrs etc.) A. Notify doctor if the following symptoms axur, Keep the dressing or wound clean and dry. 1.Unconsciousness _ Elevate the wound to help relieve soreness and help speed wound 7.Confusion ; healing. 3.Unusual steepinet 4.Vomiting more than-once - :; Use Antibiotic ointment daily to wound. S.Slurred or double vision Despite the greatest carie,any wound can be F infected.If your wound S.Increasing zziness becomes red,swollen,shows pus or rod aboaks,or feel moo sore 7.Fevverr over 100"F. instead of less sore as days go by You must report tis your doctor •8.Inability to move arms or togs ,_ riaht away,or return to emergency mom. 9.Convulsions,fits or seizures Have safaris removed in d R~ 10.Colorless fluid or bleeding from ears or nose_ days. ocheck if worse. S.Awaken padoW every hours the first 18 hours after the SPRAIN b FRACTURE,SEVERE BRUISES Injury to check for these signs and make sure he/she knows their name,the date,and where they are. _ J` ' Elevate the injured part to lessen swelling.This may be comfortably done with pillows,blankets,etc. �S NECK INJURY INSTRUCTIONS Z tee packs also help prevent swelling,especially during the fist 48 hours. Place ice in a plastic or rubber bag,with a cloth cover. Use heat or cold on the injured area,whichever seems to help the most. 3. 1f the part swells or gets coin,blue or numb,or if pain increases Be careful not to bum yourself. ty}*- t markedly;have it chekefi prpmpdy by physician. 2 Avoid activity causing pain. ...; 4. yoU have an eta icrrbeiiige,rewrap#if tae tight octose,Leeann for 30 minutes at least every tight hours. 3. You generally fee]worse in 36-48 hours after the injury;then improvement should definitely begin if you are not aggravating the Injury and are following instructions.If not,contact your doctor. ❑ UTI INSTRUCTIONS �� r 4 If you develop numbness and or weakness in arms or legs aq*f 4�K A. your bladder after. emergency treatment,notify phy " Intercourse sician ' i n ' Intercourse(sex) 3.Bicycler riding Nottub 4.Subtle bath Physician's Time 8ipnaturo _ I hereby ar1mowledQ+s roaeNpt of She- t6i!abtille:fljfi 1 trains had margency traatrnent and that I may be relepnd torero aH y medical Problem are g. knoam and treated.I wale arrange.forfollow-up tare asdrmkUcted above. '.. Preprinted Aftercare inssrudions Pertient or Patients "nature Other than above:. 'YES 0 NO, Sutter Delta Medical Center i LONE TPEE WAY•MMOCK CA WM 10598829 05/31/98 0028322 THOMAS,CLAYTON 8 EMERGENCY DEPARTMENT 08/22/63 34 M ER/34 AFTERCARE INSTRUCTIONS YwMITE-Chari `r.. VALVERDE--SALAS,VICKY,DR. 4. NURSING CAREThis h" mvidos only �uY un ls ProvkW mono k nelvs nursing care, It the patlenft cwndibon is�h ea to need the service of a spacial duty nurse,It is agreed that such must be by the patient or hilow legal repreeentsiNs. The hospital shelf In no way be responsible for t t Wkft to provide the same and Is hereby released from any and all IiabtNty arising from the fact that said patient is not Provided with such additional cars. i. It. MEDICAL AND SMOICAL CONSENT s The undersigned consents to the basic care and procedures which may be performed during this l n or on an out-patient basis, *@*tai freatnent or surgical procedures will be carried out upon the order of the Wwaiclan and the agreement of the undersigned. Emergency trestrnent or services,which may Incl de but ars trot Ilmtfed to-laboratory procedures,X-ray examinations,rrnedk*or surgical treatment,anesthesia,will be rendered to the patient under the general and spedflcc Instructions offhe pabanft physiclsn of Win• r 9. E OF INFORMATION To tare extent rse0e tyr tg distercmins Ifabitfty,fou payment WWI*obtain nelmNssament,the -any person or aaporadon wtdeh is or > e #the PatiersCs raasond, htalfnsr rnedieai records,to. may be It1lbler.for sit or any portion tfse hospital ,lncludirlg but rat Iirnitwed Insurance ownpanies,fssaRh oars service pians orwor kers h romper n carriers,To ensure coordination of my medical came,I*Uth0 lze n &medical irdonnation to eery ply physician and/or�physician. 3. PERSONAL VALUABLES _ N It Is understood andasgreed bhot the flospisi maintains a safe far the ng of mossy and valuables,and the ho@P tat Shall not be liable for the toa a derails to any money, Jewelry,documents.furs,furgamterrta or other atticl"of unusual value and*mail compass,unless i therein,and SWI.not be lime for loss or ;property,urAft depoe#ad with the hospital forte. d any other personal S. FfNANCiAi.JItiRSENIfSNT .r The undersigned agrees,whetherhe/ahe as agent oras patient,the in consideration of the aervices to be terwered to"patient.he/she hereby individually obligates hlrnrelfRtetsalt to page the account of the hoepltei In accordance with the regular.s�es and terms of the fwepsai. Sboufd the account be referred to an attorney for collection,the undersigned pay areal�f m and oolwction este. AN delinquent shall bear Interest as the legal rate.At my option,I may d nose the Hosplial's•Preferred Payment Ptart`and make payments of the amounts owed in tnotritnly Irsstalhrrerats,''Pradetred Ptsymertt Plan acconrras etre subject io a 1lnartoe charge and will be opened upon receipt of the first monthly payment under the fsmts of the Plan. An account disclosure describing the terms and conditions of the`Preferred Psyrront Plan`is auallabie on request and is included on the reverse side of the hospitals Wiling statement. I will#iso receive a statement of billing rights under the Fair Credit Billing Act. I understand that U payments not trade as and when due,the unpaid balance may be assigned for collection, I agree to pay all collection costs,court acais,and reasonable attcrmays'fess Incurred In the enforcement of this -. obligation. 6. ASSIGNMENT OF INSURANCE BENEFITS The undersigned authorizes,whether he/she signs as agent or as patient,direct payment to the hospital of any Insurance bsnsflts otherwise:payable to the undersigned R care tendered a nate not to escoeed the regular charges, it is that T ,m I►aY�►m to Chi hospital,pursuant t0 this authorization,by an Insurance company shall discharge said Insurance company of any and all obligations under a policy to the extent of such payment. it is understood by the undersigned that he/she is financially responsible for charges not covered by this agreement. 7. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION .,$TATE I,AW flDW TKATJ)P.DN AN tNQYIRY AS TO THE PRESENCE OR OEM CONDiTNIN OF.THE-PAT EW,DELTA MEMORIAL 1iOSP ITAL MAY,#JNLEaS - s' OTHERWISE REOUESTED BY THE PATIENT,NEXT OF)ON,OR PROVIDER OF HEALTH CARE,RELEASE AT ITS DISCRETION NONE,PART OR ALL OF THE FOLLOWING '#WORMATMN: THE PATIENT'S NAME,ADDRESS,AGE AND SEX,REASON FOR ADMISSION,GENERAL MATURE OF INJURIES,OR THE GENERAL CONDITION OF THE >, PATIENT. $TATUSOF ADVANCED IXRECTIVE I. Imormetlon SOUM .,(Girt"one) Patlent Spouse Oiler(rano) 2. Does patient heves Advaftoed Dlrafstive? O Yes Z No - If Yes:is copy In record? Ll Yes © No No(padog inetruotsd to provide) & Polloy/Bro+otiune given? o Yee 3 so(reason Why not) -4. Info raaW-div—r« rdad br.Adndttinq Rehear Nursing 5. Adtranted�rnlaldtrlded Ib�►Pint- Dazs revoked ; dlangsd The csrtON Vest Wft fees read fl,e foregoksg,is tg a Ihsmsof and is ttte paOstrt.oris d�Iy�by ties ae,ps tlerttYs Von"agent to execute els x:, anti sap otrpd as trmns. _ ..,,Saul. ..1.'.4z..^.y�..?J 5 ...:sL.• _ -- _� '' }� .T f v I:to scow�ll � aarVo a Pandered 'ttD tfte paifer>t Ustif fq accept ilea tirrlre Of fits l�Agseerns�I,ss�t>Inera Of � S f{jJ �'utfer De1W Mediml r, WDI Lt�TREE'VMY.�CA2$Wp CONEHTIONS OF ' ADMISSION f RE+GISTfiAMON till", �'-tsa(ise~FlGkarmartror �'ff�lC YRrarinses'C7Elois T p 't ""`3ac. r+,xyoc{e,„, 'nc*." ,'" Y PLEASE RETURN TO QR A RECHECK IF NOT MUCH BETTER IN THE NEXT DAYS,AND RECHECK AT ONCE F YOU ARE GETTING WORSE. USE THE EMERGENCY ROOM IF YOUR DOCTOR OR CLINIC IS NOT AVAILABLE.WE ARE OPEN 24 HOURS A DAY. ❑ The following are specific instructions which you should follow: ❑ HEAD INJURY ❑ WOUND CARE(cuts,abrasions,bums etc.) 4 A. Notify doctor if the following symptoms occur:" Keep the dressing or wound clean and dry. 1.Unconsciousness Elevate the wound to help relieve soreness and help speed wound 2.Confusion healing. 3.Unusual sleepi Use antibiotic ointment daily to wound. 4.Vomiting more th nc� aylY 5.Blurred or double vision - - Despite the greatest care,any wounid can be infected.If your wound 6.Increasing dizziness becomes red,swollen,shows pus or red streaks,or feet more sore 7.Fever over 100°F. # instead of less sore as da 6.Inability to move arms or legs r'e Ys go by you must report to your doctor S.Convulsions,tris or seizures right away,or return to'emergency room. 10.Colorless fluid or bleeding frcxn�esrs or nose. Have sutures removed in days.Recheck if worse. B.Awaken patient every hours the first 18 hours after the ❑ SPRAIN&FRACTURE,SEVERE BRUISES injury to check for these signs and make sure he/she knows their name,the date,and where they are. 1. Elevate the injured part to lessen swelling.This may be comfortably done with pillows,blankets,etc. ❑ BACK S NECK INJURY INSTRUCTIONS 2• Ice packs also help prevent swelling,especially during the fist 48 hours. Place ice in a plastic or rubber bag;with a cloth cower. 1. Use heat or cold on the injured area,whichever seems to help the mast. 3• If the part awrelisor gets cold,blue or numb,or if pain increases Be careful not to bum yourself. markedly;have it checked promptly by physician. 2. Avoid activity causing pain. , d 4. If you have an elastic bandage,rewrap it if too tight or loose.Loosen for 3. You generally feel worse in 3648 Curs atter the im , n" 9 mynufes at feast every eight hears. irnprovement should definitely begin if you are not aggravating the injury 10, and we following instructions.If not,contact your doctor._ � `❑ 1UTI INSTRUCTIONS 4. If you develop numbness and or weakness in arms or iegs.after rf. A. F_tnpty your bladder after. -emergency treatment,notify physician. 1 Intercourse Iwo) 3.Bicyclie riding �~ 2-iHottub 4.Bubble beth Phyamisn's TimsCate f hereby sx*nt ryAedge receypt of lmstryztioris fndit ted r I undwst that i have had emergency treatment and that 1 may be released before all my medical problems are known and treated.i will a arrange for follow-up pyre as i nsUucted above. Prowl tad Allerrme Instructions or atierd's it atherthan above. ❑ YES 0N x 4 a Sutter.delta tical Center 10600237 46,01«e 0028322 9601 LONE TREE WAY-fNTioCK CA OWNg Ti-ia:IMAS.CLAYTQ#d 8 08122/63 34 Mi ER/34 EMERGENCY DEPARTMENT AFTERCARE'INSTRUCTIONS M RAN,DONAL.D M. .DR. 2"M(1ow) WHITE-Chart YEu.Uw-Patient ..... .::..::: ' I. NURSING CARE This hospital proWdes only general ditty nursing cares union upon orders of the patient's physician the patient is Provided more tritstrShrre An to need the Servhw of a Special duty nurse,tit is read that such MuOt urs nurpital she. If hiss pat be r condition la such � agreed by the patient or hIs/har tsgal rapreser#ativa. The hospital Stmarlt in no way be�sparrsybt®wpr Mure to provide this am*and is hereby released from any and all liability arising from the tact that Said patient is not provided with such additional care. g. MEDICAL AND SURGICAL CONSENT The undersigned consa m to the basic ares and procedures which may be perforated during this hospitalization or on an out-pollen baste, SPOCIW treatment or surgical procedures will be carried out upon the order of the physlotan and the agreement of the undersigned. Emergency treatment or services,which may Include but are nottirniled to WbotaArxy procedures,X-ray ,meidicai or surgiow tnestrnent,arvothoola,will be rendered to the patient under the general and apwft from"of the poderrts p hysiclan or surgeon. RELMSE OF INFORMATION t To the exlert necessary to uietermirme tteWNty for paynieatt and to obadr#tetnbursomentthe hospital may dlaetae9 pot6arss of the Pada record,inoW ft lfiS h r moddal records,to any person or corporation which Is or may be iialafe,for all or any portion-of the hospital charge,inotuding but not&nbd to trounsnoe manias,health care service Purrs or worker's componso w carerars. To ensure oactrdirwom d my medical c om,I authorize release of m rdioai InfOr;natIon m my try telae Physician,and/or referring physician. y 4. PERSONAL YAt t#ASLE15 it in understood and agreed that the txxVW maintains a saris for the Safekeeping of money and valuables,and the hrttptW shag not be liable for the tails or damage to any money, Miry,documents,furs,far garments or other articles of unusual value and small oompase,union placed therein,and shall not be liable for loss or damage to any other personal t rty,unisse depostfed with the trospirtrd for sdaAaeping. 5. FINANCIAL AOREEMOFT The undatslfjnsd egress,whWw he/she Wynn as agent or as patient,that In consideration of the servfose to be rendered to the Patient,t*M*hereby}rWvJdusRy obligates himseti/har"If to Pay the scooamt at the haspitat in ac:cordanos with the regular rales and tarns of the hospka#. Should the account be reFanad err an attorney for collection,the undersigned*hall pay actual tatornaytit fens and collection expense. AN delinquent a000unffi shah bear Interval at the legal retie. At my option,f may otaoaara the Hospitatss'Prafarred Payment Pian'and make payments of the ampurft owed in manthty irsstahmenie. `PrMarred Payment Plan accounts are subject to efinarve charge and will be opened upon receipt of the first monthly payment under this tarns of the Plan. An account disclosure describing the terms and conditions of the'Preferred Paymant Plan'is avalable on request and is Included on the reverse skis of the hospitaft billing Statement, I will also recohm a statement of billing rights under the f=air Credit Silting Act i understand that If payments not made as and when due,the unpaid bala nos may be assigned for cottabtlon, l agree to pay all collection oasts,court 00812,and reasonable attorneys'tee$incurred In the anforcamord of this obligation. 6. ASSIGNMENT OF INSURANCE BENEFITS The undersigned authorbve,whether he/she signs as agent or as patient,direct psto the hospital of any Insurance benSNts otherwise payable to the undersigned for the care rendered at a rale not to encased the regular charges. it is agisad i f l#psyment to pitet pursuant w this authoehattion,try an Insurance company shall discharge said insurance company of"and all obligations und#a policy to the extat of.ialisk payment. ft. understood by the urgisrsigned that he/she isfinanclalty responsible for chargee not coved by this agreement. 7. AUTHORIZATION FOR RELEASE OF MEDWAL HOORMATION STATE LAW PROYiCit„A'jMA't UPON-Ay,INMtJgfiYAg'TOW PtiESENCE OR GENERAL CfSRlD1TiON OF 314E PATIEtiT,1iEC'IyI MEfNORIAL tfiSRPETAi MAY,UNLESS _ OTHERWISE REQUESTED By THE PATIENT,NE)ff OF KIN,OR PROVIDER OF HEALTH CARE,RELEASE AT II''S DISCRETION NONE,PART OR ALL OF THE FOLLOWING INFORMATION: THE PATIENTS NAME,ADtRES$,AIDE AND SEX,REASON FOR ADMISSION,GENERAL NATURE OF INJURIES,OR THE GENERAL CONDtTtOH OF THE PATIENT. STATUS OF ADVANCED DIRECTIVE { I. Information Source:(o le ons) Padstt * 8Poueua Odner(Who) 2. Doss prttiont#terve Advanced Dirsod"? Q Y" U No If Yee:b cagy In record? a Yee O No No(Patient instructed to provide) $: 9. Policy/Brochure phren? Cl Yes CI No(reason wiry not) 4. k faY tooldvaed(recorded by:Admitling Rogbtrar S. A&renced DIrWll"feaC'Ntded by Pattani: Drfa t w6ked "'tiRte m" The undoMigned wrtflise that he/she has swSrtttsalcragaa y,reaaiving a oepytharsol~and*ft iieitlSrg,ren to f, above surd ncfoSpt fla ttwm. {, �au lhorixsd by ftre:�tt mea Psdonela gsnaaai a and to snouts Bre i V 6' f3 v #'atlarrt __^ faarsrgttwkaSne armolal t r ';reaattn ,.�.+tl�,6Mr paNata JW tho Patients p4prreaanni atift:I Sam to scow*vsnew awpata r Tavor*ft rendered w .t4itre� thrr forms of the FIVISM!"Ages of #=firaSoe Ilarsr►ff6lr firwAgw! Panty - ' IV Sutter Delta rcter � �Dft7 Tt 1MAY•JV�i'fIO�C`i,i`rA'?SOD_: € CONDITIONS LIQ`. e t Yy ADMISSION/REGIIST 71OI+I w-26447(tty1D9) Whit -Chart LOPE`�/D;,ar rraor. PINIFC .."_- -----'^.._ ,•:........-..�.._ . lute.i .. :' - �. :- ,. is ;� ,�' ea s OR Y... *t.