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Home My WebLink AboutMINUTES - 04201999 - C23 �I 6, 2,3 Afl CJF SIMERMORS OF CONTRA C{ TA(�OOtJNTY� CA,,�'C}12�NTA Imp ACl'lttt .sprit 20. :,Y99 Claim Against the County, or District Governed by the Beard of Supervisors, Routing Endorsements, NOTICE TO CLAI MNT 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 Goverronient Code Section W and MAR 18 1999 915.4. Pease note all "Warnings„ AMOUNT: Exceeds $25,000.00 COUNTY COUNSEL MARTINEZ CALIF. CLAIMANT: Stephanie Cotton ATTORNEY: c/o R. Nicholas Haney, Esq. DATE RECEIVED: March 17, 1999 227 Broadway March 17, 1999 ADDRESS: Richmond, CA 94804 BY DELIVERY TO CLERK ON: BY MAIL POSTMARKED: March 16, 1999 1 V.RflM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. March 1$ 1999 PHIL BA ffiLOR, Clerk ..7 Dated: By: Deputy IL FROM: County Counsel TO: Clerk of the Beard of SupervisKrs 1< 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 91(3.8). ( ) 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: j Deputy County Counsel W l III. FROM- Clerk of the Board TOsCIO 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 sectio I3) 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 claire. 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. AFFMAVIT OF A AILING 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 Bully prepaid a certified copy of this Board Order and notice to Claimant, addressed to the claimant as shown above. Dated: ,J'�+'-2:i( j By: PML BATCHELOR By _Deputy Clerk CC: rnty CotsttseI County Administrator R.NICHOLAS HANEY Attorney at Law 223 Broadway Richmond,California 44804 (510)237-1624 FAX:(5 10)237-7267 6 March 9, 1999 Clerk of the Board of Supervisors Contra Costa County 651 Pine Street, 1st Floor Martinez, CA 94553 ATTN: Risk Management Department RE: FORMAL NOTICE TO PUBLIC ENTITY, CONTRA COSTA COUNTY, OF CLAIM WITHIN SIX (6) MONTHS - DATE OF LOSS: 1/4/99 1. CLAIMANT: Stephanie Cotton 896 Carlson Blvd Richmond, CA 94804 5101) 236-3842 2 SEND NOTICES TO: R. Nicholas Haney, Esq. SBN 91179 227 Broadway Richmond, CA 948014 5103) 237--1624 (fax) 510) 237-7267 3. On January 4, 1999, Claimant Stephanie Catton was being serviced by a clerk in the Social Services Offices of Contra Costa County located at 1305 macDonald Avenue in Richmond, CA. As Ms. Cotton took a seat in the waiting area, the chair collapsed and broke causing her to sustain a severe fall., injuring herself substantially. I enclose herewith all of the medical .records, reports and billings relative to these injuries. 4. Claimant, Stephanie Cotton, sustained severe acute thoracic lumbosacral sprains, strains, radiculitus. Right arm, right wrist right elbow sprain. (see attached) . 5. Contra Costa County, the Social Services Department and its offices located at 1.305 MacDonald Avenue, Richmond, CA, and its employees responsible for this accident and caused this accident. 6. The claim amount exceeds $25,000.00. The Court of jurisdiction for this claim is the Superior Court of the County of Contra Costa, State of California. RESPECTFULLY SUBMITTED?: R. NICHOLAS HANEY, ESQ SBN 91179 R:NHJdw STOP ! The following pages are medical records. Do not print or distribute without written consent from County Counsel. MEDICAL REPORT Claim NO. : Patient's Name: STEPHANIE COTTON Age: S M Phone: Oc upation: Employer: Phone: Address: 896 CARLSON BLVD. �RIOND.CA 94844 Date of Injury: 14-99 Date Of First Treatment: 1-11-99 Patient's Account of Injury:CHAIR BROKE IN HAT..P WHEN I SAT DOWN. Diagnosis: SEVERE ACUTE TIIORACIC UMBOSACRAL 5PRAJN5.STRAINS RADICULITIS LOWER E20REMITIES.PAIN ANTALSPAS OGENIC HEADACHES RT RT WRIST RT`ELBOW SPRAIN. 847.1 94'7.2 724.3.784.13841.842 I Pre-existing Injuries or Illness: Treatment Rendered.PHYSICAL&ORTI EXAM PI YSICAL THERAPY ICE.HEAT ULTRA SOUND MASSAGE SPINAL MANIPULATION. X-Ray:NONE Findings Hospitalized Yes NO If Yes,Where? Surgery Yes NO If Yes,,Explain Prognosis:PATIENT CQNTINUES TO 1JAVE SLIGHT iNTERMIT'I'ENT EXACERBATIONS OF SYMPTOMS. Permanent Impairment—Yes NO IF Yes,Explain in Detail Patient still under treatment _ Patient discharger)(Date) Patient disabled from To Date of last visit 2-2.99 Have you reported this injury to any one else? Yes NO If Yes To Whom? Bill To Date$ 1,752.98 (Itemized Statement Attached) Estimated Final Bill$ Has This Bill Been Paid? Yes NO If Yes,By Whom Provider's Name Typed: PATRICK.J.SZUCS D.C. DEGREE: CHI PRACTI Address: 221 BROADWAY RICHMOND CA. 94844 PHONE: (510)232-8434 IRS NO. : 68-0471699 DATE 2-11-99 Provider's Signature STATEMENT PATRXCR J. SZUCS, D.C. 221 Broadway 02-11-1999 Richmond, CA 94804 (510)232-8434 BALANCE: $1752.98 ACCOUNT NUMBER: 1000-433 STEPHANIE COTTON LAST CLAIM. 896 CARLSON BLVD LAST PAYMENT: RICHMOND CA 94804 LAST CHARGE: 02-02-1999 Date Description Code Charge Credit Adjust Balance 01-08-1999 Massage-Brief 97124 22.14 .00 .00 22.14 01-08-1999 Ultra Sound 97035 20.91 .00 .00 43.05 01-08--1999 NP OV Intermediate 99204 92.24 .00 .00 135.29 01-08-1999 cold packs 97010 18.45 .00 .00 153.74 01-08-1999 Massage-Brief 97124 22.14 .00 .00 175.88 01-08-1999 Ultra Sound 97035 20.91 .00 .00 196.79 01-08-1999 EP OV Brief 99211 20.02 .00 .00 216.81 01-08-1999 Man Manipulation 97260 32.60 .00 .00 249.41 01-08-1999 heat /cold packs 97010 18.45 .00 .00 257.86 01-13--1999 Massage-Brief 97124 22.14 .00 .00 290.00 01-13-1999 Ultra Sound 97035 20.91 .00 .00 310.91 01-13-1999 EP OV Brief 99211 20.02 .00 .00 330.93 01-13-1999 Man Manipulation 97260 32.60 .00 .00 363.53 01-13-1999 heat /cold packs 97010 18.45 .00 .00 381..98 01-14-1999 Massage-Brief 97124 22.14 .00 .00 404.12 01-14-1999 Ultra Sound 97035 20.91 .00 .00 425.03 01-14-1999 EP OV Brief 99211 20.02 .00 .00 445.05 02--14-1999 Mart Manipulation 97260 32.60 .00 .00 477.65 01-14-1999 heat /cold packs 9701.0 18.45 .00 .00 496.10 01-15-1999 Massage--Brief 97124 22.14 .00 .00 518.24 01-15-1999 Ultra Sound 97035 20.91. .00 .00 539.1.5 01-15-1999 EP OV Brief 99211 20.02 .00 .00 559.17 01-19-1999 Massage-Brief 97124 22.14 .00 .00 581.31 01-19-1999 Ultra Sound 97035 20.91 .00 .00 602.22 01-19-1999 EP OV Brief 99211 20.02 .00 .00 622.24 01-19-1999 Man Manipulation 97260 32.60 .00 .00 654.84 01-19-1999 heat Fold packs 97010 18.45 .00 .00 673.29 01-19-1999 add manipulation 97261 22.1.4 .00 .00 695.43 01-20-1999 Massage-Brief 97124 22.14 .00 .00 717.57 01-20--1999 Ultra Sound 97035 20.91 .00 .00 738.48 01-20-1.999 EP OV Brief 99211 20.02 .00 .00 758.50 01-20-1.999 heat /cold packs 97010 18.45 .00 .00 776.95 01-21-1999 Massage-Brief 97124 22.14 .00 .00 799.09 Continued. . . STA 'T` EMENT PATRICK J. SZUCS, D.C. 221 Broadway 02-11-1999 Richmond, CA 94804 (510)232-8434 BALANCE: $1752.98 ACCOUNT NUMBER: 1.000-433 STEPHANIE COTTON LAST CLAIM: 896 CARLSON BLVD LAST PAYMENT: RICHMOND CA 94804 LAST CHARGE: 02-02-1999 Date Description Code Charge Credit Adjust Balance 01-21--1999 Ultra Sound 97035 20.91 .00 .00 820.00 01-21-1999 EP OV Brief 99211 20.02 .00 .00 840.02 01-22-1999 Massage--Brief 97124 22.14 .00 .00 862.16 01-22-1999 Ultra Sound 97035 20.91 .00 .00 883.07 01-22-1999 EP OV Brief 99211. 20.02 .00 .00 903.09 01-22-1999 Man Manipulation 97260 32.60 .00 .00 935.69 01-22-1999 heat /cold packs 97010 18.45 .00 .00 954.14 01--25-1999 Massage-Brief 97124 22.14 .00 .00 976.28 01.25-1999 Ultra Sound 97035 20.91. .00 .00 997.19 01-25-1999 EP OV Brief 99211 20.02 .00 .00 1017.21 01-25--1.999 Man Manipulation 97260 32.60 .00 .00 1049.81 01-25-1999 heat /cold packs 97010 18.45 .00 .00 1068.26 01-26-1999 Massage-Brief 97124 22.14 .00 .00 1090.40 01-26-1999 Ultra Sound 97035 20.91 .00 .00 1111.31 01-26-1999 EP OV Brief 99211 20.02 .00 .00 1131.33 01-26-1999 Man Manipulation 97260 32.60 .00 .00 1.163.93 01-26-1999 heat /cold packs 97010 18.45 .00 .00 1182.38 01-27-1999 Massage-Brief 97124 22.14 .00 .00 1204.52 01-27-1999 Ultra Sound 97035 20.91 .00 .00 1225.43 01-27--1999 EP OV Brief 99211 20.02 .00 .00 1245.45 01-27-1999 Man Manipulation 97260 32.60 .00 .00 1278.05 01-27-1999 heat /cold packs 97010 18.45 .00 .00 1296.50 01--28-1999 Massage--Brief 97124 22.14 .00 .00 1318.64 01-28-1999 Ultra Sound 97035 20.91 .00 .00 1339.55 01-28-1999 EP OV Brief 99211 20.02 .00 .00 1359.57 01-28--1999 Man Manipulation 97260 32.60 .00 .00 1392.17 01-28-1999 heat /cold packs 97010 18.45 .00 .00 1410.62 01-29--1999 Massage-Brief 97124 22.14 .00 .00 1432.76 01-29-1999 Ultra Sound 97035 20.91 .00 .00 1453.67 01-29-1999 EP OV Brief 99211 20.02 .00 .00 1473.69 01-29-1999 Man Manipulation 97260 32.60 .00 .00 1506.29 01-29-1999 heat /cold packs 97010 18.45 .00 .00 1524.74 02-01-1999 Massage-Brief 97124 22.14 .00 .00 1546.88 Contin;ed. . . STATEMENT PVZRICX'J. SZUCS, D.C. 221 Broadway 02-11-1999 Richmond, CA 94804 (510)232--8434 BALANCE: $1752.98 ACC0UNT NUMBER: 1000-433 STEPHANIE COTTON LAST CLAIM: 896 CARLSON BLVD LAST PAYMENT: RICHMOND CA 94804 LAST CHARGE-. 02-02-1999 Date Description Code Charge Credit Adjust Balance 02-01-1999 Ultra Sound 97035 20.91 .00 .00 1567.79 02-01-1999 EP OV Brief 99211 20.02 .00 .00 1587.81 02--01-2999 Man Manipulation 97260 32.60 .00 .00 1620.41 02-01-1999 heat /cold packs 97010 18.45 .00 .00 1638.86 02--02-1999 Massage-Brief 97124 22.14 .00 .00 1.661.00 02-02-1999 Ultra Sound 97035 20.91 .00 .00 1681.91 02-02-1999 EP OV Brief 99211 20.02 .00 .00 1701.93 02--02--1999 Man Manipulation 97260 32.60 .00 .00 1734.53 02-02--1999 heat /cold packs 97010 18.45 .00 .00 1752.98 TOTALS 1752.98 .00 .00 For proper credit, please enclose this portion with your payment. STEPHANIE COTTON BALANCE: $1752.98 896 CARLSON BLVD PAY THIS AMOUNT: RICHMOND CA 94804 AMOUNT ENCLOSED: _ Please fill in blank. DATE DUE: PATRICK J. SEUCS, D.C. Tax ID.68-0071699 THANK YOU. 221 Broadway Richmond, CA 94804 ACCOUNT NUMBER: 1000-433 OM)WA"Y -CHIROPRACTIC TAX Z .D. : 68-..0071699 - ✓r--+y��t , .TRICK J. SZUCS, D.C. DCO=1381 7 c•�- CHARD M. NORTON, D.C. DCO-011631 1 BROADWAY t CHMOND, CA. 94804 10)232-8434 YSICAL THERAPY Qiag Dare `' Notes /40 ' S f Z 3 C# i • , * � . t f sir ,i�';�.��•�.�,_. �+MY'Mfii+wAlgt :rte A r � !�• s P f � J S rel, 40 A Oil a Ma FA,iiiiiiiiiiii oAr NO.-*A-9 IdU gg AWK �..,,. '. '4" itiw� .rte• � �. r � 7 f �i .kl)W;AY CftItO 'RACTIC TAX. Z .D. : 68-0071699 RICK J. SZUC5, D.C. DC0,13887 'HARD M. NORT0N, D.C- DCO-011631 . BROADWAY :HMOND. CA. 94804 0) 232--84.34 (SICAL THERAPY , { D gag Date Nates 1001 751 1 •• l i i k t k k 9 Patient Name:COTTON,STEPHANIE 0110mg Subjective:.On today's visit, Ms.Cotton reported she is feeling constant sharp pain in the region of the THORACIC. She rated the severity 9/10 on a 1 to 10 grade scale with 10 being the most severe. Her pain seems to be worse while bending or twisting and worse while walking or moving and worse while lifting or straining and increased on cervical flexion and increased on rotation.The patient also indicated that she is having constant sharp pain in the region of the LUMBOSACRAL with radicular pain into the bilateral lower legs area. Ms. Cotton graded the severity 9110. Her pain seems to be worse while bending or twisting and worse while walking or moving and worse while lifting or straining. Objective.Discomfort of a(+4)severely tender degree was revealed during palpation at T8 thru T12. Discomfort of a(+4)severely tender degree was found during palpation at L1 thru 51.A trigger point was noted with an active pain in the T10-T12 muscle area. Evaluation of the 1-3-1-5-51 muscle area revealed a trigger point with active pain.T8-T12 was revealed to be malaligned with mild restriction of joint function.L3-L5 was revealed to be misaligned with mild restricted mobility. Hypomobile segmental movement was revealed at T8 thru T12. Segmental movement to be hypomobile at L1 thru S1.A(+5)level of hypertonicity was revealed in the T8-T12 musculature. Hypertonicity of a(+5)level was revealed in the LI-L6-S1 musculature. Soto-Hall Test was positive,T8 thru T12,with moderate pain at 100.Additionally,KEMPS TEST was positive, L1 thru S1,with severe pain at 10'. In addition,Straight leg raising was positive,Bilateral legs,with moderate pain at 40". Range of motion testing indicated the following: Lumbar ROM: FLEX. -50*with sharp pain at LUMBAR. EXT.-5'with sharp pain at LUMBAR. R. LAT.FLEX-5°with sharp pain at LUMBAR. L.LAT. FLEX.-5"with sharp pain at LUMBAR. R. ROT.-10"with sharp pain at LUMBAR. L ROT_-10"with sharp pain at LUExamination found:All DTRs normal. Assessment Ms. Cotton is in a relief/repair phase of care. Plan:.Therapy on the THORACIC will include mechanical massage, ultrasound and hoticold to improve circulation and to reduce pain and to reduce swellingiin lamation and to increase mobility and to speed up metabolism and to prevent disc degeneration and to reduce muscle spasm and to speed the healing process.Therapy on the LUMBOSACRAL will include mechanical massage, ultrasound and hoticold to improve circulation and to reduce pain and to reduce swellingfiinflamation and to increase mobility and to speed up metabolism and to prevent disc degeneration and to reduce muscle spasm and to speed the healing process. BROADWAY CHIROPRACTIC (510)232-84 PATRICK J_SZUCS,Diw. Fax(51q)233-41 BROADWAY CHIROPRACTIC TAX I.D.fib-Wim PATRICK J.SZUCS,D.C. DCO-i3N7 RICHARD M.NORTON,D.C. 000.011631 STEPHANIE COTTON 221 BROADWAY 896 CARLSON BLVD RICHMOND,CA 94804 RICHMOND CA 94804 (510)232.84U FAX(5I0)233.4106 PHYSICAL THERAPY NOTES 01-12-99 T 0 * NOTE FOR S. COTTON * BD: at 02:25 p. By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE, MOBILIZATION. 01-13-99 T 0 * NOTE FOR S. COTTON * BD: at 02:25 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE, MOBILIZATION. 01-14--99 T 0 * NOTE FOR S. COTTON * BD: at 03:05 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE, MOBILIZATION. 01-15-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 10:06 a By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: US, MASSAGE. - 01-19-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 02:48 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE, MOBILIZATION. 01-20-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 02:07 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE. 01-21-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 04:44 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: US, MASSAGE. 01-22-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 09:42 a By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE, MOBILIZA'T'ION. 01-25-99 T 0 * NOTE FOR. S. COTTON * BD: 04-25-1.961 at 04:32 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE, MOBILIZATION. 01-26-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 11:28 a By: LK "Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, IIS, MASSAGE, MOBILIZATION. 01-27-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 03:26 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE, MOBILIZATION. 01-28_99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 12:22 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. "THERAPY: HEAT, US, MASSAGE, MOBILIZATION. 01-2.9-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 10:38 a By: LTi Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY HEAT, US, MASSAGE, MOBILIZATION. 02-01-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-1961 at 03:17 p By: LK Thoracic/Lumbar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, us, MASSAGE, MOBILIZATION. 02-02-99 T 0 * NOTE FOR S. COTTON * BD: 04-25-2961 at 12:4$ p By: LK Thoracic/Lar pain, spasm, restriction associated leg radiation. THERAPY: HEAT, US, MASSAGE, MOBILIZATION. BROADWAY CHIROPRACTIC TAX LD.68-0071699 PATRICK J.SZUCS,D.G. DCO-13M7 RICHARD M.NORTON,D.C. DOD011631 221 BROikDWAY RICHMOND,CA 94804 (510)232-9434 FAX(610)233-4106 PHYSICAL THERAPY AUTHORIZATIONTO RELEASE X-RAYS & INFORMATION To: ��- �7 , (NAME Of HEALTH CARE PROVIDER.MINIC,HOSPITAL,ETC.) Address r7 J"J Birthdate—Y9f--6-L request the following information: (PATIENT'S NAME Ix' s istor cards ❑GOlagnosis deports rea nt �l y Y /►') f concerning my: ❑ Illness L7-pcccident ❑ Injury ® C3ther ATAW OPPACTWI To be released to: 1 A E PLOVER,NEXT Of KIN.ETC) {NAME OF PRACTITIONER,vaSURANC P� -. - Y 1 _. NY 221 BRt}CA 94804 For the purp�3se of: AgDPOSE REASONABLY RELATEDTOTHEABOVE} (REVIEW,EVALUATION,INSURANCE CLAIM PAOCESS ,-' . I understand that I have a right to receive a copy of this authorization upon my request. Signature: Date: ' Patient Spouse ❑ Parent ❑ Guardian ❑ Dr. Signature •+� " ' Date: Address 017 MISSION PRINTING(289)227.7640 UIRED FOR YOUR CASE HISTORY FILE r garnet ,- Date Ad ress t 511�IS t; City �rv� State Soc I Securi No. S`� AS= � 9'y Driver's License No. Lf? ' Te#ep on ty r�.�-- � Age I8ir#hdatel Sex _l._. Marriage Status: M ( j W D No.Children - - Occupation Employer -1 E Years Employed Employer's Addres Work Phone Bank Spouse's Name Occupation Employer Person responsible for this account Referred by INSURANCE;INFORMATION Are you covered by Medicare? Yes❑ No❑ Medi-Gal? Yes ❑ No ❑ County Do you have any group,union or personal health and accident Insurance? Yes❑ No❑ Name of Insurance Company Group No. I.D.No. Address City State - --- Zip Is your condition due to an accident or illness? Did your accident occur while at work? Yes ❑ No ❑ When Were you involved in an automobile accident? Yes ❑ No ❑ When Cash payment Other SYMPTOMS HEP: MACK: SHOULDERS: HIPS,LEGS&FEET: 12''Headache CLow back pain 0 Pain in shoulder joint(R-L) ❑ Pain in buttocks(R-L) ❑ entire tread ❑ Low back pain is worse when: ❑ Pain across shoulders Ci Pain in hip join ❑ back of head ❑ working Cl Bursitis(R-L) 0--4ri down leg> ❑ forehead © lifting ❑ Arthritis(R-L) ❑ Pain down both legs Ci temples ❑ stooping CI Can't raise arm 0 Leg cramps ❑ migraine ❑ standing ❑ above shoulder level ❑ Pins&needles in legs(R-L) Q Heads feels heavy ❑ sitting ❑ over head Ci Numbness of leg(R-L) ❑ loss of memory ❑ bending 13 'Pension in shoulder(R-L) 0 Numbness of feet(R-L) 0 Light-headedness ❑ coughing Q Muscle spasms in shoulders © Numbness of toes 0 Fainting © Pinched nerve in low back ❑ Feet feel cold 0 Lights bother eyes ❑ Slipped disc ARMS&HANDS: ❑ Cramps in feet(R-L) Loss of smell CI Low back feels out of place ❑ Pain in upper arm a Swollen ankles(R-L) Q Loss of taste ❑ Muscle spasms Ll Pain in forearm ❑ Swollen feet(R-L) ❑ Loss of balance ❑ Arthritis -ET-Pain in hands ❑ Painful joints in toes ❑ Dizziness © Pain in fingers CI Pain in foot(R-L) ❑ Loss of(tearing ❑ Pinched nerve in arm O ft n in knee ❑ Pain in ears ❑ Pinched nerve in fingers d Ringing in ears MID-BACK: 0 Sensation of pins&needles in arms ❑ Burning in ears 4�W-back pain ❑ Sensation of pins&needles in fingers ❑ Pain between shoulder blades ❑ Fingers go to sleep NECK: ❑ Sharp stabbing pain in mid-back 0 Hands cold GENERAL: Cl Pain in neck ❑ Muscle spasms ❑ Swollen joints in fingers © Nervousness Neck pain with movement ❑ Sore joints in fingers ❑ Irritable ❑ Pinched nerve in neck d Arthritis in fingers 0 Depressed 0 Neck feels out of place ABDOMEN: ❑ Loss of grip strength Cl Fatigue ❑ Stiff neck ❑ Nervous stomach ❑ Generally feel run-down ❑ Muscle spasms in neck 0 Nausea CHEST ❑ Loss of sleep D Grinding sounds in neck ❑ Gas ❑ Chest pain O Loss of weight ❑ Grating sounds in neck 0 Constipation ❑ Shortness of breath n Popping sounds in neck © Diarrhea © Pain around ribs ❑ Arthritis in neck Have you had X-rays before? ❑Yes ❑ No When? What areas were X-rayed? WOMEN ONLY. ❑ Menstrual Paint ❑ Cramping ❑ Irregularity Date of last period? Are you now pregnant? ❑Yes ❑ No How long? PAYMENT IS EXPECTED AT TIME OF VISIT, UNLESS OTWR AR NGEMENTTS'HAVE BEEN MADE. M36 PATIENT'S SIGNATUR 11- f2M 22))6{0 " AUTOMOBILE AND JOB INJURY INFORMATION Name \ttrData Telep Address t City Statea— Zip C JOB INJURY INFORMATION Date —d-4Z9—q— Time MAD injury reported to employer © Yes ❑ No Date Employer Employer's Address Description ofAcci' sit---" s�' AUTO ACCIDENT INFORMATION:Date Time t3;rJ ^Police report made? &—lres ❑ No Date Location Were you struck from: Behind O Right Side ❑ Left Side Cl Front ❑ _Were you: Driver O Passenger ❑ Description of Accident: 3 a"7 Were you injured? E] Yes ❑ No How? Where? Were you unconscious? ❑ Yes ❑ No Fractures Cuts Abrasions Bruises Patient taken to r r?Jt,-- Hospital for treatment_ Confined to hospital for Days Hours. Name of hospital doctor What are your present complaints: What treatments have you received? OTHER DOCTORS SEEN FOR THIS CONDITION: MD ❑ DC ❑ DO ❑ DDS ❑ Doctor's Name Diagnosis X-rays Urinalysis Blood Tests Other Treatment: Pills Shots Traction Physiotherapy Results Length of time under his care Other Have you had any problems as the result of the injury? Were you off work? D Yes ❑ No if so, how long Have you returned to your same job? ❑ Yes ❑ No if not, why HISTORY OF PRIOR INJURY,ILLNESS OR SURGERY: Name of other party Address City State Phone Their insurance company Insurance Agent ATTORNEY: Name n,t-=, Address Phone Litigation: ❑ Yes ❑ No ❑ Maybe INSURANCE INFORMATION: Do you have any group,union or personal health and accident insurance? ❑ Yes ❑ No Name of Insurance Company Claim No. Address Agent Patient's Signature: est WSSION PRINTING S269I2V-7640 F b.. t� PATrm*s PAIN CHART t7umbes: Please use all of the figures on baht Date-_ L sides of thLs page to show me exactly where AIL your pains are, and where they radiate to. Shade or draw with blue pen. tktly the patient is to fill out this sheet. Please be as precise and detailed as possible. Use ..... RIGHT ~�- LEFT J RICHT LEFT F RIGHT LEFT RICHT LEFT 1 RIGHT LEFT �J Z ti l/ OVER v ........... ........................I....................... AUTHORIZATION TO RELEASE X-RAYS & INFORMATION TO: 1D-bCY-VX-f (NAME OF HEALTH CARE PAMMA.CLINIC.HOSPITAL.STCJ Address Birthdate request the following information: (PATIENT-S NAME) tl X-Rays lei-V—is—tory 3-Records 0-01gnosis -tT11-eports 0--Treatm'ent 6 concerning my: 0 Illness 0-Accident 0 Injury 0 Other 0 To be released to: MW%v CIAROPP 4t,i it I 410t (NAME Or PRACTITIONER.INSORANCVJi �- W ;7XEPUYIER NEXT OF KIM,ETC,) FA 221 BROW, For the purpose of: A/-��,Yi2ry alcilitntiD. CA (REVIEW,EVALUATION.INSURANCE CLAIM PROCESS VVAMQYQd*XW AJAPOSE AEASONASLY REI-xma To THE AwvE1, I understand that I have a right to receive a copy of this authorization upon my request. Signature: Date: - Patient Gl-' Spouse 0 Parent 0 Guardian 0 Dr. Signature Date. /7-2 Address WSS40N PAINTING(2M)227-7640 JAN 2 1999 Voctors ' Medicaltenter San Pxblr,Campus ADMISSION RECORD Tenet California fieelthsyslem Mu JH A 12:46:$6 PST IM AccDv"T ADMiSSfON DATE 131ME F.C.1 DAT"FUMP41 ciE�AT,10N ROOM NO. ACC, PAT TYPE F"l UNIT HUM— x L H 0412516 Al t: ER MGH 2 99004002-i>5 . 011041991 2-45 37Y F :� 771363 PATIENT W 56c5-Ec-o PATIENT EMPLOYER TEIfPNtYNE NO. COTTOWSTEPHANIE R 565-15-6397 1805 ROOSEVELT AVE, TELEPHONE#10. NOW LOWS (510)236-3842 RICHMOND CA 94801 fiiUA OR NAME AND ADDFIESS.. - SOC•SEC NO GUARANTOR EMPLOYER TELEPHONE NO. COTTON,STEPHANIE R 565-15-6397 1805 ROOSEVELT AVE TELEPHONE?40. OCCUPAMN (510)236-3842 RICHMOND CA 94801 RELATHM NOW LONG SELF AFLATive I RELATIVE 2 LUCKEY,BERNADINE MOTHER (5101236-3842 [MEDI-CAL LOCAL INITIATIV 595 CENTER ST.SUITE 100 MARTINEZ CA 94553 CCHID 565-15-6397 COTTON,STEPHANIE R NCE 3 INSURANCE 2 "c 7 MWI-CAI,LOCAL INI'TIATI CCHP r ,_"_c", NCf ACMENT I Wx.M, — WE ARRIVAL MODE - -PAY.CLS DE14 0M BACK PAIN,FELL FROM CHAIR YES 01/04/99 10-3o AMBULANCE ADMIT PHYSICIAN WVb r AXwrf"k, DATE SMX VVAL VETE( BED pfwyBELL,ROBEAT BELL.ROBERT COTTON,STEPHANIE R 12/24198 N N PRIMARY CAM FWS—lCt" MIMESMORTUARY— CUNIC.RtCHMOND HEALTH ADvANCf.DWECTWES GROAN DONOR NO ED ORIGINAL DO N COTTON, STEPHANIE 77.13-53 KENNETH KUMAMOTO, M.D. 1/4/99 CHIEF COMPLAINT: Back pain. HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old obese black female who apparently fell onto her buttocks. The patient denies any syncopal kind of feelings. The patient slipped off a chair while she was trying to sit down and fell onto her bottom. The patient is ambulatory but is complaining of severe pain. No other traumatic injuries or complaints. PAST MEDICAL HISTORY: Revealed the patient has no headache, no upper back pain. No chest pain. No shortness of breath. No abdominal pain. No numbness, weakness or paresthesias. No hematuria. No bowel . or bladder incontinence. PAST SURGICAL HISTORY: Negative. Medications: None. ALLERGIES: None. PHYSICAL EXAMINATION: Temperature 97.70 , respiratory rate 16, pulse 82, blood pressure 1.26/89 . The patient is in no acute distress HEENT: Normal. Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. The lungs are clear to auscultation bilaterally'. Heart. : Regular rate and rhythm. No murmur. Abdomen has positive normal bowel sounds, soft, nontender, nondistended. No organomegaly. Extremities: No clubbing, cyanosis, or edema. No defects. Positive pulses in all extremities. Back examination: No percussion tenderness to upper cervical, thoracic, or upper lumbar spine. Theme is percussion tenderness to the lower lumbar spine. No crepitance. Neurologic: The patient is alert and oriented x 3 . Glasgow Coma Score 15. Cranial nerves II-XII are intact. Deep tendon reflexes are 2+ bilaterally. Strength is 5/5 bilaterally. Negative straight leg raise bilaterally. No cerebellar signs. Deep tendon reflexes are 2+ bilaterally. EMERGENCY DEPARTMENT COURSE- The patient had LS-spine x-ray which was normal . There was no evidence of fracture. The patient was given Tylenol and Vicodin for pain control and the patient had achieved sufficient relief. The patient will be discharged home with instructions on no bending over. No heavy lifting. The patient is instructed to follow up with her primary care physician. Emergency Department Report DOCTORS MEDICAL CENTER Page 1 2000 Vale Road San Pablo, CA 94806 COTTON, S'T'EPHANIE 77-13-53 KENNETH KUMAMOTO, M.D. 1/4/99 ASSESSMENT 1. Low back pain. KENNETH K KK:rsi/td M.D. DD: 1/4/99 1556 DT: 1/5/99 Doc. #EO05TD11 .BRK [284583] Emergency Department Report DOCTORS MEDICAL CENTER Page 2 2000 Vale Road San Pablo, CA 94806 ,...s ...R..�.,.•,>.,.3..._,.¢a_aa L.r:ir..a aa.,i s..e+lVs iYiL..Lti.+J�i,.iiLS.0 LJi iLl . Triage Locurnernatiart DATE. " '"> D Unscheduled Return Within 72 Hours \\ NAME st,First,M.I.) Se Age jDOI3 METHOD t3F © AmbtAatory 0 BLS 0 W/C PCP ARRIVAL ALS 0 Other : .. . t TRIAGE TI EXAM RM TIME JLNMP n rt } :41 "' ?�� i 7 ° P AB `a TtJ Chief Mniplaint VA D OS PMH IMMUNIZATIONS YES NOIMMUNIzATION l UP TO DATE? © ❑ INFORMATION GIVEN d SU8/t383 DATA YES f�•5ba s .,s r y POLICE NOTIFIED? SOCIAL SERVICES l C C OYES DYES BP P...,..T � MEDICATIONS None ALLERGIES: o— R ViT PULSE OX: INTERPRETER LANGUAGE FAMILY/FRIENDS Q YES INWAITIMI RM DYES S' ure RX H+P HMO AUTl I AE)T#iC3RIZING PERSON s .. .. v.. v. .<,. C]SEE PROGRESS NOTE: Consulting Physician's Name Time CTed Time Responded Time Arrived MD ORD LAB ENTRY CLERK RESULTS TIME OF TIME TIME TIME INITIAL MD ORD MED/ TX LIVEN 1 ITIAL LTCHEM 7 0 CRC 0 Lytes 0 PT/PTT O ABG 0 U!A 0 Urine Cx 0 UTA DREG 0 Btd Cx 0 ETOti X-RAY 0 Cx R 0if Abd X.p 0 C-Spine rt 0 (, 0 0 Old Record 0 EKG DX Condition: Q Improve Stabte CI Critical 0 Expired tri r-3 . DISPO: ome D A 0 Transfer O AMA O LWOBS DISP: AD IT SERV RM TIME ADM O TRANS TO: ACCEPTING MD MD/SIG TRANSPORTBY: C7 BLS CIALS SMD TIME Dl A D ED/DC TIME._.__ .... .._ !_ '_._.__ Y-`t.CHART COMPLETE 0 FOLLOW-UP DATE: NAME: 13!1 02 LJmin 0 Cannula ©Mask Cardiac Rhythm 0 t 2 3 4 5 s 7 a s tr. Pu 'lrGau a mm O V A I 1' 14 PEDIATRIC TIME MEDICATIONS ROUTE SITE RN HYDRATION MUCOUS COLOR ACTIVITY LEVEL S N. MEMBRANE o Pirtle O Playful t� 0 Moist o pale 0 irritable 0 Dry 0 Cyanotic O Dull Ci Phar Skin Turgor GENERAL ASSESSMENT CARDIAC RESP EENT TRAUMA 0 HR Reg. OUaL Normal RNo Deficit ILNothing Visible ❑HR kreg. fear Bilat 0 Deficit ceration D Chest Pains 0 Labored SKIN 0 Palpitations 0 Rhonchi Warm 0 Edema- 0 Rates y 0 Retractions slot 0 Bums O Wheezes 0 Diaphoretic 0 Puncture 0JVD 0Pate OGSW ~ GI 0 Rash — GL ASCOW COMA SCALE 0 WA Activity Infants Children and Adutts L7 Soft EYE 4 Spontaneous Spontaneous f3awel Sounds L7 Deformity To at sl>eerrr C3 SWeiiirtg OPENIN 2 To patWntuitsrimuirs o pales O Tender INPUT OUTPUT O Bruising Npne None 0 Distended ed VERBAL 5 Appropriate wards or sounds: Oriented PO URINE RCM Decrease six fol.mils:fixes and ktflows ❑Rio f l 4 Cries but consolable Confused Ehlt SIS 3 Persistently Irritable inappropriate words SRestless:agitated � rtpeehansue words IV AMT LEFT MdTC1R 6 Spontaneous movement Obeys commands S Localizes to pain Localizes OTHER OTHER �drawst r Withdirawstopairs 3 Abnormal flexion(decorticate) Abnormal flexion(dircorticate) 2 Abnormal extension(decerebrate) Abnatnalextensiort(decer96eaFo) _ t Norte ffiaz�td) None LftcFid PRIMARY Adapted hem Teasdale,G.,A JWOW 6,(1974) tet•iso:"James,R.E.(19W)_P.O.i Amfs,t5(t),IT. NURSE TOTAL SIGNATURE TIME: pupas: Size R NR Size R NR TIME BP P REsp T PULSE GCS NURSING PROGRESS NOTES r � kz METHOD OF DISCHARGE: DISCHARGE DISPOSITION TIME: WI MIBULATORY t.„,i WIC ®CARRIED ©CRUTCHES 0 CRUTCH WALKS WELL ©AMBULANCE II ADMIT PT.BELONGINGS: 0 PATIENT CI FAMILY 0 SAFE LIST ITEMS: 0 MEDS TO PHARMACY DISCHARGING RN SIGNATURE Wo DOCTORS MEDICAL CENTER 2000 VALE ROAD SAN PABLO,CALIFORNIA 94806 TELEPHONE(510)970-5189 REPORT OF ROENTGEN EXAMINATION OF COTTON,STEPHANIE R 37Y 771353 Name Age Patient Number KUMAMOTO,KENNETH ATT: BELL,ROBERT REFERRED BY: 01/04/99 1721 DIS DATE: ROOM NO: Chk-i n ; Order Exam 64485 0001 7215 XR SPINE LUMBOSACRAL Ord Diag: BACK PA. LUMBAR SPINE (72100) Clinical History: Back pain. Findings : AP, lateral and spot views of the lumbar spine were obtained. The alignment of the bones reveals a slight dextroscoliosis centered at L4 . Surgical clips are seen in the gallbladder fossa and a clip is seen in the right lower quadrant . The retroperitoneal soft tissues structures and bowel gas pattern are unremarkable. Mild multilevel degenerative changes are seen most prominently at L3--4 and L4-5 . IMPRESSION 1 . Mild multilevel degenerative changes . 2 . Otherwise negative . UM-0 i /Read By/ MICHAEL A. BRODSKY, M.D. ,Radiologist LCL /Released By/ MICHAEL A. BRODSKY, M.D. Radiologist FINAL REPORT CHART r 3 CLAIM IBUARD OF SUE&US RS OF QQMA COSTA CC}ITI ins CAI.IFCCRNTA BARD A0I1t April 20, 1999 Crim Against the County, or District Governed by } the Boardof 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 Godes. ) notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below}, given pursuant to Govern Code Section 913 and MAR 15 1999 915.4. Please note all "Warnings". AMOUNT: Unspecified COUNTY COUNSEL MARTINEZ CALIF, CLAIMANT: Bill J. Forrest ATTORNEY: DATE RECEIVED: March 12, 1999 ADDRESS: Contra Conte County Head Start BY DELIVERY TO CLERK.ON: March 12, 1999 Bay Grantee Operated Program 847 B Brookside Drive BY MAIL POSTMARKED: Interoffice Mail Richmond., CA 94801 L FROM: Clerk of the Board of Supervisors TO County Counsel Attached is a copy of the above-noted claim. PHIL BA IELOR, Clerk Dated: March 15, 1999 By: Deputy_____ IL//FROM County Counsel TO: Clerk of the Board of Superviscvs {V) This claim complies substantially with Sections 910 and 910.2. { ) This claim NAILS 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: ��w% `t `i `? By: i Deputy County Counsel III. FROIVL• Clerk of the Board TOs County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant(Section 911.3). IVB BOARD tRtDER: 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 slate. Dated: Z2 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code sectio 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. *Farr Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF NIAHXgGG 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 Carder and Notice to Claimant, addressed to the claimant as shown above. Dated:_ r ` By: PHIL $ATCHELOR By - Deputy Clerk CC: County Counsel County Administrator r 4 March 9, 1.999 To: Mr.Victor J. Westman,County Counsel Mr.Gregory C. Harvey, Assistant County Counsel From: Mr. Bill J. Forrest,Program Manager Contra Costa County Head Start Bay Grantee Operated Program 847 B Brookside Drive Richmond,CA 94801 Re: Letter dated March 4, 1999 Subj.: Request that you treat my February 22, 1999 letter as a Government Tort Claim Mr. Gregory C.Harvey,Esq., I respectfully request that you treat my February 22, 1999 letter of complaint as a Government Tort Claim,regarding causes of action,not based on FEHA and EEOC statutory filing requirements. If a Tort by definition is"a wrongful act which does not involve a breach of contract and for which the injured party can recover damages in a civil action",I believe that some of my complaint basis meet the Tort criteria. Even though the adverse actions that threaten my position and past position may not be a breach of contract, they are a breach of the covenant of good faith and fair dealing. Therefore,I am requesting that my February 22 letter be deposited with the Clerk of the Board as a formal claim. cc: File LFEB191999 COSTA COUN t'Y February 22, 1999 Tc�: Mr. Phil BatchelorINISTRATOR County Administrator Chief Equal Employment Opportunity Officer Contra Costa County 651 Pine Street Martinez,CA 94553 Mrs. Emma Kuevar, Deputy Equal Employment Opportunity Officer Contra Costa County 651 Pine Street Martinez,CA 94553 From: Bill J. Forrest, Program Manager Contra Costa County Head Start Bay Grantee Operated Program 847 B Brookside Drive Richmond,CA 94801 Re: Harassmenttintimidation>coercion/deception to remove from existing;position under false pretences and get me to voluntarily demote. Subj.: Alleged Harassment,differential treatment,and retaliation based on race,(African- American),religion(Pentecostal/Holiness)political affiliation(republican), by Tony Colon, Community Services Department Director(CSD)and Pat Stroh, Head start Director Dear Mr. Batchelor and Mrs. K.uevar: 1 began working for Contra Costa County Head Start on May 3, 1993. 1 went through the preliminary interview in Martinez,CA and was referred to Mrs. Cheryl Franklin-Golden and the Policy Council Chairperson for the final interview for Head Start Program Monitor and was selected for hire along with Ms. Amelia Scott. On or about October 14, 1994,the county decided to eliminate my position effective October 31, 1994,but ultimately changed its mind. Subsequently, I went through a tumultuous negative and dehumanizing experience with the previous Head Start Program Manager and community Services Director resulting in a Federal E.E.O.C.complaint against the county represented by and through the Community Services Department Director and the Head Start Program Manager and settled in 1998. Mr.Tony Colon was hired to replace Daneen Cali; after several interim directors or managers were placed over Head Start including Faye Graef, retired from ACYF Region IX and Scott Tandy, Assistant County Administrator. Finally, Tony Colon was hired'as the Head Start Director, by the county and ultimately became it's Community Services Director after numerous interviews and area competitive examination through a consultant f rrn that also interviewed me for CSD Director. I was contacted by Scott Tandy that the selection on Tony was made and he appreciated the wok that t achieved in far East County, as Ail Area Manager and finally selected through competition which included Stephan Betz for Area Manager, East Grantee Operated Program on or about October 1996. The Area Manager appointment was very controversial, in that, both Scott Tandy and Daneen Cali attempted to block my promotion,even though the initial screening and interviewing committee, which included Darnell Turner and others rated me#I candidate for the position. I was the best candidate then and I am the best candidate to date, given my cumulative knowledge, skills, ability, experience, education and references. I believe that I have served the county well,in that, my responsibilities were expanded to include the consolidation of Central County as part of my responsibilities and renaming East and Central(Delta GOP).(See 1998 Basic Grant) I competed with Tony Colon and others for the position of Community Services Director and was informed that I came in second in a field of originally 18 finalists. I competed for the Head Start Director position but dropped out after Tony Colon had it re-advertised the third time. After I dropped out he selected Pat Stroh. On or about July 1998, I was informed by Tony Colon and Pat Stroh that I was being transferred to Bay Grantee Operated Program,(formerly West GOP)in order for myself,who was Area Manager for Delta Grantee Operated Program and Doris Stephans, Area Manager for Bay Grantee Operated Program,to experience the totality of the program in terms of staffs and communities served. My official date of transfer was August 3, 1998 and my actual office relocation was on or about September 7, 1998. Doris Stephans,(African-American female)and I (African-American male)hold the highest-ranking positions of African-Americans in the Community Services Department. To my knowledge, I am the only African-American male manager in the department. Tony Colon and Pat Stroh knew or should have known that I had an open and previously settled E.E.O.C.Title VII case that was closed during Tony's tenure as Director. When informed by Scott Tandy that Tony was selected for CSD Director, I was satisfied that I was beat by the better candidate, in that, his influence with region brought numerous additional funding to our county. But I will not sit idle while Tony Colon and Pat Stroh attempt to eliminate me from my position and retaliate against me for filing a former complaint of discrimination by subjecting me to harassment/intimidation and differential treatment due to, I believe,my race,religion,sex and political persuasion. I am an American citizen and simply because I may be or think differently, should not be construed as a barrier, but an asset to the depamnent. A meeting was held in Pat Stroh's office at Bisso Lane,Concord and Pat indicated to me and Doris Stephans that our positions of Area Managers had been eliminated from the 1993 grant and that we needed to explore other options. She suggested Education Supervisor and a position called Facilities Operations Manager, which was in the Early Head Start budget. Both of these positions represented demotions. I have worked in Bay GOP since September 1998 and I indicated to Pat Stroh, the Bay Management Team and the Bay Staff that my two initial goals were to clean up funded enrollment and actual enrollment inequities. I believe I have achieved the enrollment goal despite the reorganization, collaboration, consolidation, strategic planning, revisiting the vision/mission statement, and the regulatory problems and management/staff problems associated with integrating Child Development/Head Start Programs. But for Pat Stroh to look me and Doris in the face and tell us that the Area Manager positions no longer existed in the 1999 grant and we should be considering voluntary demotions, when in fact our positions were stilt in the basic grant, well, let me simply say that I do not think that i would be treated as an incompetent docile idiot and devalued/dehumanized, regulated to the status of a nom-person, in this manner, IF I was white/Caucasian. This was and is an insult to me as a person and a manager. On Friday February 19, 1999, 1 spoke with the Head Start Accountant, Vivian Faraquar, and she indicated to me that the position in the 1999 basic grant currently described as Program Manager was formerly in the 1998 basic grant described as the Area Manager. 1 went to white schools, studied both white and universal concepts, passed tests that were structured based on Euro-Centric values and passed basic and academic competencies that are deeply rooted in the Anglo-Saxon value system. if I was born white, all other factors being equal, I would be much further along career wise. I do not believe they would treat a white tnale manager this way. But since Almighty God in his divine providence chase to snake me what I am,who 1 aim.,and how I am, accept me as I am! I would appreciate your expeditious intervention regarding my issues and concerns and prohibitions against retaliation by Tony and pat as a result of this formal written complaint. cc: copy to file RECEIVE,, h April 26, 1999 APR 27 a N}RA STA CO.poen+,........ n.:r To: Contra Costa County Board of Supervisors County Administration Building 651 Pine Street,Room 105 Martinez, CA 94553 c/o Mr. Phil Batchelor, Clerk of the Board of Supervisors From: Mr. Bill J. Forrest / Contra Costa County Head Start Bay Grantee Operated Program 847 B Brookside Drive Richmond, CA 94801 Re: My Government Tort Claim Subj.: Acknowledgement of receipt of your determination regarding my claim and your subsequent board action dated 3/17/99 and affidavit of mailing dated 4/21/99 1 am extremely appreciative of the opportunity to present my Government Tort claim regarding a Breach of the Covenant of Good Faith and Fair Dealing and continuing pain and suffering perpetrated against me by the Community Services.Department and Contra Costa County Head Start. In settlement of my claim I am requesting$1,000,000, which will not compensate for the humiliation, subjugation, repression and oppression that I have suffered at the hands of your department heads. cc: Antonio Larson, Esq. 130 Webster St., Ste. 105 2"d & Webster, .lack London Square Oakland, CA 94612 ` A LU r } Io CLAIM 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 railed 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: Unspecified MAR 18 1999 SEL CLAIMANT:Francisco Ramirez 0AURV AWP: ATTORNEY: DATE RECEIVED: March 17, 1999 ADDRESS: c/o Martinez Detention Facility BY DELIVERY TO CLERK ON: March 17, 1999 901 Court Street - FA/01 March 16, 1999 Martinez, CA 94553--1.700 BY MAIL POSTMARKED: L FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. March I8, 1999 PHIL BA HELOR, Clerk Dated: By: Deputy IL FROM County Counsel TO: Clerk of the Board of Supervisors ( This claire complies substantially with Sections 910 and 910.2. } This claim TAILS 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 claire 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: t Dated: 1 ► By: ��DeputyCounty Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claire was returned as untimely with notice to claimant (Section 911,3). IV. BOARD ORI EFU 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: i `f PHIL BATCHELOR., Clerk, By , Deputy Clerk WARNING (Gov. code section(413) 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 claire. See Government Code Section 945.6. You may s,-.ek 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 NL41 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 Beard Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By: PHIL BATCHELOR. By �. Deputy Clerk CC: Cowry Counsel County Administrator NOtICE OF CLAIM.AGAINST THE COUNTY-OF CONTRA _ (Governraent-Code. ss 910 92:0.2) „ Return to Countycl.erk's Office 651 Pine Street Martinez, CA 94553 K90A OF R , Phone Number: CLAIMANT NAME: F -12 C i . .. t 2 1 Y CLAIMANT'S ADDRESS: ; ' t .'<t ' 4--� - , « Number Stet City State - Zip Code NAME AND�ADDRESS'"OF PERSON. Tt7`=.WHIM NOTICES' REGARDING THIS CLAIM SHUULL}' BE SENT (if different than "above) DATE OF THE ACCIDENT OR, OCCURENCEs , -- �'.. �� 1( PLACE OF. THE, ACCIDENT OR OCCURENCE: GENERAL: DESCRIPTION .OF-- THE.ACCIDENT OR.00CURENCE'(attach additional pages if more space is needed) • � '" _ , .....Q`•. . . sag,,,,.. Y k'?.t YYNA 11 NAMES, IF KNOWN,' ''6F 'ANY PUBLIC EMPLOYEES `CAyU(SZNGg�THE1 y1HJURY yOR LOSS:` h.: My �- may"^ - Q Y, Tin p .i.}.• i }'.�vj <'h{ r. a is 7u 'i mo--,y $,c.;. R �+f c eGt -9'b �f_ :C: 0:4 .i. T.. L. AMES AND ADDRESS OF WITNESSES: NAME ADDRESS TELEPHONE NAME AND ADDRESS OF DOCT6RS; HOSPITALS WHERE TREATED: NAME ADDRESS TELEPHONE o GENERAL DESCRIPTION pF 'THE LOSS; INJURY OR DAMGAGE SUFFERED: �°�� . .............. L+ AMOUNT CLA11 BASIS OF COMPUTING THE TOTAL AMOUNT CLAIMED IS AS FOLLOWS: Damages .incurred to date. ;Medical .Expenses.'. Loss ;of .tair iings: $ Special damages ".:far: {Attach cop es " f available} : . the undersigned', declare .0 nder,..penalty, of:perjury that :I/we :have I the foregci ng .c1a3 m_ ,for :`dari�ages'..and know the -contents -'thereof.,:,that s ame<: is ..true :of myjour °own -knowledge.,and belief',- save and :except. as :;hose matters :wherein stated ,on information and belief, "and` as to n, T/we "believe it ;to be true. , .. ZD. S gnature of Claimant(s) w eived at County -Clerk's _:office this day of ` r` 19,98.= ' --signature'-'.... t, s sr .y CLAIMS RELATEA.:TO 'INJURY-Ta ,PERSON ©R*. PERSONAL FNC?PERTy, lS FtII�M s T BE FILED WITH THE %C:o.:',Cc . Corm w;WITHIN ;,1 a- days ". FRt7M THE b :RUAL bF THE -CAUSE.'OF..ACTION. -A 'CLAIM .RELATED -TO:,ANY OTHER .CAUSE PION `SHALL SE ;PRESENTED .NO LATER THAN ONE, YEAR AFTER* ACCRUAL" bjF`.THE ;JSE OFACTION... _. _.._... ......... _._...._. _._.._... . . ._. .._.._...._....._ ...._....._........... ........ ..... __ ............................U� -------Y,... ...... ......... ..k v ...f. ��vl t ..'. '�Y............. .. .. ..... N �'!. Yl': :!'+ ..'f -A ^{A....... ......... .. /°+ : ✓iw;.+�o""�k)'c..k,d"xew j'x`..`��""°+a'llt: ,y. a c9°'"�f} ��, -/c, W Z'A . � r < A. �. ..................... y ............... ......... ........... t ... ...- ............. ......... .. ? € __.-_.__. ........... .......... .................. ........:. ..L6A' ...i':. ,. y�;.L. i..:.:. .............................................................. -......_ ......... ..-_.. ......_..... - 3•. . ......... ..... ......... .....--.. ......... .. ....... ..... ....--..-.. .......... ... .. .... .... .......... ......... .............. .. :.. ....... e ......... .......-. ........- ... .....--.. ----: ------ b .:...-........................................... '6............................. .. ... .. ................................... ........ ...... ......... ........ ............ .... .... .- .. ....... . fid:. '� :. ..:.-.._ ..... ..... i� ...�pny �n w ... 4a `i a s $ Lmy? °c to .___... ......... ..... ......... ......... a•""". .... ?._. ------ f 'y;w :`.a.. ... .... .?t�. Qa. .. _......._...... ...... .... ........ .:,uk,.-..-.-- .y� 2 � :� 4 M/� y� ......... ......... .....--.. ... -S K A�: 4 :-..:- 3`.: .......... .. v.� kys,... ... h;s: .......... x _......_ ........._ _. . { . ... ,), _ t ..... ................. ........ ...........t ..........g --- .. .' � � . �. ::. �..: ::.... _ :. �.... ..... 6 rn 61 w : - 41sn� >.. _ If :. •mow" )'9 aaa K ..✓' 't,,,.. h y uvea �P { r LAt Nwol rl ,W, Cop f CLAIM t10ARD OF SITERYLSOM OF CONTRA COSTA CALEFORMA lJ AC'I O E April 20, 1999 Claim Against the County, €r District Governed by � the Board of Supervisors Routing Ursa rents, } NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this dt.Ll mt mailed to you is your California Governrrent Codes. l not ce of the action taken on your claim by the Board of Supervisors. (Paragraph IV beloY4, given pursuant to Governmient Code Section 913 and 3, ZE3) 915.4, 'lease note all "Wernings". AMOUNT: Unspecified MAR 18 1999 COUNTY COUNSEL CLAIMANT:Francisco Ramirez MARTINEZ CALIF. ATTORNEY: DATE RECEIVED: larch 17, 1999 ADDRESS: c/o Martinez Detention Facility BY DELIVERY TO CLERK. ON: March 17, 1999 901 Covet Street -- FA/01 March 16 1999 Martinez, CA }4553-•1700 BY MAIL POSTMARKED: s L FROM- Clerk of the Board of Supervisors TO.- County Counsel Attachedis a copy of the above-noted claim.. March 18, 1999 PHIL BA HELOR, Clerk Dated: By: Deputy o. IL FRONT: County Counsel M. 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 noiv; 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 ,c; t warn_ c claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: on Dated:*��R 611 By: Deputy County Counsel M. FROA2 Clerk ofthe Board T0.- County Counsel (1) County Administrator (2) ) Claim was returned as untimely with notice to claimant (Section 911.3). TV. 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 daft. Dated: 6ti PML BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 13) ,object to certain exceptions, you leave only six (6) months from the date this notice was personally served or deposited a the mail to file a court action on this claim. See Government Code Section 945.5. You may sftk the advice of an ttorney of your choice in connection with this matter. If you want to consult an itftorney, you should do so nmediately. *For Additional Warning See Reverse Side of This Notice. AFFiDAvffmiGOF MA-21 declare ander penalty,of perjury that I am now, and at all times her ;in ment;oned, have been a citizen of the United tates, over age 18; and that today I deposited in the United Ste-es Postal Service in Martinez, ialifomia, postage fully repaid a certified copy of this Board Order and Notice to t'='taimant, addressed to the claimant as khown above. ated: ~ By: PHIL BAT`CHEIR By Deputy C rk -Comty CWMI County Aftinistrat'Ot a ` This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa docs not waive any of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act. NOTICE OF CLAIM.AGAINST THE COUNTY�OF CONTRA (Government_Code` sss 9X0, 910.21 ' ' RE Return to. .. CountYClerk'a Office 651 Pine Street Martinez, CA 94553CI.ERKSOARDOF,SU;!ERVISORS < CON a�r Phone Number; / CLAIMANT NAME: CLAIMANT'S ADDRESS: .. , Number St' e _ : 'City State ! Zip Code NAME AND'ADDRESS' OF` PERSON _TO'�WHOM NOTICES' REGARDING °THIS CLAIM SHt3ULb" $E, SENT (if different than-'above)-i ` =1 ' ``F.• . #� DATE OF THE ACCIDENT OR OCCURENCE. .` J: PLACE .OF THE ACCIDENT OR UccURENCE " r " + +� ..0 _ry GENERAL 4DESCRIPTION. OF--THE:.ACCIDENT OR O.CCURENCE-(attach additional pages if more space is needed) : - # . _ . ,. . r ' # NAMES, IF KNOWN, ;OF °:ANY PUSLZd'EMPIAYEES `CAUSING THE INJURY OR WSS:"' (4 AXES ANI! ADDRESS OF WN NESSES SCJ NAME ADDRESS TELEPHONE 20 c-t , - . NAME AND ADDRESS OF. DOCTORS, HOSPITALS WHERE TREATED: NAME ADDRESS TELEPHONE 1. .�.„ .. 2. .. GENERAL DESCRIPTION OF 'THE LOSS f INJURY OR DAMGAGE SUFFERED; Low _ 14 I C- ' C. 14" 1. L� -11 t N AMOUNT C'LAIMFif3•,µ, .SIS OF. COMPUTING THE. TOTAL AMOUNT CLAIMED IS AS FOLLOWS: . Damages Incurred to mate: ; Medical Expansesi:. $ Loss of Earnings: Special 'damages :for: {Attach cop es f available) the undercignd, declare under .penalty: of :perury`:that xJwe have the fo'regaing clafro. far"dari a+ges:rnzid knc4 .t'�ie contents thereof, '.:that axe' is ..true of-rdn /6ui�o�wh -know-Iedge. and belief,:. save karic'l::except as . :ose. ett rs wherein: etated -,cn :�informition, and :belief, ;'and "aa to I Jwe:believe :'fit .to be trues _ S gnature of Cla mant V ., v � r .f f "y`.a _ ' �1.}i ZIT=�,y.,� •w„ f �vedt , Clerks s 'Officeay o 7 -1938 S i - .• ;...Y x. '_r.r• A ice' t'3r i.r rts,,...r• „{, w. v w '«... w-» awr*.. .>-. • -f.S.,r..,.r: sr ,� r .•r2 lNiti s+.}+kA'.+. .. •i �.. t } ♦ 1 , , Y .._� r t • ' ". ' �' gnatu�'e _. ^'w .,,.I-!vim' s ...... ... v.\., • •.t r —+* r- '-r ° ' r-' . i. +}. � M+-'$i.'+'L.b. �L Y+°'4i;'.... +x td+Y 4.f+- +•F !-L.tt Y .fw ,4•'W+r. �j.Y•p` � 1 a y +,i E,,'1 f ♦ 'r.L k 'F' C v.' t t ACktry CLAIMS tELAZ'ED !TO INJURY TOS PERSON OR•�PERSONAL PROPERTY, _.THTLS.40RM wt ' :BE fLEt WIT`H.`:fiHE'� c►. `;Ccs. ,'County WITHIN r,18b Days . `PROM .' FiE :UAL .OF THE ''CAUSE-'OF..*ACTION. A' -CLAYM ..R.ELATED..T&1 - Y.•-OTHER 1 CAUSE ..0 ' t :ON :ISHALL BE,*PR ESEN'TED •NO .LATER :.THAN:•.ONE, YEAR AFTER'ACCRUAL`)OFi :THE 3E 'OFACTION. - • . ". Al r O�n�-t Y ° - J, RIO . e, t16� = _.C __. ..... Ic -4 VA C3 .. - -' -\OA P 6 p cz. p., r . -- � —� �P_ All h ri i i RUN DATE: 03/09/99 Merrithew Memorial Pharmacy *LIVE* PAGE 1 RUN" TIME: 1244 PHARMACY MONOGRAPH AIt3NrTE r;FrtANCISCO AU'�NTIN 5.at}MO .�; TAHL�TS GENERIC NAME: AMOXICILLIN (a-mox-i-SILL-in) and CLAVULANATE (klav-yoo-LAN-ate) COMMON USES: This medicine is a penicillin antibiotic used to treat bacterial infections. HOW TO USE THIS MEDICINE: Follow the directions for using this medicine provided by your doctor. THIS MEDICINE MAY BE TAKEN WITH FOOD if it upsets your stomach. STORE THIS MEDICINE at room temperature, away from heat and light. TO CLEAR UP YOUR INFECTION COMPLETELY, continue taking this medicine for the full course of treatment even if you feel better in a few days. Do not miss any doses. IF YOU MISS A DOSE OF THIS MEDICINE, take it as soon as possible. If it is almost time for your neat dose, skip the missed dose and go back to your regular dosing schedule. Do not take 2 doses at once. CAUTIONS: DO NOT TAKE THIS MEDICINE IF YOU HAVE HAD A SEVERE ALLERGIC REACTION to a penicillin antibiotic (sugh as amoxicillin, ampicillin) or a cephalosporin antibiotic (such as Ceclor,(KefTgth Ceftin, Duricef) . A severe reaction includes a severe rash, hives, breath ficulties, or dizziness. If you have a question about whether you are allergic to this medicine, contact your doctor or pharmacist. IF MODERATE TO SEVERE DIARRHEA OCCURS during or after treatment with this medicine, check with your doctor or pharmacist. Do not treat it with non -prescription (aver-the-counter) medicines. IF YOU EXPERIENCE difficulty breathing or tightness of chest; swelling of eyelids, face, or lips; or develop a rash or hives, tell your doctor immediately. Do not take any more of this medicine unless your doctor tells you to do so. FOR WOMEN TAILING BIRTH CONTROL PILLS, this medicine may decrease the effectiveness of your birth control pill. To prevent pregnancy, use an additional form of birth control. IF YOU HAVE DIABETES MELLITUS, this medicine may cause false test results with some urine glucase tests. Check with your doctor before you adjust the dose of your diabetes medicine or change your diet. POSSIBLE SIDE EFFECTS: SIDE EFFECTS, that may go away during treatment, ,include nausea., vomiting, or mild diarrhea. if they continue or are bothersome, check with your doctor. CHECK WITH YOUR DOCTOR AS SOON AS POSSIBLE if you experience a skin rash, hives, or vaginal irritation or discharge. if you notice other effects not listed above, contact your doctor, nurse, or pharmacist. Copyright 1999 Medi-Span, Inc. All rights reserved. Information Expires APR 1999 2 1 w w l ...a r a iu C-11 a o t�.x rrn ter G� w t . a ♦b v /�n X Eby✓ f CLAIM . . A April 26, 1999` 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 Goverment Code Section 913 and MAR 1 915.4. Lease nate all "Mmings". AMOUNT: In Excess of $25,000.00 COUNTY COUNSEL MARTINEZ CALIF. CLAIMANT: Trudie Rogers ATTORNEY: DATE RECETVED: March 18, 1999 ADDRESS: P. 0. Box 4646 BY DELIVERY TO CLERK. ON: March 18, 1999 Antioch, CA 94531 BY MAIL POSTMARKED: Interoffice Mail L FROM: Clerk of the Board of Supervisors 'TCM County Counsel Attached is a copy of the above-noted claim. March 19, 1999 PHIL BA ; OR, C Dated: By: Deputy EL FROM: County Counsel TO: Clerk of the Board of Supervis rs { ) 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 clays (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: 'jI� .L $y= 4h eputy County Counsel r IIL FROM: Clerk of the Board TO: ' my 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 ie. —, Deputy Clerk WARNING (Gov. code secti 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 M,AEUNG 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 Berard Order and Notice to Claimant, addressed to the claimant as shown above. Dated: By: PHIL BATCHELOR By Deputy Clerk CC: County Counsel County Administrator ARH 15-1999 0e:01 P.03/04 lttLss trudie rogem RECEIVED PO Bat: 461E - Antioch CA 94531 FEB fly 4999 SOCIAL SERVICE ANTIOCH M.a WCIA Petsmue,d of Me Pen of a ready Writer. Psat 45:1 CLAIM FOR DAMAGES AGAINST STATE OF CAUFORNIA DEPAR1'tuM OF SOCIAL SEMCES CoNmA CosTA Cotmy SocEAL SERVICE DEPARTMENT (un&r separatc cover) Per Govt.Code If 900; 905; 906 ; 910-910.2 ; 911.2 ; 91 L6; 915-915.2 F ELOISE ANDERSON RE .RIED D;rtxtor, state of Cad famb MAR 18 1999 Department of SocW Services 744 ".�" � - MS 17-11 CLERK BOARD Of SUPERVISORS Sa�Menth CA 95814 Calor A CosrA �. 916-65"1-255E eco / via JOHN D. CUULEN, Dire Contra Costa County Social Sarvke Depsrtttteat 40 Douglas Drive Martinez CA 94$53 S10-313-1579/77; 510-313-1575 (f*4 Director Anderson; I Vu&rogers 'dw cWtal, nu&:Cram this day Febmq 3,IM prior to filing a Compkira for Damagas ire a Court of taw. The tot d natoum of my claim is within the juri4etion of the FQdeW su&or Superior Court (star than$2S,000). The addm to which ah notices ace to be seat is P O Box 4546 Antioch CA 94531. Tbie dates of my loss indude T#u achy Ab18ttst 13, 1998=d on going; Friday AuguA X4,1998 and ole-gcwng; Monday August 17,1998 through to am pm9m and aill on-ping. The)6om of the ions T have suffered is within the County of Contra Costa and inclnrlus the city of Antioch. - Ite nmral persons and fiodtiously--named entities who have caused my iAjurks and damages and losses include John B.OWka,dire for of tha Contra Costa County Social SeMte D*st=t; the Contra Costa COUX4 Social Service Dqx dment; the Contra Costa County Board of Supervisors; Stare of Califbmia DVartment of Social Services ; ` mod Maharaj,supervisor; T. Becerra,public service officer, K Barrow,public service officer; Gail Gwaltney,eligibility wod=; Fmuu es Kelly,eligibility woricrr; and Dots l through 50,inclusive. Now Co, HE write it ba Foca thacm is a Whk, -d twtc it is a$tuft that it may be fir th&t me to eoerm CRIQl: par ever tab evm. taaia!<J099 N E vV S R E L E A S E — _ Hcmeless Daughter of retired U. S. Army Veteran denied Fuad Stamps a j; Aft!!xch Galffa^nla - rwuary5, 19.99 _ - Tlae homeless daughter of a retired U. S. Army WWII vctcaun filed and 1 stivCrl a Claim br.Dmnages against the Contra Costa County&California State Social Service r),_?artmenm Earned were 3 1 several resppotdenta=secluding county director John 8, Cull=,two police oi�icers,two eligibility workers,azaci a supervisor. When miss tmdie svgcrs became homeless last year on her birthday she applied the next day for emergency food stamps and housing aid at the Antioch welfare office,as well as for general assistance and the ane-time-only Voucher program. She was informed that emergency housing aid and the Voucher program are"only for people with children." miss rogers has re mainod childless, by choice_ She consider this restrictive policy"blatantly discriminatory !" # Denied She was subsequently told by eligibility workers that she is ineligible for anything at all until she proves l that she is a citizen of the U>hi d States. She was instructtd to go to the '11tit5 crud YA" miss rogers has never beers or reported l! to either one of these age ncze:s and has neither the financial resour=nor the whero-with-all to pursue the endless mouths I of time which this obvious wild goose chase would entail. She states unequivocally that she is indeed a U.S.citizen. muss rogers shay be s:t#1t1t.*tx �'� t? 'Deaahly' Afraid She has found sporadic`housing' by sleeping isbusimes=before opening&aftear closing,as well as est peoples'sofis and outside on backyard-lawn chaits. miss rogers remains homeless and destitute,fearing even more for her safety and that she shall amain soon be`sleeping'outdoors"in this small Fast Contra Casts County community whesz a madman has serially killed four woman -all of whose were walking alone- dozing the past three months; a fift1z woman was bosphalized beaten so severely she remained comatose and unable to speak fora month," miss rogers susspacts their attacker behaved these to be homeless. She has no car'and has been drench often lu this winter's fretxind rains She lar3cs the ability or resources to coat money practicing her regular profession,which is to prep=papers for people- Homeless '& Destitute "My natural and biological father —who was bora in Virginia- fought in World War It and served this country in Korea,in order to unsure that these bearefits would be available for me. 1 was conceived and barnin 4 Stuttgart Germany whEle Daddy was stationed there as a Sargeant,"the dirninuadvolady softly yet pesuaslvely sea es, "He brought we to this country. Dodcly retired honorably after more than twenty years service. What is happcniag is horribly wrong and is a disgrace to his memory," In Pro Per mtu rogers rescmrled,composed,typed and frled ail the documents herself'In Pro Per.' She says a lawsuit ( Camplaznr yr Damages ) is forthcoming,pending the County Board of Supervisors'routine Denial -after 45 clays- of her C'taim jbr Dwwges. She is desperately seeking an attorney to represent her in these matte:m Site believes she is but one member of class of tens-cif-thousands of single childless women in need who have baa tit aced in this "shamefully uncaring manner." HumilWon I myselfweirked as a civilian far several ye2rs at various Naval stations throughout nortbem California during the Vxetra=conflict, X cannot believe this is even happening,"la zz ats nays rogers. Harassment On her zlW visit to the Antioch social service office,sho was summarily ordered to leave the premises by two large male,co"public service officers' in dark blue uniforms. Site has not returned. She is of ASrican faesitage and weighs about a hundred pounds, Approximately two percent of the city of Antioch's population is Afxicam, # As a result,miss rogers has suffered an extreme,deep,and lingering depression. "I`ve lost weight,have not carted about my appearauce,been horribly hues iiliaied,am spiritually broken,feel utterly destroyed. The respondents'contempt for single women without cbildtt~n has literally rendered me a woman without identity or country,"she dejectedly adds. Civil Rights Violaforts miss rogers picks up her narrative, "1 have been subjected to grevious anguish and totally needless pain and suffering and hardship. The conduct of the staff and employees at the welfare department has been outrageously cruel,despicable and m4cious,with no regard whatsoever far my rights,my health,my safety." t ""2 he motto hanging in the wciftxre office waitjng mora -to treat clients with respect,dignity and fairness- is a joke!" She r onteuds in her court papers that the respondents,by their actions (and inactions) displayed no semblance of compassion or humility or kinduess or any other virtue. rnis., rogers,insists their acts (and failurees to act) arecontrary TO fcxSeral end szYt.-law,is in violation of h civil rights, xnd is base upon l;crr racy,color,rwioxxal origin,gender,age,and t}n ta<r rilipious.3rsci Ixalittcjl b Aiefs. "lt is in a:front to single childless women acid the leg sl wattrs roust`�e te:tc d°" DEPUTIES: VICTOR J.WESTMAN PHILLIP S.ALTHOFF COUNTY COUNSEL JANICE L.AMENTA NORA G.BARLOW B.REBECCA BYRNES ANDREA W.CASSIDY SILVANO B.MARCHESICONTRA COSTA COUNTY MONIKAL.COOPER CH IEF ASSISTANT COUNTY COUNSEL VICKIE L.DAWES OFFICE OFTHE COUNTY COUNSEL MARK ES. FARR SHARON L.ANDERSON COUNTY ADMINISTRATION BUILDING LILLIAN T.FUJII ASSISTANT COUNTY COUNSEL 651 PINE STREET 9th FLOOR J N Tis HOLMES$ GREGORY C.HARVEY MARTINEZ, CALIFORNIA 94553-1228 KEVIN KERR BERNARD L.KNAPP ASSISTANT COUNTY COUNSEL EDWARD V.LANE.JR. BEATRICE LiU MARY ANN MASON GAYLE MUGGLI PAUL R.MUNIZ VALERIE J.RANCHE OFFICE MANAGER STEVEN P.RETTIG DAVID F SCHMIDT PHONE 925 335-1800 DIANA RSILVER ( ) BARBARA N.SUTLIFFE FAX(925)646-1078 JACQUELINE Y.WOODS NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Trudie Rogers P.Q. Box 4646 Antioch, CA 94531 RE: CLAIM OF: Trudie Rogers Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ ] L The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [ ] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ 15. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [XX] 6. The claim is not signed by the claimant or by some person on his behalf. Page 1 [XX] 7. Other: The claim fails to describe any duty or obligation of the public entity and any action giving rise to the claim. VICTOR J. WESTMAN, County Counsel By:A& l D puty County ounsel CER11FICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 1013x,2015.5;Evidence Code§§641,664) I declare that my business address is the County Counsel's Office of Contra Costa County,651 Pine Street,Martinez,California 94553;1 am a citizen of the United States,over 18 years of age,employed in Contra Costa County,and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Dated: March 23, 1999,at Martinez,California. cc: Clerk of the Board of Supervisors(original) ° Risk Management (NOTICE OF WSLTFICIENCY OF CLAIM:GOVT.CODE§§910,910.2,920.4,910.8) Page 2 CLAIM = AM April 20, 1999 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: $316.00 MAR 19 WJ CLAIMANT: Ravinder Sawhney 00� Ty C00"A IF, MAl�"rUNEZ A!»1F. ATTORNEY: BATE RECEIVED: March 18, 1999 ADDRESS: 3221 Ravenglas Court BY DELIVERY TO CLERK ON: March 182 1999 Walnut Creek, CA 94598 BY MAIL POSTMARKED: Interoffice L FROM: Clerk of the Board of Supervisors 'I`Q: County Counsel Attached is a copy of the above noted claim. PHIL BATPIJELO& Clerk Dated: March 19, 1999 By: Deputy L, �-�—•--� IL FROM: County Counsel TO: Clerk of the Board of Superviso s I ( This claim complies substantially with Sections 910 and 910.2. ^ { } This claim PAILS 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 claire 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: eputy County Counsel j , f Illi. FROIYI: Clerk of the Board aunty 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: PML BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code sectio 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. AFFIDAvtT OF MAIJIG 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:&mak 1 /q11 By: PHIL BATCHELOR B5QCKSn�)&JAI,Deputy Clerk CC: County Counsel County Administrator 11........................................................................................................................... ................I.......... ....................................... ..... ............ .. .. ........ . ......... Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT 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 10e 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 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 form. RE: Claim by Reserved for Clerk's Filing Stamp Irlfi� 4 Ra0A-1V\1U S4-,WkyXq--J 01qe7-CP1- RECEIVED Against the County of Contra Costa MAR 1,8 1999 or CD UPE CLERK BOARD OF SWon District (Fill in Name) The undersigned claimant hereby makes claim against the County of Contra Costa the above`-famed District in the sum of S 1 and in support of this claim represents as follows:4=1 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) - ------------------ /- ----------------------- 11 3. How did the damage.or injury occur? (Give full details;use extra paper If required) T14� ----0�t---�0-. , a_ ----------------------------- - --- ---------------------------- 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? S (Over) 5. What are the names of county or district officers,sealants,or employees causing the damage or injury? -- ------------------- -t-------------- ---- -r 1• e -- ----------------- 6. What damages or injuries do You claim resulted? (Give full extent of injuries or damages claimed. Attach two auto damage.) ---- A e ------ ---------------------- 7. How was the above claimed amount computed" (Include the estimated amount of any prospective injury or damage.) ----- 2)-—a ----------------------------------------------------------------- 8. Names and addresses of witnesses,doctors,and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE PfEM AMOUNT Gov.Code Sec.910.2 provides: "The clai.irn must be signed by the claimant SENT)NOTICES TO: (Attorney) or by some.person:on his behalf." Name and Address of Attorney { laimant's signature) (Address) Telephone No. Telephone No. 9 NOTICE Section 72 of the Penal Code provides. "Every person who,with intent to defraud,presents for allowance or for payment to any state board or officer,or to any county,city or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account,voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand dollars (S1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fide of not exceeding ten thousand dollars{S10,000), or by both such imprisonment and fine. AMR4D D 2�3 CLAIM BOARD DE SI Fit SORS DE CMIRA COSTA C"QUNTY, CAIBRNIA HWD ACTlL3flE April 20, 1999 Claim Against the County, or District Governed by } the Board of Supervisors, Routing Endorsements, } NOTICE TO CLAIMANT and Board Actions. All Section references are to } The copy of this docurnent mailed to you is your California Goverment Codes. } notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given pursuant to Governrnent Code Section 913 and 915A. Please note all "Warnings". AMOUNT: $2,000,000.00 MAR 3 1 CLAIMANT: Lori J. Coffey COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: DATE RECEIVED: March 29, 1999 ADDRESS: 230 Buckley St. , #B BY DELIVERY TO CLERK ON: March 29, 1999 Martinez, CA 94553 Hand-delivered BY MAIL POSTMARKED: L FROM: Clerk of the Board of Supervisors 70. County Counsel Attached is a copy of the above-noted claim. Dated: March 31, 1999 PHIL B CHIrLOR, Clem By: Deputy II. FROM: County 'Counsel TO: Clerk of the Board of Supe sons ( '} This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days(Section 910.$). ( ) 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: Dated: By: uty County Counsel III. FROM Clerk of the Board T� liounty Counsel (1) County Administrator (2) ( } Claim was returned as untimely with notice to claimant (Section 911.3). IV, BOAIW ORDIIL• 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: ►j per, BATCHELOR, Clerk, By , Deputy Clerk 41 to, WARNING (Gov. code section 13) 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. AFFIDDAVTT OF MARMiG 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 ByQq6,2Deputy Clerk 41 CC: County Coulisel County Administrator f Ct.a s .ot SOMW OF #VPPLRVISORS OF CONTRA COSTA COMITY RI'e-nde ! c..Iar'►?� 1k. 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 911.2.) a. Claims must be filed with the Clerk of the board of Supervisors at its office in Room 105, County Administration Building, 651 Pine Street, Kartin*z, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the game of the District should bs filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. rrAud, 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 the County of Contra Costa) � � or } } CLMR MRFKI s District) Care►COSTA . (Fill in name) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of ScbCC and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) /9 2 5 - :zLrJa V 2. Whir* did the damage or injury occur? (Incl de city and county) r� 3. Now did the damage or injury occur? (Give full details use extra Paper if r quired) V I� �(Arr�tu'yac) SLIC.\L 4. What particular act or omission on the part of county o4 district officers, servants or employees caused the injury or damage' Py �, ,�`� ace-- (-MV(% C.. 'rck cQ� c� -- " P IDlee g over) . what are the names of county or district officers, servants or employees causing the damage or injury? C); -M- n c/ CL: --J -Z --� r-) 6. What damage or i uritis do you claim resulted? (Give full extent of injuries or d ages claimed« a tach two estimates for auto damage.) e' o4 i ce 1'5 oame-d rb oue'r J . Doo, 0c)o ' 0 7. Nov was the amount Claimed above computed? (Include the estimated azount of any prospective injury or daam�age.) �� ;� rr �g eco\ AO.Masp'15 S. Names and addressIs" of witnesses, doctors and hospitals. 9. List the expenditures you &ade on account of this accident or injury. nom n ��...:,r.�+�..:�s.•��::,��,e��s��:��►,��.�..t•�.•.:,t,t�t+s.�►,r,�tt.,ts:�a.,t�.�� } Gov. Code Sec. 910.2 provides } "The claim must be signed by the } claimant or by some person on his rgENZ NOTICES- TO: " Name and Address of Attorney } -r- } �.„OV N �}r Y } (Cl ant's ature) ST � ( zui Z , c- `-/655 3 (Addre s) Telephone No.1, ~.,t J.�,.. .} 'Telephone r�,err":rr�"�+r�,��s#r��rs�",r�+�*��rs+��#�,�t��ss�+��r+�+�t:�r��r��#�►��►,�r��s+�#,�� XoTXCN Section 72 of the Penal Code provides; Rvery 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 wore than one year, b�y a fins of not exceeding one thousand ($1,100) , or by both such imprisonment and fine, or by imprisonment in the state prison, by a fins of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. CLAIM BOARD Af1t A Il 24, Claim Against the County, or District Governed by } the Board of Supervisors, Routing Endorsements, NOTICE TO CLAIMANT and Board Actio. All Section references are to } The copy of this doccirnent mailed to you is your California Government Codes. } notice of the action taken on your claim by the Cllr?} Board of Supervisors. (Paragraph IV beloO, given pursuant to Government Cade Section 913 and MAR 2 5 1999 915.4. Please note all "Warnings". AMOUNT: $2,000,000.00 SAF t'tY COUNSEL CLAIMANT: LoriJ. Coffey ATTORNEY: DATE RECEIVED: March 24, 1999 ADDRESS: 230 Buckley St. , #B BY DELIVERY TO CLERK ON: March 24, 1999 Martinez, CA 94553 BY MAIL POSTMARKED: IT L FRt)ft Clerk of the Board of Supervisors M. County Counsel Attached is a copy of the above-noted claim. PHIL Cler Dated: MarQh 24, 1999 By: Deputy r IL 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 clays (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: < County Counsel III. FROM- Clerk of the Board TQ: { my Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDEFL 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 (b) 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. AFMA IT OF MAIMG 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 Deputy Clerk CC: County Counsel County Administrator VICTOR J.WESTMAN DEPUTIES: HILLIP COUNTY COUNSEL JANICE L.AMENTTAF NORA G.BARLOW B.REBECCA BYRNES SILVANO B.MARCHES/ DY CONTRA COSTA COUNTY ANDREA .COOPW. R CH IEF ASSISTANT COUNTY COUNSEL MONI=A L.COOPER OFFICE OFTNE COUNTY COUNSEL VICKI S.ESTIS MARKE S.ESTIS SHARON L.ANQERS©NMICHAEL D COU#3TY-ADMiNISTRATIONBUILDING LILLIAN TFUJIII ASSISTANT COUNTY COUNSEL 651 PINE STREET,9th,F'LOOR; DENNIS C.GRAVES JANET L.HOLMES GREGORY C.HARVEY MARTINEZ,CALIFORNIA 94553.1229 KEVIN KERR BERNARD L.KNAPP ASSISTANT COUNTY COUNSEL EDWARD V.LANE,JR. BEATRICE LIU MARY ANN MASON GAYLE MUGGLI AUL R.MUNIZ OFFICE MANAGER VALERIE J.RANCHE STEVEN P.RETTIG DAVID F SCHMIDT PHONE(925)335-1800 DIANA J.SILVER FAX(925)646-1078 BARBARA N.SUTLIFFE JACQUELINE Y.WOODS NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Lori J. Coffey 230 Buckley Street, #B Martinez, CA 94553 RE: CLAIM OF: Lori J. Coffey Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [ D. The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [X] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [X] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10,000), the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [ ] 6. The claim is not signed by the claimant or by some person on his behalf Page 1 [X]-7. Other: The claim fails to describe any duty or obligation of the public entity and any action giving rise to the claim. VICTOR J. WESTMAN, County Counsel By: mp, puty County o nsel V C TIFIC TE O SERVICE E BY MAU (C.C.P. §§ 1012, 1013a,2015.5;Evidence Code§§641,664) 1 declare that my business address is the County Counsel's Office of Contra Costa County,651 Pine Street,Martinez,California 94553;I am a citizen of the United States,over iS years of age,employed in Contra Costa County,and not a party to this action I served a true cops=of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above,sealed and postage fully prepaid thereon,and thereafter was,deposited this day in the U.S.Mail at Martinez,California. I certify under penalty of perjury that the foregoing is true and correct. Dated: March 26, 1999,at Martinez,California. 4y,( f r t/ cc: Clerk of the Board of Supervisors(original) ! Risk Management (NOTICE OF INSUFFICIENCY OF CLARvi:GOVT.CODE§§910,920.2,920.4,910.8) Page 2 Clair[ tot BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCT NS TO CLUXANT 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 911.2. ) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By Reserved for Clerk's filing stamp Against the County of Contra Costa) or District) CLERK (Fill in name) ) CO�LTAA ) n� The undersigned claimant hereby makes claim against th County of Contra Costa or the above-named District in the sum of $ ,C)04 and in support of this claim represents as follows: I. When did the damage or injury occur? (Give exact date and hour) Q 0 Am, 2. Wherk did the damage or injury occur? (Include city and county) i 6u w 41, CC)ara QOSTQ 3. How did the amage or injury occur? (Give full detail ; use extra paper if required) hn:�a_ ToVice- r!�iporT- ocT> ck 4,1c, 4. What particular act or emissUal ion on the p rt of county or district 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 lama a or injuries do you claim /resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 7. Ho was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage. ) 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury.DATE TIME &MMUT } Gov. Cade Sec. 910.2 provides } "The claim must be signed by the } claimant or by some person on his + k1 Name and Address of Attorney ) ... , } (C 'many's natures) �5t It E, lit r` < } ( ddress) cj yi > 67 Telephone No. } Telephone No.�2 .o=�.u'� 1_ �**�r�r��r�>k,��,��r��#>wr��r,��+��,��>w►��#��>k,��a�,��r�r**r��r�+��r�r�r*�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 ($>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 ($10,0300, or by both such imprisonment and fine.