HomeMy WebLinkAboutMINUTES - 03062001 - C.15 CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
4 BOARQ AC110N: MARCH 6, 2001
Claim Against the County, or District Governed by 1
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".
FEB 0 5 2009
AMOUNT: $100,000.00 COUNTY COUNSEL
CLAIMANT: EDNA DELORISE HILL MARTINEZ CALIF.
ATTORNEY: DATE RECEIVED: JANUARY 31, 2001
ADDRESS: 1459 SEMINARY, APT. A BY DELIVERY TO CLERK ON: JANUARY 31, 2001
OAKLAND CA 94621
BY MAIL POSTMARKED: HAND-DELIVERED
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim..
PHIL BATCHELOR, Clerk
Dated: By:5, 2001 By: Deputy Dw�
II. FROIVL• County Counsel TO: Clerk of the Board of Su ervisors
( his claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: Z/ e�_l 6 f By: C=::6 ��,—Deputy. County Counsel
M. FROIVL• Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order ntered ' its minute for this date.
Dated: JOHN SWEETEN Clerk, By , Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited
in the snail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection 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 MAIIdNG
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United
States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully
prepaid a certified copy of this Board Order and Notice to Claiman addres&ed to themant as shown above.
Dated: By: JOHN SWEETEN- By , X;a . Deputy Clerk
CC: County Counsel County Administrator
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. does 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.
' 1 2001
JAN 3
CLAIM -GOVERNMENT CODE §910
CLERK BOARD
TRAMCC).
CCOISORS
CN
CLAIM AGAINST: The Contra Costa County Sheriff's Department and Contra Costa County
CLAIMANT'S NAME: Edna Delorise Hill
CLAIMANT'S ADDRESS: 1459 Seminary, Apt. A, Oakland, CA 94621
CLAIMANT'S PHONE NUMBER: (510)568-0219
AMOUNT OF CLAIM: $100,000.00
ADDRESS TO WHICH NOTICES ARE TO BE SENT: 1459 Seminary, Apt. A, Oakland, CA 94621
DATE OF OCCURRENCE: On or about August 12, 2000
PLACE OF OCCURRENCE: Contra Costa County Jail
DESCRIPTION OF INCIDENT: Claimant was in the custody of the Contra Costa County Sheriff's
Department. She was in need of a tooth extraction. This was to be performed at the jail by a
dentist. Prior to the extraction claimant informed the medical personnel that she could not be given
novocaine due to intolerance to that drug. Despite this, the drug was administered and resulted in
an adverse reaction. Claimant suffered convulsions, loss of consciousness, and damage to her
mouth, teeth, and gums. This damage required surgery that was performed at a local hospital.
Claimant still suffers pain and disfigurement as a consequence of this incident.
DATED:
Ql � D
Edna Delorise Hill
CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
BOARD ACTION;MARCH 6, 2001
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
��m Board of Supervisors. (Paragraph IV below), given
pursuant to Government Code Section 913 and
915.4. Please note all "Warnings".
FEB ® 52001
AMOUNT: In Excess of $10,000.00 COUNTY COUNSEL
MARTINEZ CALIF.
CLAIMANT: GLORIA A. DOBKIN
ATTORNEY: c/o. .CLYDE I. BUTTS DATE RECEIVED: FEBRUARY 1, 2001
LAW OFFICES OF CLYDE I. BUTTS
ADDRESS: 1225 ALPINE ROAD, STE 204 BY DELIVERY TO CLERK ON: FEBRUARY 2, 2001
WALNUT CREEK CA 94596
BY MAIL POSTMARKED: JANUARY 31, 2001
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim..
PHIL BATCHELOR, Clerk
Dated: FEBRUARY 5, 2001 By: Deputy
II.7This
County Counsel TO: Clerk of the Board o Supervisors
( claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: �'� D� By: Deputy County Counsel
III. FRONt- Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
(� This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order tered ' its min for this date.
Dated: - JOHN -SWEETEN, Clerk, By a , Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited
in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United
States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully
prepaid a certified copy of this Board Order and Notice to Claiman Iddreld to th imant as shown above.
Dated: By: -JOHN .SWEETEN By 3 Deputy Clerk
CC: County Counsel County Administrator
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 does 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.
i
SLAW OFFICES OF CLYDE 1. BUTTS
1225 Alpine.Road 0 Suite 204 0 Walnut Creek, CA 94596
Telephone: (925) 943-1850 0 Fax: (925) 943-7994
E-mail: buttslaw@pacbell.net RECEIVED
FEB - 1 2001
January 31, 2001 CLERK BOARD OF SUPERVISORS
CONTRA COSTA CO.
Board of Supervisors
County of Contra Costa
651 Pine Street
Martinez, CA 94553
Re: Dobkin v. State of California, et al.
REQUESTED ACTION:
X Please file original(s), and return endorsed-filed face page.
Please present to the Judge for signature, file original(s), and return
endorsed-filed copies.
Please issue original summons and return.
Please certify copy(ies) and return.
Other:
ENCLOSURE (S):
Check in the amount of$
X Self-addressed, stamped envelope.
X DOCUMENTS: CLAIM
Sincerely,
/LAW0FICES OFCLYDE Y. BU TS
Chaffin, Paralegal
to CLYDE I. BUTTS
Enclosure(s)
Clai'm•fo: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAII�ZANT
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
GLORIA A. DOBKIN )
RECEIVE®
Against the County of Contra Costa or )
) FEB 5 2001,
District)
(Fill in name) )
ON CSO ISORS
CLERK CRACCTAC
The
undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district
in the sum.of$ in excess and in supDort of this claim represents as follows:
of $10,050, according to proof
1. When did the damage or injury occur? (Give exact date and hour) December 30, 2000 at 6:11 p.m.
2. Where did the damage or injury occur? (Include city and county) Mt. Diablo Blvd. , Lafayette,
Contra Costa County, California
3. How did the damage or injury occur? (Give full details; use extra paper if required) See Attachment 1
4. 'What particular act or omission on the part of county or district officers, servants, or employees 'caused the
injury or damage?
See Attachment 1
5. What are the names of county or district officers, servants, or employees causing the damage or injury?
Unknown at this time
6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed.,Attach
two estimates for auto damage.)
Claimant sustained a fractured right fibula; contusions/lacerations to the left
side of her face, requiring sutures; crushed right thumb; and right ankle
ligament injuries
7. How was the amount claimed above computed? (Include the estimated amount.of any prospective injury or
damage.)
Damages based on general damages, medical specials - present and future - which damages
are unknown at this time
8. Names and addresses of witnesses, doctors, and hospitals.
See Attachment 2
9. List the expenditures you made on account of this accident or injury.
DATE TDvIE AMOUNT
Gov. Code Sec. 910.2 provides "The claim must be
signed by the claimant or by some person on his behalf."
SEND NOTICES TO: (Attorney
Name and Address of Attorney )
CLYDE I. BUM )
o behalf of C aimant, Gloria A. Dobkin
LAW OFFICES OF CLYDE I. BUTTS
1225 Alpine Road, Ste. 204 ) (Claimant's Signature)
Walnut Creek, CA 94596 )
4 Red Bark Court
(Address)
Lafayette, .CA 94549
Telephone No. 925.943.1850 )Telephone No. 925.284.2852
NOTICE
Section 72 of the.Penal Code provides:
Every person who,with intent to defraud,presents for allowance or the 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 aline of not
exceeding one thousand(S 1,000), or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine,of not
exceeding ten thousand dollars($10,000),or by both such imprisonment and fine.
J
Attachment 1
Claimant, a pedestrian, was walking southbound in the marked crosswalk on Mt. Diablo
Blvd., in Lafayette, California, 30 feet west of the entrance to the Lafayette Park Hotel. The
crosswalk, in this area, runs north/south across Mt. Diablo Blvd., from curbline to curbline. A
traffic control device is installed across the crosswalk which, when activated, flashes yellow
reflectorized lights across the crosswalk to warn oncoming traffic of a pedestrian crossing. This
device was not functioning at the time of the subject collision (see Traffic Collision Report,No.
00-37151, attached hereto as Exhibit 1), which claimant contends was a contributing cause to the
subject accident.
The subject collision occurred as Linda M. Beltran, who was driving a Volkswagen
convertible eastbound on Mt. Diablo Blvd., attempted to pass a vehicle which had slowed to
make a right turn into the entrance of the Lafayette Park Hotel. Ms. Beltran attempted to drive
around the vehicle, on the left, and struck claimant in the crosswalk; claimant was struck in the
number 2 lane of eastbound Mt. Diablo Blvd. Ms. Beltran was traveling at approximately 30
mph when she struck claimant.
Attachment 2
WITNESSES:
1. Linda M. Beltran - 1608 Bayview Circle, Benicia, CA 94510 (See Exhibit 1);
2. Brian Alan Smith - 1077 Brown Ave., Lafayette, CA 94549 (See Exhibit 1);
TREATING HEALTH CARE PROVIDERS:
1. American Medical Response - address unknown at this time
2. John Muir Medical Center - 1601 Ygnacio Valley Road, Walnut Creek, CA 94598
3. Michael W. DeBloisblanc, M.D. - 1515 Ygnacio Valley Road, Ste. A, Walnut Creek, CA
4. Erica Mariotti, M.D. - 2700 Grant Street, Ste. 302, Concord, CA 94520
5. William R. Cimino, M.D. - 12 Camino Encinas, Ste. 10, Orinda, CA 94563
6. Mark Tidyman, M.D. - 3466 Mt. Diablo Blvd., Lafayette, CA 94549
'•TATE OF CP.LIFORNIA7_^ A I '/� 00 �6`
FRAFFI(' COLLISION REPORT,
T• V (.
:.;P 5�5 CARS-Page 1 (Rev 8/98)OPl 042 Page 1 or o
SPECIAL CONDITIONS NUMBER MT4 RUN CITY JUDICIAL DISTRICT LOCAL REPORT NUMBER
INJURED FELONY
T n L4FAYETTE WALNUT CREEK SUP.
N'✓"eERKa:-Eo IKT'Sa RUN COUNTY REPORTING DISTRICT BEAT 00-371.51
0 �U� CONTRA COST.,, 06 40 .
COLLISION OCCURRED ON: MO DAY YEAR TIME(2400) NCIC POFFICER I.D.
ZZ MT.DIABLO BL. 12/30/2000 1811 0700 55983
0 MILEPOST INFORMATION: DAY OF WEEK TOW AWAY PHOTOGRAPHS BY: n NONE
U
SATURDAY 'ES NO S.LETTS �I
O AT INTERSECTION WITH; STATE HWY REL
FOOR: 30 FEET WEST OF E/OF ENTRNC TO PARK HTL n YES n NO
PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH.YEAR MAKE/MODEL/COLOR LICENSE NUMBER STATE
1 B4449059 CA C
EQUIP.
19861RBB845 CA
VOLK CONVERTI WHI
- - ------------------ ------
DRIVER NAME(FIRST,MIDDLE,LAST)
-- - ----- ----
nLINDA M.BELTR,,N OWNER'S NAME SAME AS DRIVER
PEDES STREET ADDRESS
TRUW
n1608 BAYV IEW CIR. OWNER'S ADDRESS ❑SAME AS DRIVER
,PARKED CITY I STATE 1 ZIP
VEHICL-c
Lin BENICIA CA 94510 DISPOSITION OF VEHICLE ON ORDERS OF: I OFFICER I�DRIVER j�OTHER
BICY- Sly( HAIR EYES HEIGHT WEIGHT RACE
COST VEH.DRIVEN FROM SCENE L-1
F BRN BRN 5-0S 155 W PRIOR MECH.DEFECTS ix I NONE APP. I I REFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION NUMBER: WV WCA0154GKO06337
❑ CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
INSURANCE CARRIER POLICY NUMBER VEHICLE TYPE ❑LINK ®NONE 1:1 MINOR
CSAA 7P-68-93-3 F]MOD nMAJOR ROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT
CA DOT
E MT.DIABLO BL. 35 CAL-T TCP/PSc MciuX �^
PARTY DRIVER'S LICENSE NUMBER STATE CLASS SAFETY VEH.YE R MAKE/MODEL/COLOR UC
---------------- SE NUMBER STATE
2 N2465495 CA C P
DRIVER NAME(FIRST.MIDDLE,LAST)
----- ------
-- ---- ------
GLORIA ARLENE DOBKIN OWNERS NAME El SAME AS DRIVER
PEDES- STREET ADDRESS
TRIAN
D4 RED BARK CT. OWNER'S ADDRESS ❑SAME AS DRIVE
PARKED CRY I STATE/ZIP
VEHICLE
ElLAFAYETTE CA 94549 DISPOSITION OF VEHICLE ON ORDERS OF ❑OFFICER E]DRNER [:]OTHER
BICY• SEX HAIR EYES HEIGHT WEIGHT RACE u
CUST
F BRN BRN 5-05 155 W PRIOR MECHANICAL DEFECTS nNONE APP. I I REFER TO NARRATIVE
OTHER HOME PHONE I BUSINESS PHONE VCI'I1CLF IDENTIFICATION NUMB I ''
/ CHP USE ONLY ESCRISE VEHICLE DAMAGE SHADE IN DAMAGED AREA
LLL��J INSURAUCE CARRIER POLICY NUMBER VEHICLE'YPE ElLINK ❑NONE []MINOR
I1 - l❑1 MOD LJA)I OR FIROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY SPEED LIMIT
CA DOT
S IN CROSSWALK CAL-T TCP/PSC MVMx
PARTY ORIVER'S LICENSE NUMBER STATE CLASS SAFETY VEN.YEAR MAKE/MODEL/CALOR LICENSE NUMBER STATE
3
DRIVER NAME(FIRST.MIDDLE,UST)
❑ - OWNER'S NAME ❑SAME AS DRNER .
PEDcS
TRIAN STREET ADDRESS
nOWNER'S ADDRESS I 'SAME AS^ IVER
PARKED CITY/STATE/ZIP
VEHICLE
nDISPOSITION OF VEHICLE ON ORDEP. F: OFFICER DRIVER I OTHER
BICY- SLI( HAIR E' S HEIGHT WEIGHT BIRTHDATE RACE U
COST Mo Day Year
PRIOR MECIIANC1AL DEFECT 71i NONE APP. F-IREFER TO NARRATIVE
OTHER HOME PHONE BUSINESS PHONE VEHICLE IDENTIFICATION UMBER:
I CHP USE ONLY DESCRIBE VEHICLE DAMAGE SHADE IN DAMAGED AREA
INSURANCE OICRRIER POLICY NUMBER •-""'-' UNK N101.12 .
Li
nMOD MAJOR [—]ROLL-OVER
DIR OF TRAVEL ON STREET OR HIGHWAY I SPEED LIMIT II II II I
CA DOT I
CAL-T TCP/PSC MC(Mx i
PREPARER'S NAME DISPATCH NOTIFIED REVIEWERS NAME I DATE REVIEWED
STATE OF CALIFORNIA
TRAFFIC COLLISION CODING..'
ilHP 5515 CARS Paget(8/98)OPI 042 Page 2 of g
DATE OP COLLISION(MO.DAY YEAR) TIME(2400) NCIC N OFFICER 1.0. NUMBER
12/30/2000 1811 0700 55983 00-37151
RADDRESS 71YES
IEDOYNER [�NOPROPERTY
DAMAGE D=_SCRIPTION OF DAMAGE
SEATING POSITION OCCUPANTS M/C BICYCLE-HELMET SAFETY EQUIPMENT EJECTED FROM VEHICLE
L-AIR BAG DEPLOYED 0-NOT EJECTED
A-NONE IN VEHICLE M-AIR BAG NOT DEPLOYED 1-FULLY EJECTED
B-UNKNOWN N•OTHER DRIVER 2-PARTIALLY EJECTED
C-LAP BELT USED P-NOT REQUIRED V-NO 3-UNKNOWN
) 2 3 1-DRIVER D-LAP BELT NOT USED W-YES
4 5 6 2 TO 6-PASSENGERS E-SHOULDER,HARNESS USED CHILD RESTRAINT
7-STA.W GtJ REAR F-SHOULDER,HARNESS NOT USED Q-IN VEHICLE USED PASSENGER
B-RR.OCC TRK.OR VAN G-LAP/SHOULDER,HARNESS USED R-IN VEHICLE NOT USED X-NO
7 9-POSITION UNKNOWN H-LAP/SHOULDER HARNESS NOT USED S-IN VEHICLE USE UNKNOWN Y-YES
0-OTHER J-PASSIVE RESTRAINT USED T.IN VEHICLE IMPROPER USE
K-PASSIVE RESTRAINT NOT USED U-NONE IN VEHICLE
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(')SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICESTYPE OF VEHICLE MOVEMENT PRECEDING
LIST NUMBER(X)OF PARTY AT FAULT 1 2 3 1 _ 31 COLLISION
VC SECTION VIOLATED: CITED
1 q IYEs A CONTROLS FUNCTIONING A PASSENGER CAR/STATION WAGON A STOPPED
21950(A) �NoXIB CONTROLS NOT FUNCTIONING- II IB PASSENGER CAR W/TRAILER YI I IB PROCEEDING STRAIGHT
OTHER IMPROPER DRIVING' C CONTROLS OBSCURED C MOTORCYCLE/SCOOTER C RAN OFF ROAD
B ID NO CONTROLS PRESENT/FACTOR D PICKUP OR PANEL TRUCK I I ID MAKING RIGHT TURN
C OTHER THAN DRIVER- TYPE OF COLLISION I IE PICKUP/PANEL TRUCK W/TRAILER IE MAKING LEFT TURN
ID, UNKNOWN' A HEAD-ON IF TRUCK OR TRUCK TRACTOR IF MAKING U TURN
E FELL ASLEEP- B SIDE SWIPE IG TRUCK/TRUCK TRACTOR W/TRLR. IG BACKING
C REAR END IH SCHOOL 13US IH SLOWING/STOPPING
WEATHER (MARK 1 TO 2 ITEMS) ID BROADSIDE I OTHER BUS I I PASSING OTHER VEHICLE
A CLEAR E HIT OBJECT J EMERGENCY VEHICLE IJ CHANGING LANES
B CLOUDY F OVERTURNED IK HIGHWAY CONST.EQUIPMENT I IK PARKING MANEUVER
C RAINING XIG VEHICLE/PEDESTRIAN IL BICYCLE L ENTERING TRAFFIC
D SNOWING H OTHER': IM OTHER VEHICLE M OTHER UNSAFE TURNING
E FOG/VISIBILITY FT. I X IN PEDESTRIAN N XING INTO OPPOSING LANE
FOTHER• MOTOR VEHICLE INVOLVED WITH 10 MOPED 0 PARKED
:
G WIND A NON-COLLISION P MERGING
LIGHTING B PEDESTRIAN I Q TRAVELING WRONG WAY
A DAYLIGHT IC OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTORS X R OTHER': W PLV_1ti1 C;
B DUSK-DAWN ID MOTOR VEHICLE ON OTHER ROADWAY 1 213 - -(MARK 1 TO 2 ITEMS) 1 J C,(t.pSC.wALr_'
C DARK-STREETLIGHTS E PARKED MOTOR VEHICLE - A v.secnoN VIOLATED. CITED I�YES
D DARK-NO STREET LIGHTS IF TRAIN rNO
VC SECTION VIOLATED. CITE?
E DARK-STREET LIGHTS NOT G BICYCLE B I;-�-�IYES
FUNCTIONING* H ANIMAL: ENO
SOBRIETY•DRUG
ROADWAYSURFACE - C vcsecnoNVIDtATEo crteD I�YrS 1 2 3 PHYSICAL
X A DRY I FIXED OBJECT: h—INp (MARK 1 TO 2 ITEMS)
8 WET D -_ - -- A HAD NO7 BEEN DRINKING
I C SNOWY-ICY iJ OTHER OBJECT: IE VISION OBSCUREMENT: B HBO-UNDER INFLUENCE
D SLIPPERY(MUDDY.OILY,ETC.) IF INATTENTION-: C HBO-NOT UNDER INFLUENCE
ROADWAY CONDITION(S) I IG STOP&GO TRAFFIC D HBD-IMPAIP.MIENT UNKNOWN
(MARK 1 TO 2 ITEMS) PEDESTRIAN'S ACTIONS IH ENTERING!LEAVING RAMP IE UNDER DRUG INFLUENCE-
I A HOLES.DEEP RUT' A NO PEDESTRIANS INVOLVED I PREVIOUS COLLISION F IMPAIRMENT-PHYSICAL-
18; LOOSE MATERIAL ON ROADWAY' BCROSSING IN CROSSWALK J UNFAMILIAR WITH ROAD G IMPAIRMENT NOT KNOWN
C OBSTRUCTION ON ROADWAY' AT INTERSECTION K DEFECTIVE VEH.EQUIP.: CITED H NOT APPLICABLE
D CONSTRUCTION-REPAIR ZONE X C CROSSING IN CROSSWALK-NOT YES I SLEEPY/FATIGUED
E REDUCED ROADWAY WIDTH AT INTERSECTION No SPECIAL INFORMATION
F FLOODED' D CROSSING-NOT IN CROSSWALK L UNINVOLVED VEHICLE A HAZARDOUS MATERIAL
I G OTHER': E IN ROAD-INCLUDES SHOULDER X M OTHER-:CNTRLS NOT WKNG
H NO UNUSUAL CONDITIONS F NOT IN ROAD YI IN NONE APPARENT
G APPROACHING/LEAVING SCHOOL BUS 1 10 RUNAWAY VEHICLE
SY.ETCH0 MISCELLANEOUS
INDICATE NORTH
S� �AGTV r�1- D►A C-�(Z.q M I
i
}TATE OF CALIFORNIA
INJURED / WITNESSES / PA' aERS ,ASE 3
DATE F, 90N TIME TJ400 NCIC NUMBER OFFICER I.D. NUMBER
`3 o c I 1 O? o o
Wr NESS PASSENGER EXTENT OF INJURY( "X" ONE) INJURED WAS ( "X" ONE )
PARTY SEAT SAFETY CJECTE:
ONLY ONLY AGE SEX NUMBER POS, EOUI P.
FATAL SEVERE OTHER VISIBLE COMPLAINT
INJURY INJURY INJURY OF PAIN DRIVER PISS. PED. BICYCLIST OTHER
❑tt ❑ C9Lo ❑ ❑ ❑ ❑ ❑ I sn I ❑ ❑ Z
NAME/D.D.S.I ADDRESS
TELEPHONE
n_2-
(INJURED
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
MR 7owrz l2 vs T
DEGCRIBE INJURIES
�tC.liT (3f-oK�aJ FiC3ll1� g_t&w-r 6Pt:>L-C--rJ TPU ti; F/�C_tAl. LiltE'E E� 6oc�l �P,��f?5(O►-�S 12
STI uAas
E] VICTIM OF VIOLENT CRIME NOTIFIED
❑ i ❑ ❑ ❑ ❑ ❑ lolol ❑ ❑ 's 1c. lc>
NAME I D.O.R..O /ADDRESS G c {� (7 � / Q
Ag,-x c-urz lsTo p C� VF_�T„"lt� Lp�L�� 1 ! TELEPHONE
(INJURED ONLY)TRANSPORTED BY: TAKEN TO:
DESCRIBE INJURIES
VICTIM OF VIOLENT CRIME NOTIFIED
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;TATE OF CALIFORNIA
4ARRATIVE SUPPLEMENTAL '
'HP556(Rev.7-90)OP1 042
)ATc OF INCIDENT!OCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D.NUTABER NUMBER
12/30/00 1811 0700 55983 00-37151
'X.ONE 'X'ONETYPE SUPPLEMENTAL('X'APPLICABLE)
Narrative ® Collision report ❑ BA update ❑ Fatal ❑ Hit and run update
❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other:
CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT/BEAT CITATION NUMBER
LAFAYETTE/ CONTRA COSTA/WALNUT CREEK 061 BEAT 40 1 N/A
LOCATION/SUBJECT STATE HIGHWAY RELATED
/ E] Yes ® No
FACTS
NOTIFICATION: I RECEIVED A RADIO CALL OF AN UNKNOWN INJURY COLLISION AT 1811 HRS.
THE PERSON REPORTING THE COLLISION STATED THAT IT OCCURRED IN FRONT OF THE
LAFAYETTE PARK HOTEL (3287 MT. DIABLO BL.). I RESPONDED FROM THE LAFAYETTE POLICE
DEPARTMENT AND ARRIVED ON SCENE AT 1816 HRS. ALL TIMES, SPEEDS, AND DISTANCES ARE
APPROXIMATE. ALL MEASUREMENTS WERE OBTAINED BY ROLATAPE AND STEEL TAPE.
SCENE DESCRIPTION: THIS COLLISION OCCURRED ON MT. DIABLO BL. IN FRONT OF THE
LAFAYETTE PARK HOTEL. MT. DIABLO BL. IS AN EAST/WEST, TWO-WAY, STRAIGHT, ASPHALT-
PAVED ROADWAY. THE EASTBOUND LANES ARE SEPARATED FROM THE WESTBOUND LANES
BY A TWO-WAY LEFT HAND TURN LANE. THE ROADWAY IS MARKED WITH YELLOW SOLID AND
BROKEN STRIPES, AND RAISED REFLECTORIZED MARKERS. THE SOUTH SIDE OF MT. DIABLO
BL. IS CURBED AND HAS TWO ENTRANCES TO THE LAFAYETTE PARK HOTEL OFF OF MT. DIABLC
BL. THE NORTH SIDE OF MT. DIABLO BL. IS ALSO CURBED. THERE IS A CROSSWALK THAT
RUNS NORTH AND SOUTH FROM CURBLINE TO CURBLINE OF MT. DIABLO BL. THE CROSSWALK
IS PAINTED WITH WHITE LINES AND HAS A TRAFFIC CONTROL DEVICE INSTALLED ACROSS THE
CROSSWALK. THE DEVICE CAN BE ACTIVATED AT EACH END OF THE CROSSWALK. WHEN
ACTIVATED, YELLOW REFLECTORIZED LIGHTS FLASH ACROSS THE CROSSWALK. THIS IS TO
WARN ON COMING TRAFFIC OF A PEDESTRIAN CROSSING THE CROSSWALK. THIS DEVICE WAS
NOT FUNCTIONING DURING THE COLLISION. THE SPEED LIMIT ON MT. DIABLO BL. AT THE AREA
OF IMPACT IS 35 MPH.
PARTIES:
VEHICLE #1 (VOLK) WAS FOUND ON ITS WHEELS, PARKED IN THE EAST ENTRANCE TO THE
LAFAYETTE PARK HOTEL. V-1 HAD BEEN MOVED FROM ITS POSITION OF REST. V-1 DID NOT
SUSTAIN ANY VISABLE DAMAGE. V-1 WAS DRIVEN FROM THE SCENE BY D-1 (BELTRAN).
DRIVER#1 (BELTRAN) WAS FOUND STANDING NEXT TO P-2 (DOBKIN). SHE WAS IDENTIFIED
BY A VALID CALIFORNIA DRIVERS LICENSE. D-1 WAS ESTABLISHED AS THE DRIVER OF V-1 BY
HER STATEMENT, AND THE STATEMENTS OF WITNESSES. D-1 IS THE REGISTERED OWNER OF k
1. D-1 WAS NOT INJURED IN THE COLLISION.
PARTY#2 (DOBKIN) WAS FOUND LYING IN THE ROADWAY. P-2 WAS IDENTIFIED WITH A VALIC
CALIFORNIA DRIVERS LICENSE. P-2 WAS DETERMINED TO BE INVOLVED BY THE INJURIES THA
SHE SUSTAINED AS A RESULT OF THE COLLISION. P-2 HAD VISABLE INJURIED TO HER FACE
AND LEGS. P-2 WAS TRANSPORTED TO JOHN MUIR HOSPITAL BY AMR PERSONNEL.
PREPARER'S NAME AND I.D.NUMBER DATE REVIEWER'S N DATE
HOFFMAN, D 1#55983 t'1,�30/0V
Use previous editions until depleted 90 57;
.ATE OF CALIFORNIA
IARRATIV'E SUPPLEMENTAL'
HP 556(itev-'7-90)OP1 042
,TE OF INCIDENT/OCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D.NUMBER NUMBER
2730/00 1811 0700 55983 00-37151
ONE -X'ONE TYPE SUPPLEMENTAL("X'APPLICABLE)
Narrative ® Collision report ❑ BA update ❑ Fatal ❑ Hit and run update
] Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other:
ITY/COUNTY/JUDICIAL D;STRICT REPORTING DISTRICT/BEAT CITATION NUMBER
AFAYETTE/CONTRA COSTA/WALNUT CREEK 06/ BEAT 40 I N/A
OCATION/SUBJECT STATE HIGHWAY RELATED
/ ❑ Yes ® No
PHYSICAL EVIDENCE: SKIDMARKS WERE FOUND AT THE SCENE, TERMINATING THE EAST
EDGE OF THE CROSSWALK. BY WITNESS STATEMENTS AND THE TRACK WIDTH OF V-1, IT WAS
)ETERMINED THAT THE SKIDMARKS BELONGED TO V-1. BLOOD STAINS WERE LOCATED AT THE
POSITION OF REST OF P-2.
PHYSICAL EVIDENCE LEGEND-
VEHICLE POINT OF REST:
COULD NOT BE DETERMINED, V-1 WAS MOVED FROM P.O.R.
PHYSICAL EVIDENCE DESCRIPTION:
A) 23'8" OF LOCKED WHEEL SKIDMARK
B) 22' OF LOCKED WHEEL SKIDMARK
PHYSICAL EVIDENCE LOCATION:
ITEM A (BEGIN) 12'8" WEST OF THE EAST CURBLINE PROLONGATION OF THE WEST
ENTRANCE OF THE LAFAYETTE PARK HOTEL AND 11'9" NORTH OF THE SOUTH CURBLINE OF MT
DIABLO BL. (END) 36'5" WEST OF THE EAST CURBLINE PROLONGATION OF THE WEST
ENTRANCE OF THE LAFAYETTE PARK HOTEL AND 12' NORTH OF THE SOUTH CURBLINE OF MT.
DIABLO BL.
ITEM B (BEGIN) 14'3" WEST OF THE EAST CURBLINE PROLONGATION OF THE WEST
ENTRANCE OF THE LAFAYETTE PARK HOTEL AND 16'2" NORTH OF THE SOUTH CURBLINE OF MT
DIABLO BL. (END) 36'3" WEST OF THE EAST CURBLINE PROLONGATION OF THE WEST
ENTRANCE OF THE LAFAYETTE PARK HOTEL AND 16'1.0" NORTH OF THE SOUTH CURBLINE OF
MT. DIABLO BL.
STATEMENTS
DRIVER #1 WAS CONTACTED AT THE SCENE. SHE TOLD ME THAT SHE WAS TRAVELING E/B II
THE #2 TRAFFIC LANE OF MT. DIABLO BL. D-1 WAS APPROACHING THE LAFAYETTE PARK HOTE
AND THE VEHICLE IN FRONT OF V-1 SLOWED DOWN. D-1 TURNED.HER ATTENTION THE THAT
VEHICLE AS IT BEGAN A RIGHT TURN INTO THE WEST ENTRANCE OF THE LAFAYETTE PARK
HOTEL. D-1 STAYED IN THE #2 TRAFFIC LANE, BUT DROVE AROUND THE LEFT SIDE OF THAT
VEHICLE. D-1 DID NOT SEE P-2 CROSSING THE CROSSWALK, UNTIL THE LAST SECOND, AND
LOCKED UP THE BRAKES TO V-1. V-1 STRUCK P-2 AND V-1 SLOWED TO A STOP. D-1 MOVED V
OUT OF THE ROADWAY. D-I 5-ra eD -`Pra-r 5H,-L- was 1-9- vELirJC, APf'Rrx. 3o MPP LO EO
5�1 E ST2 V
P-7 .
PREPARER'S NAME AND I.D.NUMBER DATE REVIEWER'S N' S DATE
HOFFMAN, D /K55983 i2/So I?c >
Use previous editions until depleted 90 57'
STATE OF CALIFORNIA or-is
NARRATIVE SUPPLEMENTAL'. . :
CHP 5.156(!r e'I:7-90)OP1 042
DATE CAF INCIDENT I OCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D.NUMIBER NUMBER
1:2b0/00 1 1811 0700 55983 00-37151
:Y'ONE "X'ONE TYPE SUPPLEMENTAL('X-APPLICABLE)
® Narrative. ® Collision report. ❑ BA update ❑ Fatal ❑ Hit and run update
❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other:
CITY I COUNTY I JUDICIAL DISTRICT REPORTING DISTRICT I BEAT CITATION NUMBER
LAFAYETTE/CONTRA COSTA/WALNUT CREEK 06/ BEAT 40 I N/A
LOCATION I SUBJECT STATE HIGHWAY RELATED
/ ❑ Yes ® No
PARTY #2 WAS CONTACTED AT THE SCENE AND ALSO VIA TELEPHONE ON 01-02-01. SHE
TOLD ME THAT SHE WAS WALKING SIB IN THE CROSSWALK AT A NORMAL WALKING SPEED.
DOBKIN HAD CHECKED FOR ON COMING TRAFFIC, AND HAD NOT NOTICED ANY VEHICLES
TRAVELING IN THE E/B DIRECTION. SHE HAD WALKED FROM THE NORTH CURBLINE OF MT.
DIABLO BL. IN THE CROSSWALK, AND HAD TRAVELED ACROSS THE #1 AND #2 W/B LANES OF
MT. DIABLO BL, THE TWO WAY LEFT TURN LANE, AND THE #1 TRAFFIC`LANE OF E/B MT. DIABLO
BL., WHEN SHE WAS STUCK BY V-1 IN THE #2 EIB TRAFFIC LANE OF MT. DIABLO BL. P-2 COULD
NOT TELL ME HOW FAST SHE THOUGHT V-1 WAS TRAVELING. P-2 HAD PUSHED THE
PEDESTRIAN CROSSWALK LIGHTS TWICE, BUT THEY DID NOT APPEAR TO BE WORKING.
WITNESS #1 WAS CONTACTED AT THE SCENE. W-1 (SMITH) HEARD A VEHICLE START TO SKIS
ON MT. DIABLO BL. W-1 TURNED HIS ATTENTION TO MT. DIABLO BL. W-1 SAW V-1 HIT P-2 IN THE
#2 TRAFFIC LANE OF MT. DIABLO BL. W-1 SAW P-2 FLY IN THE AIR AND LAND AT THE POINT OF
REST OF P-2, W-1 IS AN EMPLOYEE OF THE LAFAYETTE PARK HOTEL.
WITNESS #2 WAS CONTACTED AT THE SCENE. W-2 (ALEX) WAS A PASSENGER 1N V-1. W-2
STATED THAT V-1 WAS TRAVELING IN THE #2 EIB LANE OF MT. DIABLO BL. THE VEHICLE
SLOWED TO GO AROUND A VEHICLE THAT WAS TURNING INTO THE HOTEL. W-2 DID NOT SEE
THE P-2. W-2 WATCHED P-2 GET HIT BY THE RIGHT FRONT CORNER OF V-1 AND GO OFF THE
SIDE OF THE VEHICLE. W-2 BELIEVES THAT V-1 WAS TRAVELING APPROX. 30 MPH AT THE TIME
OF THE COLLISION.
OPINIONS AND CONCLUSIONS
SUMMARY: V-1 WAS TRAVELING EIB IN THE #2 LANE OF MT. DIABLO BL. D-1 SLOWED TO GO
AROUND A VEHICLE THAT WAS TURNING RIGHT INTO THE WEST ENTRANCE OF THE LAFAYETTE
PARK HOTEL. D-1 HAD TURNED HER ATTENTION TO THE VEHICLE THAT WAS TURNING INTO THE
HOTEL AND NOT THE ROADWAY IN FRONT OF HER. P-2 WAS WALKING AT A NORMAL WALKING
PACE SIB IN THE CROSSWALK ACROSS MT. DIABLO BL. TOWARDS THE LAFAYETTE PARK
HOTEL. THE WARNING LIGHTS ON THE CROSSWALK HAD BEEN PUSHED TO BE ACTIVATED
TWICE, BUT WERE NOT WORKING AT THE TIME OF THE COLLISION. D-1 DID NOT SEE P-2 TILL.
THE LAST SECOND AND STRUCK P-2 WITH THE FRONT RIGHT CORNER OF V-1. D-1 HAD
SLAMMED ON THE BRAKES OF V-1. LOCKED WHEEL SKID MARKS WERE LEFT ON THE ROADWA'
BY V-1. SEE THE FACTUAL DIAGRAM FOR THE POINT REST OF P-2. THE P.O.R. OF V-1 COULD
NOT BE DETERMINED, BECAUSE IT HAD BEEN MOVED FROM THE P.O.R. BY D-1: SEE THE SPEEC
FROM SKID CALCULATIONS FOR ESTIMATION OF SPEED. D-1 BELIEVED THAT SHE WAS
TRAVELING APPROX. 30 MPH AT THE TIME OF THE COLLISION.
PREPARER'S NAME AND I.D.NUMBER DATE REVIEWER'S NAS� DATE
HOFFMAN, D 1#55 of
983 !'2/'C) c! j
Use previous editions until depleted 90 575.
i TATE OF CAL I'
C,;:7NAEiPAT IVE SUPPLEMENTAL(
-HF 556(Aev'7-90)OP1 042
)AT%OF'INCIDENT I OCCURRENCE TIME(2400) NCIC NUMBER OFFICER I.D.NUMBER NUMBER
12/30/00 1811 0700 55963 00-37151
'X'ONE 'X'ONE TYPE SUPPLEMENTAL(W APPLICABLE)
Narrative ® Collision report ❑ BA update ❑ Fatal ❑ Hit and run update
❑ Supplemental ❑ Other: ❑ Hazardous materials ❑ School bus ❑ Other:
CITY/COUNTY/JUDICIAL DISTRICT REPORTING DISTRICT I BEAT CITATION NUMBER
LAFAYETTE/CONTRA COSTA/WALNUT CREEK 061 BEAT 40 NIA
LOCATION/SUBJECT STATE HIGHWAY RELATED
/ ❑ Yes ® No
SPEED FROM SKID ANALYSIS:
THE RIGHT WHEEL SKID LEFT BY V-1 WAS APPROX. 23.75' IN LENGTH.
VELOCITY= 30(DISTANCE)(COEFFICIENT OF FRICTION)
V= 30(23.75)(.7)
V= 498.75
V= 22.33 MPH
ESTIMATE THAT V-1 WAS TRAVELING APPROX. 22.33 MPH
AREA OF IMPACT- THE AREA OF IMPACT WAS DETERMINED BY WITNESS STATEMENTS.AND
THE LOCATION OF SKIDMARKS ON THE ROADWAY. THE AREA OF IMPACT IS IN THE #2 TRAFFIC
LANE OF E/B MT. DIABLO BL., AT 30' WEST OF THE EAST CURBLINE PROLONGATION OF THE
WEST ENTRANCE TO THE LAFAYETTE PARK HOTEL AND 11'11" NORTH OF THE SOUTH CURBLINE
OF MT. DIABLO BL.
CAUSE- D-1;CAUSED THIS COLLISION BY BEING IN VIOLATION OF CVC 21950(A). D-1 FAILED
TO YIELD TO A PEDESTRIAN IN A CROSSWALK. I BELIEVE THAT AN ASSOCIATED FACTOR TO
THE COLLISION IS THE FACT THAT THE WARNING CROSSWALK LIGHTS WERE NOT FUNCTIONIN(
AT THE TIME OF THE COLLISION.
RECOMMENDATIONS:
NONE.
PREPARER'S NAME AND I.D.NUMBER DATE REVIEWER'S M DATE
HOFFMAN, D /#55983 2I3a/00
Use previous editions until deplete 90 5?;
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CLAIM C
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFO IA
BOARD ACTION: MARCH 6, 2001
Claim Against the County, or District Governed by )
the Board of Supervisors, Routing Endorsements, 1 NOTICE TO CLAIMANT
and Board Action. All Section references are to 1 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
11177T'�� pursuant to Government Code Section 913 and
915.4. Please note all "Warnings".
0 5 2009
AMOUNT: $7,500.00
MA
CLAIMANT: ARLENE COHEN
MARTINEZ CALIF
ATTORNEY: c/o JOHN M. CAHILL, 4102287 DATE RECEIVED: FEBRUARy 1, 2001
LAW OFFICES OF JOHN CAHILL
ADDRESS: 1190 CHESTNUT STREET BY DELIVERY TO CLERK ON: FEBRUARY 1, 2001
MENLO PARK CA 94025
BY MAIL POSTMARKED: JANUARY 31, 2001
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim..
PHIL BATCHELOR, Clerk
1:4Dated: FEBRUARY 5, 2001 By: Deputy ZZ1� A&�
II. FROA1 County Counsel TO: Clerk of the Board ofSupervisors
(�,�-Tfiis claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: Z / By: CDeputy. County Counsel
III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
�( This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered ' its minu for this date.
Dated: JOHN S6,7EETEN Clerk, By a , Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited
in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVIT OF MAULING
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 Claims addr s ed to t imant as shown above.
Dated: By: JOHN SWEETEN- By a Deputy Clerk
CC: County Counsel County Administrator
r.
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 does 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.
JOHN M. CAH I LL
ATTORNEY AT LAW RECEIVE®
1.190 CHESTNUT STREET
MENLO PARK. CA 94025 FEB - 1 2001
(650)324-0644
Enx:(650)324-9173 CLERK BOARD OF SUPERVISORS
CONTRA COSTA CO.
January 31, 2001
Clerk of the Board of Supervisors
Room 106
County Administration Building
651 Pine Street
Martinez, CA 94553
RE: Our Client: Arlene Cohen
To Whom It May Concern:
Enclosed please find the original six-month claim form, including attachments, as well as one copy
of the claim form and attachments. Please file the claim forms and return the filed copy to my
office in the enclosed envelope.
I look forward to speaking with someone regarding our demand in the near future.
Very truly yours,
LAW OFFICES OF JOHN M. CAHILL
hn M. Cahill L
JMC/acz
Enclosure
cc: Fl 6726
Arlene Cohen
T
.Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAIAZANT ORIGINAL.
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 100 ' 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 Distrlci should be Liiiou 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
Arlene Cohen, Plaintiff - )
Against the County of Contra Costa or )
District)
(Fill in name) )
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district
in the sum of$7, 500.00 and in support of t;is -.lair::represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
Saturday, September 23, 2000 at approximately 12: 30 p.m.
2. Where did the damage or injury occur?(Include city and county)
Near 1451 Danville Boulevard in Alamo, Contra Costa County.
3. How did the damage or injury occur? (Give full details; use extra paper if required)
Please see attached - "Brief .Factual Statement"
4. What particular act or omission on the part of county or district officers, servants, or employees caused the
injury or damage?
.Allowing the existence of a large pothole, described in attached.
5. What are the names of county or district officers, servants, or employees causing the damage or injury?
Unknown
6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach
two estimates for auto damage.)
Please see attached.
7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or
damage.)
Please see attached.
8. Names and addresses of witnesses, doctors, and hospitals.
Please see attached.
9. List the expenditures you made on account of this accident or injury.
DATE TEME AMOUNT
Please see attached.
******************************************************************************************
Gov. Code Sec. 910.2 provides "The claim must be
signed by the claimant or by some person on his behalf."
SEND NOTICES TO: (Attorney
Name and Address of Attorney )
John M. Cahill, ; 102287 )
LAW OFFICES OF JOHN CAHILL ) i
1190 Chestnut Street ) (C atmant's Sigrte)
.e)
Menlo Park, CA 94025 ) 6tN:�.�
( 650) 324-0644, x2 )
(Address)
Telephone No. )Telephone No.
******************************************************************************************
NOTICE
Section 72 of the Penal Code provides:
Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any
county,city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account,
voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not
exceeding one thousand($1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not
exceeding ten thousand dollars($10,000),or by both such imprisonment and fine.
1, 1. BRIEF FACTUAL STATEMENT
2 On September 23, 2000, at approximately 12:30 p.m., plaintiff, Arlene Cohen, was
3 riding her bicycle in the designated bike lane on Danville Boulevard in the city of Alamo. When
4 she was near 1451 Danville Boulevard, the front wheel of her bicycle hit a large, unmarked hole
5
in the pavement, causing Ms. Cohen to lose control and fall. Attached are photographs of the
6
7 hole and surrounding area. The hole measured approximately twenty inches by eighteen inches
8 and was four-and one-half inches deep.
g 2. ARLENE COHEN'S INJURIES
10 Attached as exhibits hereto are Arlene Cohen's accident-related medical records from
11 John Muir Medical Center and William DeWolf, M.D., all showing that Ms. Cohen sustained
12
the following injuries:
13
1. Severe bruises and contusions to the left hip and thigh;
14
15 2. Severe abrasions and contusions to the left elbow and forearm;
16 3. Fractured ribs.
17 Her husband took Ms. Cohen to John Muir Medical Center immediately after the fall. At
18 the hospital, the doctor found exquisite tenderness to palpation along the left elbow along with
19 swelling and diffuse abrasions. The doctor also found tenderness along the left anterior chest
20
wall. X-rays were taken of the left elbow and left forearm, which were negative for fracture.
21
22 Chest x-rays were also taken which showed no acute cardiopulmonary disease. The emergency
23 room doctor diagnosed Ms. Cohen as having sustained possible acute fractured ribs along with
24 acute left arm abrasions and contusions. She was advised to follow-up with her regular
25 physician and was prescribed with pain medication.
26 Attached are photographs taken within a few weeks after the fall, showing the extensive
27
28
1
1 bruising to Ms. Cohen's left hip and thigh and abrasions to the left forearm and elbow.
2 Ms. Cohen did follow up with her regular physician, William DeWolf, M.D., on
3 October 4. At that time, Dr. DeWolf continued Ms. Cohen on Vicodin and Tylenol and advised
4 that it would take time for her wounds to heal. Ms. Cohen last saw Dr. DeWolf on November
5
8, at which time she advised that her ribs were still painful, but improving. Dr. DeWolf
6
7 reassured Ms. Cohen that her injuries would eventually heal. Indeed, after approximately six
8 more weeks, Ms. Cohen's symptoms resolved.
9 3. DAMAGES
10 A. Arlene Cohen's Present Medical Specials
11 In a personal injury action the injured person is entitled to recover the reasonable value of
12
necessary medical treatment and care that is the proximate result of the defendant's tort fMelon
13
v. Sierra Railway Co. (1970) 151, Cal.113, 1, 91, P.522].
14
15 Arlene Cohen's medical expenses to date may be itemized as follows:
16 1) John Muir Medical Center $ 1,465.30
17 2) Emergency room radiologist $ 110.00
18 3) Emergency room physician $ 266.00
19
4) William DeWolf, M.D. $ 144.00
20
TOTAL PRESENT MEDICALS $ 1,985.30
21
22 B. General Damages
23 In dealing with damages for pain and suffering, BAJI 14.13 states that a plaintiff is to
24 recover:
25 Reasonable compensation for any pain, discomfort, fears, anxiety
and other mental and emotional distress suffered by the plaintiff
26 and of which his injury was a proximate cause and for similar
27
28
2
1
1 suffering reasonably certain to be experienced in the future from
the same cause.
2
No definite standard or method of calculation is prescribed by law
3 by which to fix reasonable compensation for pain and suffering...
4 The loss of ability to enjoy life is compensable in California as a component of general
5
damages (Huff vs. Tracy (1976) 57 Cal.App.3d 939). This component has been recognized to
6
7
include the inability to participate in daily family activities (Nelson vs. Gaunt (1981) 125
8 Cal.App.3d 623) and the inability to pursue studies or recreational activities (Scally vs. W.T.
9 Garret & Co. (1909) 11 Cal.App.138; Harris vs. Lambert (1955) 131 Cal.App.2d 751).
10 4 CONCLUSION
11 As a result of the dangerous condition of the roadway, plaintiff, Arlene Cohen, sustained
12
rib fractures and severe and extensive bruising to her left hip, left thigh, and left forearm along
13
with extensive abrasions to her left elbow and left forearm. Thankfully, after approximately
14
15 three-and-one half months, Ms. Cohen's symptoms resolved after much interruption and
16 discomfort to her life.
17 Considering the nature and extent of Ms. Cohen's injuries, the impact those injuries had
18 on her life, and coupled with her present special damages totaling $1,985.30, the amount of
19 $7,500.00 would be a fair and reasonable settlement for the injuries and damages sustained in the
20
incident.
21
22 Dated: January 31. 2001
23 LAW OFFICES OF JOHN M. CAHILL
24 J /
BY
25 J Cahill
26 Attorney for Plaintiff
ARLENE COHEN
27
28
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12/13/2000 WED 15:23 FAX 510 165 7765 AIh131G 003/003
### Date. . . . Code. . . . Description. . . Dr. Fcl Dx. . . . Original Batch. . . Ref. . . .
-------------------------------------------------------------------------------
?4' 44. 1*14665 ARLENE COHEN * Closed *
16 12-02-98 99214 QFFIC/OUTPT VI 21 7 530. 81 95. 00 120998TM 24944. 1
17 12-10-98 98 ins ECSBLUE IN 0. 00 6416
21 12-23-98 2. 2 DEDUCT I RL1'!C}T 21 3 0. 00 122398JM 26849. 1
22 12-23-98 2. 1 CONTRACT ADJ W 21 3 -28. 00 122398JM 226849.2
29 01-C7-99 1. 1 CHECK PAYMENT 21 3 -67. 00 012799JM 3172. 2
Charges: 95. 0@ Credits: 95. 00 Balance : .0. 00
-------------------------------------------------------------------------------
191. 1*14665 ARLENE COHEN * Closed
25 01--06-99 99213 OFFIC/OUTPT VI 21 3 530. 10 65. 00 01079SEZ 191. 1
27 01-12-99 98 ins ECSBLUE IN 0. 00 841
30 01-27-99 2. 2 DEDUCTIBLE/PT 21 3 0. 00 012799JM 15�2j5. 1
31 01--27-99 2. 1 CONTRACT ADJ W 21 3 -21. 00 012799JM 1525. 2
33 02--24-99 1. 1 CHECK PnYMENT 21 3 -44. 00 TMO22499 3191. 1
Charges: 65. 00 Credits: 65. 00 Balance: 0. 00
---------------------------------------------_-----------------_---------------------
39386. 1*14665 ARLENE COHEN * Closed *
34 03-03-99 99213 OFFIC/OUTPT VI 21 .3 300. 00 E5. 00 031099KL 393x6. 1
35 03-12-99 98 ins ECSBL.UE IN 0. 00 12562
36 03-26--99 3 NOT ELIGIBLE 21 0. 00 03269OKL 3663. 1
38 04-28-99 1. 1 CHECK PAYMENT 21 3 -45. 00 KL042799 32-24. 1
40 05-28--99 1. 1 CHECK PAYMENT 21 3 -20. 00 052899JM 3,237. 1
Charges: 65. 00 Credits: 65. 00 Balance: 0. 00
-------------------------------------------------------------------------------
113474. 1*14665 ARLENE COHEN * Closed *
41 11-10-99 99396 PREVEN MEDS E& 21 3 V70. 0 95. 00 111699KIM113474. 1
43 11-1E-9? 98 ins ECSBLUE IN 0. 00 3VJF!36
44 i1-24--99 2 INS PAYMT 21 3 -60. 00 112499ATES254. 1
49 12-15-99 1. 1 CHECK PAYMENT 21 3 -.35. 00 lal599AC 3343. 1
Charges: 95. 00 Credits: 95. 00 Balance : 0. 00
113474. 2*14665 ARLENE COHEN * Closed *
42 11-10-99 93000 EKG 21 3 V81. 2 50. 00 111699KIM113474. 2
45 i 1-24-99 2. 2 DEDUCTIBLE/PT 21 3 0. 00 1 12499ATE6254. 2
46 11-24--99 8. 1 CONTRACT ADJ W 21 3 -17. 00 112499ATE6254. 3
50 12--15-99 1. 1 CHECK PAYMENT 21 3 --33. 04 121599AC 3343. 2
Charges: 50. 00 Credits: 50. 00 Balance: 0. 00
-------------------------------------------------------------------------------
65876- 1*14665 ARLENE COHEN * Closed
51 10-04-00 99213 OFFIC/OUTP7 VI 21 3 922. 1 72. 40 100900KIM6567G. 1
52 10-11-00 9B ins ECSBLUE IN 0. 00 53492
53 10-19-00 2 INS PAYMT 21 3 -17. 27 101 900AC 6648. 1
54 10-19-00 2. 1 CONTRACT ADJ W 21 ,?3 -19. 73 101900AC 6648. 2
56 10-31-00 1. 1 CHECK PAYMENT 21 3 -35. 40 103100ATE3476. 1
Charges: 72. 00 Credits: 72. 00 Balance : 0. 00
-------------------------------------------------------------------------------
69277. 1*14665 ARLENE COHEN * Closed *
57 11-08-00 99211 OF'FIC/OUTPT VI 21 3 999. 9 0. 00 I i IS JOKW 69277. 1
Charges: 0. 00 Credits : 0. 00 Balance: 0. 00
-.----------_------------------------------------------------------------_--------------_---
TOTAL 0. 00
PATIENT NAME: COHEN, ARLENE
DATE OF ADMISSION: 09/23/2000
DICTATING PHYSICIAN: THEOPHILE KOURY, MD
MEDICAL RECORD # : 023-02-82
DATE OF BIRTH: 07/21/1940
TIME : 1405 hours .
CHIEF COMPLAINT: "I fell off my bike . "
HISTORY OF PRESENT ILLNESS : The patient is a 62-year-old female who
was riding her. bike this morning with protective head gear when she
fell off the bike onto her left side about an hour ago . She struck
her left elbow onto the pavement and her chest as well . She is
complaining of left chest pain as well as left elbow pain. No loss
of consciousness . She denies neck, back or abdominal pain. She
denies any other injuries . She was brought in by her husband .
REVIEW OF SYSTEMS : Other than present illness is negative .
PAST MEDICAL HISTORY: Esophageal reflux. Medications include
Zoloft , Ativan, Synthroid, Prilosec . No known drug allergies .
SOCIAL HISTORY: Her last tetanus immunization was more than ten
years ago.
PHYSICAL EXAMINATION:
VITAL SIGNS : Please see the emergency room record; however, they are
normal . Oxygen saturation 1000i on room air which is normal.
GENERAL: Well nourished and well hydrated, appropriate and
interactive .
HEENT: Normocephalic , atraumatic . Nontender. Pupils equal , round,
react to light . Sclerae clear, 'conjunctivae pink. Extraocular
motions intact . Ears and nares clear bilaterally. Mouth, mucous
membranes are moist . Uvula is midline .
NECK: Supple . No lymphadenopathy.
LUNGS : Clear to auscultation equally, bilaterally with no wheezes,
rales or rhonchi .
COHEN, ARLENE JOHN MUIR MEDICAL CENTER
023-02-82 1601 Ygnacio Valley Road
0026700069 Walnut Creek, CA 94598
Emergency Room Report
Page 1
ORIGINAL
HEART : Regular rate and rhythm. No murmurs, rubs or gallops .
ABDOMEN: Soft nontender. No rebound or guarding.
EXTREMITIES : 2+ distal pulses . She is very tender to palpation
along the left elbow, especially over the radial head and olecranon
with some swelling and mild ecchymosis . She has diffuse abrasions in
this region as well . She is able to almost completely extend the
elbow and has a difficult time supinating the forearm as this
recreates the pain. There is no obvious deformity otherwise to the
extremities . ..
CHEST : Very tender to palpation along the left anterior chest wall ,
just beneath the left breast . There is no ecchymosis . No crepitus
noted, however
NEUROLOGIC: Cranial nerves II through XII intact . Deep tendon
reflexes 1+ . Muscle strength of the left arm is limited due to pain
in the left elbow. Otherwise sensation is intact to soft touch.
MEDICAL DECISION MAKING: The patient appears to have injured her
left elbow. I will perform x-ray to rule out any fractures . The
abrasions will need to be cleaned and dressed with Neosporin
ointment . Will . obtain a chest x-ray to rule out any pulmonary injury
due to a rib fracture . I suspect that she most probably has
sustained a rib fracture given the degree of tenderness she is
experiencing on palpation of the chest . Her oxygen saturation
appears to be normal .
LABORATORY STUDIES : Chest x-ray reveals normal cardiac silhouette .
No effusions or infiltrates, normal mediastinum. No obvious rib
fractures . Three view x-ray of the left elbow reveals normal soft
tissue, normal bony alignment . No joint effusion or any fractures .
EMERGENCY ROOM COURSE: I• explained to the patient the findings . I
discussed with her and her husband the treatment plan. She was given
vicodin, two tablets orally. The wounds were cleaned with hydrogen
peroxide and dressed with Neosporin ointment . Discharge instructions
are to take vicodin for pain as prescribed by me . She is to wash the
wounds twice daily with hydrogen peroxide and apply Neosporin
ointment . She is to follow up with Dr. DeWolf in one week for
recheck. Return for any worsening pain, difficulty breathing or
fevers .
DIAGNOSIS :
1 . Acute possible fractured ribs .
2 . Acute left arm abrasion and contusion.
COHEN, ARLENE JOHN MUIR MEDICAL CENTER
023-02-82 1601 Ygnacio Valley Road
0026700069 Walnut Creek, CA 94598
Emergency Room Report
Page 2
ORIGINAL
THEOPHILE KOURY, MD
: tcc
DD: 09/23/2000 6 : 36 P
DT : 09/24 /2000 2 : 08 P
Doc ID: 137632 Ext DOCID: 000003013730006
cc : BILLING COPY ER
COPY ER
COHEN, ARLENE JOHN MUIR MEDICAL CENTER
023-02-82 1601 Ygnacio Valley Road
0026700069 Walnut Creek, CA 94598
Emergency Room Report
Page 3
ORIGINAL
CI# 565486 Exam: 01027 CHEST 2 VIEWS XRAY IP
CI# 565486 Exam: 01066 ELBOW COMPLETE XRAY IP*L
CI# 565486 Exam: 01068 FOREARM XRAY IP*L
MULTIPLE EXAMINATIONS
HISTORY: Multiple . injuries (959 . 8) .
CHEST 2 VIEW (.71020) : 09/23/00
COMPARISON: None currently available .
FINDINGS : Heart is not enlarged. Pulmonary vasculature is within
normal limits . Lungs are clear. Costophrenic angles are sharp.. . No
mediastinal or hilar mass- lesion is evident .
IMPRESSION:
No acute cardiopulmonary disease .
*0
LEFT ELBOW, COMPLETE (73080) : 09/23/00
COMPARISON: None currently available .
FINDINGS : Bony mineralization appears normal . No acute fracture or
dislocation is identified. No radiopaque foreign body is identified.
No joint effusion is evident . Mild hypertrophic spur formation is
evident .
IMPRESSION:
No acute fracture identified.
*0
LEFT FOREARM (73090) : 09/23/00
FINAL AN# : 0026700069 CONTINUED
PATIENT NAME R# D.O.B. AGE SEX
i COHEN, ARLENE 0230282 07/21/40 60Y F
DATE OF EXAM ORDERING PHYSICIAN ROOM#
09/23/00 1411 KOURY, THEOPHILE G *ERO
ATTENDING PHYSICIANPRIMARY CARE PHYSICIAN
CHILES, JOHN S DEWOLF, WILLIAM
IRA FINCH.MD CHAIRMAN JOHN MUIR MEDICAL CENTER
VIVIAN WING, MD VICE CHAIRMAN 1601 YGNACIO VALLEY ROAD
WALNUT CREEK,CA 94598
MEDICAL IMAGING DEPARTMENT
f
Checkin-Exam Code Summary
565486-01027 , 565486-01066 , 565486-01068
COMPARISON: None currently available .
FINDINGS : Bony mineralization appears normal . No acute fracture or
dislocation is evident . Mild degenerative changes are evident .
IMPRESSION:
No acute fracture .
*0
T: 09/24/00 /Read By/ William Hoddick M.D.
MJD /Released By/ William Hoddick M.D .
Report Status : FINAL
FINAL AN# : 0026700069 Page 2
PATIENT NAME MR# D.O.B. AGE SEX
COHEN, ARLENE 0230282 07/21/40 60Y F
DATE OF EXAM ORDERING PHYSICIAN ROOM#
09/23/00 1411 KOURY, THEOPHILE G *ERO
ATTENDING PHYSICIAN PRIMARY CARE PHYSICIAN
Ii
CHILES , JOHN S DEWOLF, WILLIAM
IRA FINCH,MD CHAIRMAN , JOHN MUIR MEDICAL CENTER
VIVIAN WING,MD VICE CHAIRMAN 1601 YGNACIO VALLEY ROAD
WALNUT CREEK,CA 94598
MEDICAL IMAGING DEPARTMENT
ALBC*
PATIENT NAME DRESS PHONE/SSN DATE 11ME REG. F/C PAT. C
c 0 H E*tl.A R I F.::t4 E 09/23/00 13 '50 96 00267-00069 EF,
'0 C r-)t,!Y 0 f,j V 1 E.'L4 DR: 925)254'-'94 10
567-50-8644 BIRTHDATE AGE SEX MIS Pic MED.REC.N(
OR 1H D n Ct-) 94563 O'?/21/40 60Y F m 023-02---5 :
TEMPORARY OR VISITING ADDRESS OR RELATIVE REG BY
9&
—J, 1 1.0 SPOUSE CI!
1.0 ('."(I t,Vy Cl tl V T I L-j 1)R ORINDF) f-) 94 5 6
GUARANTOR NAME/ADDRESS PHONE SSN RELATIONSHIP
q c 0 i-1 F:fq.ARI...E t1l E (92 5)254---911.10 j -50-8644 SELF:'
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CC PATIENT EMPLOYER NAME!ADDRESS OCCUPATION GUARANTOR EMPLOYER NAME ADDRESS OCCUPATION
mi
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IFSCARRIER PLAN I GROUP NAME CLAIM#-SSN RECIPIENT# GROUP ORDERS
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EKG
PHYSICIAN PRIMARY CARE PHYSICIAN
iH, i DEWOLF,W ILL IAM
.1-.ES. JOl--lN S' A.D.T.0.5 cc IM LOT
DT TIME OF ACC. TYPE OF ACCIDENT PLACE/NATURE OF ACCIDENT
0 2
TR F)1L/(i I AMO
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f. -1!:: R, (-iC, F(i I L F'R 0 M B I K Er
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COMPLAINT/COMMENT ARRIVAL MOD[
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AMBULATORY/S
C;7.
M.0 START TIME
NOTIFIED
-VT;
0 PARENTS Cl OTHER .r:. i4RRIVED
0 POLICE
0 CORONER
DIAGNOSIS
il,c,
CONDITION OF PATIENT ON DISCHARGE DISPOSITION—� OTHER ADMITTED ROOM NO. TIM!
E)
GOOD FAIR 0 SERIOUS 0 CRITICAL TO HOSPITAL
PATIENT INSTRUCTIONS INSTRUCTIONS GIVEN
11 SPRAIN/SEVERE BRUISE
0 NO DRIVING
0 HEAD INJURY
0 TETANUS
0 WOUND CARE
❑LAB RESULTS
UNDERSTAND u
SIGNATURE I HAVE READ AND NDERSTAND THE ABOVE INSTRUCTIONS El WbRK EXCUSE
PATIENT
OF x
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0 X-RAY
MEDICAL RECORDS JOHN MUIR MEDICAL CENTER --,EMBRGENCY DEPT.CLINICAL PIECOR(
V
INIT SURVEY TIME OF TRIAGE TRIAGE RN INITIALS t _
TRJgGE CATEGORY CHIEF COMPLAI PAIN LOCATION ONSET
F- Emergent �� 6x--0- ) ❑Yes ❑No
Urgent
Non-urgent HPI 7 INTENSITY 1-10 SCALE OUALITY
2 GLS<Ile
(//n �/y V FACES SCALE
LEVEL<� DISTRESS �� // lJ•-.•r/�✓ -� E., .. ..._:.: r 9Q i R / 7
None
MIld to Moderate �, /l) L MP P EXAMS
od. to Severe14-y (zA z�tOJ - L u o
Awake, Alert, Oriented
/ SOURCE F PI: _ IMMUN ATION STATUS
FAMIL /FRIEND W/PATIENT ❑P !en Other ❑N/ /Q
Yes CCC.H _ IN SIGNS
❑ No PM" arm, Dry, Normal Color
NURSING INTERVENTIONS ALLERGIES LATEX ALLE GY CARDIAC
❑ Ice / NKDA, YeYC No
Radial Pulse Strong&Regular
❑ Dressing MEDS/DOSAG
RESP
X-ray I /n'/ y/�J
� l'L"" / • i�
❑
-L� -Grossly Normal
PRE- OSP ITAL CARE'' ,,yy�� / ❑"
,A TOR SENSORY
�7 1V Grossly Normal
❑Ambulatory w/Difficulty
❑ C-Spine Pre tions ❑
SECONDARY VITAL SIGNS
SURVEYO TIME BP P R T Sp02 /PAIN MEDS/TREATMENT IN ERVENTIONS& EVALS INIT.
TIME IN ROOM `�/� 1�e,
WEIGHT____ kg - Ibs
RN INITIALS
CARDIAC L�✓`' -
❑ Monitor- NSR
"l N/A 'V 17 0 •S CL
n
RESPIRATORY - -
�Breath Sounds Normal
❑ N/A `S7�✓�1 1��
DC 8Nx _ -
- -
K"bOMEN � � rSoft, Tender, Flat
EDUCATION
El N/A PATIENT& FAMILY: peaks/understands English ❑No: Translator present F]Yes ❑No
BARRIERS TO LEAR ING: E�Wbne ❑Pain ❑Visual ❑ Emotional ❑Auditory
VISUAL ACUITY ❑Cultural-Religious ❑Cognitive
ODTOPIC(Mark all applicable):dedications ❑ Diet E] Equipment E] Home Care/Community Resources
OS reatment/Technlques mptom Management (Pain, Nausea, Dyspnea) (,�ollow-up
/A
METHOD: ritten �scuss on ❑ Demonstration
DISC AR OUTCOME:Verbalized un erstanding: tientamily/Support Person
TIME .... Demonstrated understanding: ❑ Patient `❑ Family/Support Person
�MODE INITIALS SIGN :RT'tl9- INITIALSI ATURE&TITLE
A1TfiiF1(ato ry
❑ Wheelchair
[] Ambulanc
RN INITIALS f� f
l
COHEY4 ARLENE JOHN MUIR MEDICAL CENTER
O 21 3 0 2 8 2 john MuirlMt. Diablo Health System
DR . CHILES . JOHN S
F O Y 09 /23/00 NURSING RECORD
` EMERGENCY DEPARTMENT
FORM 2656(7/00)
WHITE-CHART/PINK-ER
DATE: rage of
R:N.
TIME BP P R .'T MEDICAL SOLUTIONS COMMENTS: INITIALS
IFSOL
/Vit) mos
SCOL c 0 o u& �244book
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SIGNATURE : 1NRIALS;: ;'Ttll�E�"�.���'~�.�.,•....:_;:
"':CIGNA R
l EMERGENCY DEPARTMENT NURSES NOTES
/ Continuation Sheet
John Muir Medical Center
Walnut Creek, California
White: Medical Information
Yellow: Pharmacy
Pink: E.R. 2015 Rev. 10194
��,''�Deparlmerit�of,Emergent Seryi:ces
,John:Murr Medre :1i nter
D�Iiunter< h1.D::htedIthl;Mrectoi• .'::,,.;'::.:.. '.':':. :: .
Dan Buhler,M.D. JAh Odles,M.D. Mlles Congress,M.D.
'JOMLIIR MT.'DIABLO Mary Jane Connell,M.D. Ildefonso Corpus,M.D. Paul Freitas,M.D.
OHN Carol.loslin,.M.D. T"Drazek,M.D.. Ken Robinson,141.1):
TI►
cophile Koury;1�I.,D.'`:. .::;::'. ::Aridi',ew�Kivcs;,hi;l).;':.::. ;:; :;Ted:KI
H E A. ....L . T . H . S': Y. S; T. . E M ��h;sin-I:
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1601 Y natio Valle►Rd Walnut Creek CA 94598 925-939-5800 Tom Ti he:D.O ;'Henry Turkel;M.D Tohii;Zccticile LVI D.
8 g
Take-Home Instructions for.the Patient
20000923152647• '
.Patient'sName: .::ARLENE'COHEN Date:.:`.:
23
Dia nosis: —
� :...-..: ABRASIONS/NON-SUTURABL;E•I;ACERATION(S)': -
You have sustained injuries that include abrasions(scrapes)or superficial lacerations(cuts)that do not.require:siitures(stitches).
Proper care.of these injuries-will speed up recovery. The abrasions&.laceratiom:should be;,observed:foi signs_of.iiifection(redness/red
streaks;swelling,pain;or drainage of'pus).Thc abrasions:should be cleansed rivice daily"inth,soap} ��ater:or hydrogen peroxide
f`i chons: _ _=_ __ _ ` _=
ns r
I -
•
Clean the abrasions as above to remove/ rev ent crusting and sc #i Hien ':` y an antibiotic ointment'(Bac, :`n,Polyspo ,
P g
etc.). Then bandage(nonstick dressing-',_Telfa'pads-if nee :. pe, et Do not allow scab to;form..".: ill delay healing
; ; '' ' o soften-before.cleansin
and increase.scarring: (If:thick crusting occ ::. sox a,;tr t Vit. ,....: :: . '.. , g)..,
;::::>;::.::.
:
....:. •' til�,
Contact the-Doctor -
f - - - -
Symp
toms Increase or;-!signs. c
Addittonal.Instru
A tetanus immunii :fl13t s
edt tel: t .arran e'to see-tlte ollowt h stctan to T`:'::,,:;.. de's .or:: ollo,>~v:u ;.care
Call tmm a y o., g f.. ng-P.Y.
_.: _ -
I hereby acknowledge rece+pt oft tructi ns u:dicated above.I.understand that'I have;had emergency treatment.and.}Nat.7 maybe°releasgd before°all.my medical'.
problems are knoxv�or.ire ed =x'1 arr ge for follnx p c as instructed above.
t: t nature
M
Patten s
'Tl-IEOP'RILE KOURY�Iv1D::.
I have.expained the.instructions io the patiew' and/or:hir/her i•presentative.has
verbalized understanding of the:instrudions:;l:ligve:given_a_copy ofthe,_
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II'h�n you caU for'an appointment,say:that you were ieferred from this Emergency!Department. Ifyou have problems.mis%ii ig:lhis appouitnieiu:caU the Emergency
Department so we can try to help you. If new or worse symptoms develop.you should call your doctor.as oon as,possible If yod caiinot see the above doctor and your
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condition worsens so.that oure uire.emer en treatment�comeback.to:this_... gruneiu' -
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`Please.note:::Tlie:exariuiriaion aiid trea;tient:that= ou have received in;the Emer en ;.D _drdheru;leaVe beeir_rendered,on an_emer_ency.baric=onlyrnd a-_e,n,
intended fo be a substitute jot or an efjarl to provide completeatedical service it joUox�up doctor orfacc4ty as named above.dl isimpor[ant chat you be checked
again as recommended above and report any new or remaining problmes at that time,becuase it it impossible lorecogiii,•eand treat aU.ela�iieidr,ofinjury or illness in
a single Emergency Department visit In addition,fi an X-Ray has been taken here,:it may have been read on.a prelimiitary:baiis:only;and a fuia[i VI will be amde
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PLEASE REMIT YOUR PAYMENT TO:
JOHN MUIR/MT. DIABLO HEALTH SYSTEM
PA BO,X'9005 E
WALNUT C6;EEK,CA 94596
(925)947-3336
PATIENT NAME ARLENE COHEN
STATEMENT DATE 11/01/00
ADMISSION DATE 09/23/00 109/23/00 DISCHARGE DATE
INTERIM FROM 09/23/00 09/23/00 INTERIM THROUGH
TO: CHARGE TO MY:
ARLENE COHEN ❑VISA ❑MASTERCARD ❑AMEX ❑DISCOVER
10 CANYON VIEW DR CARD#
ORI NDA CA 94563 EXP. DATE
L J SIGNATURE
AMOUNT PAID$
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE
PATIENT NAME ARLENE COHEN PATIENT ACCOUNT NO. 00267-00069 PAGE 0211
.� DESCRIPTION
• • •
*�• 250 PHARMACY
1219/22 1894 DIP-TET TOXOID (ADULT) , 0. 5 ML 47. 00 47. 0E
09/2 5315 APAP/HYDROCOD 5MG U/D, TABLET 13. 80 1 3. 8Q
TOTAL PHARMACY 60. 80 60. 810
>F 272 STERILE SUPPLY
09/2 98038 ER-WOUND/PRE CARE KIT 70. 00 70. 010
TOTAL STERILE SUPPLY 70. 00 70. OQ
** 320 DX X-RAY.
09/2 1066 ELBOW COMPLETE .XRAY' IP ' 412. 50 412. 512
09/22 1068 FOREARM XRAY IP . 317. 25 317. 2E
TOTAL DX X-RAY 729. 75 7229. 7E
324 DX X-RAY/CHEST
09/2 1027 CHEST 22 VIEWS XRAY IP 358. 75 358. 7
TOTAL DX X-RAY/CHEST 358. 75 358. 7
** 450 EMERG ROOM
09/2 3003 EMERGENCY SERVICES 003 L 211. 00 211. 010
TOTAL EMERG ROOM 211. 00 2211. 012
>E* 460 PULMONARY FUNIC
10119/211 6500 OXIMETRY EMERGENCY ROOM 1 35. 00 35. 0E
TOTAL PULMONARY FUNC 35. 00 35. 02
11 465. 312,
10/3 303 I0084BLUE SHIELD HMO PAYMENT 00222 -1, 097. 24
10/31 303 A0004HMO PPO CONTRACT ALLOWANCE 002:2 -229, 306. 021
-30, 403. 24
-28, 937. 94
THE HOSPITAL BILLS FOR CERTAIN HOSPITAL BASED JOHN MUIR/MT.DIABLO HEALTH SYSTEM PLEASE RETAIN THIS DETAIL STATEMENT
PHYSICIANS.YOUR SURGEON,ASST.SURGEON, FOR YOUR RECORDS.ALL SUBSEQUENT
ANESTHESIOLOGIST,RADIOLOGIST,ETC.MAY BILL YOU P.O. BOX 9005 STATEMENTS WILL REFLECT BALANCE
SEPARATELY FOR THEIR SERVICES WALNUT CREEK,CA 94596 FORWARD ONLY.
FEDERAL TAX 1.D.NO.94-1461843 rnD n111 Inlr_I1In1IIDICC 01 MACC rAl I roes)on7.')�qa
VIHK—Ut3—I yJUL) UD-U
I
09,/'23/00 EI 71020 26 CHEST 2 VIEWS ! 1959 . 8 41 . 00
10/216/00 ADJ-BLUR SHIELD 46JUS' .ME + -27 . 18
09/23/00 E 73080 26 ELBOW COMPLETE ', 1 1959 . 8 36 . 00
10/26/00 ADJ-BLUE SHIELD '"JUS'ItME -25 .24
09/23/00 E 73090 26 FOREARM COMPLET4 i 959 .8 33 . 00
10/26/00; ADJ-BLUE SHIELD ADJUSTME -23 . 14
I ! I
I I .
_ ## ##:##v(w###t , *###t#ttt*#*tt#ti}�#ity#tt� t#*#��CftitEr�r#tlttii•�iQtitt ##t --
* or general estions or to u aI'lf,e your insurance information
* ax us at (9 5) 296-7174 or it. us at billing@bqu.net.
* lease inclu a your account n er i smAil or on heck.
## ####t###### t#W###########ttt t!htt#
ADAM
COHEN, ARLENE I0132- 30282 34 .44
LOCATION OF SERVICE —
JOHN MUIR HOSPITAL � I „r
1601 YGNACIO VALLEY ROAD 45.98 I HODDICK W 10/27/00
PLAU OF i[ATKt
.Mrr;yt FIOSMALL S ORICF.
KOURY.Y T I :.Pcn1f1cE�
RT1E.F MOlII•F4 .FN,PS+k4 MOPE
�ooRecarIw..n r.onuF
.EMERlEND ROOM
IBAY IMAGING CONSULTANTS MED GROUP
y ;;::•- , -ti. SPO B
OX 31455
:,a.. .: ,.,r.,.k.S. ''.; `. t i ALNUT CREEK
CA94598
IRS# 44-2965646 PHONE 925/296-7156
n e Answered- 9-00 AM- to 4100 pM-
STMT.1 I J0(5r00NGPStI
TOTAL P.04
I'IHK-Ub-1 jUL) UZ,•U i
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• CA EMER PHYS • J iN MUIR i TAX LD0 DILLINGOlmFICEPHONE
1601 CUMMINS DR., #D-03 I 66-0377445 1(800)340-1260
• MODESTO CA 953581 6403 I ACCOUNT NLUBU DATE OFSTnIEMENT
03-06-00267069 10/31/00
Address Service R�quested PATTF,NT'SNAME•
i I
COHEN ARLENE
LOCATION OF SERVICE
01782--1 CEP JOHN MUIR NED CNTR
(209) 557-1214
ARLENE COHEN � WALNUT CREEK CA 94598
10 CANYON VIEW DRI
ORINDA CA 94563
I
I
I
DATE POS "
GNOSIS I)P.SCRJM' OA'OF S VICES AMOUNI"
09/23/00 23 *• 99284 LEVEL 4 EHERGENCY, :PHYS CHA 210.00
•• 78654 71942, 9239, E8261 I
09/23/Q6 23 78652 947 0-26 PULSE OXIISETRYNGLE - 16.06
09/23/00 23 78652 710 0-26 X-RA INTERP CHOT,PA&LAT 20_00
09/23/00 23 78652 73070-26 X-RAY INTERP ELi6W ;AP LAT 20-00
10/31/00 888BSO BLUI: SHIELD ALL60ANCE 161.67-
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EMPLOYER LNJMY DAfE ADMIS4InN4 bAn DISCHARCiF.DATE
HOMEMAKER 09/23/00104.33
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- RECEIVED
CLAM 2 0 01
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY. ISA
L OF SUPERVISORS
001
Claim Against the County, or District Governed by 1
the Board of Supervisors, Routing Endorsements, I 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
1p;1HI1WZEM) pursuant to Government Code Section 913 and
915.4. Please note all "Warnings".
AMOUNT: IN EXCESS OF $10,000.00
F E 0 0 7 2009
COUNTY COUNSEL
CLAIMANT: ERIC CHILDS MARTINEZ CALIF.
ATTORNEY: c/o JAMS B. CHANIN DATE RECEIVED: FEBRUARY 7, 2001
LAW OFFICES OF JAMES B. CHANIN
ADDRESS: 3050 SHATTUCK AVENUE BY DELIVERY TO CLERK ON: FEBRUARY 7, 2001
BERKELEY CA 94705
BY MAIL POSTMARKED: FEBRUARY 6, 2001
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
PHIL BATCHELOR, Clerk
Dated: FEBRUARY 7, 2001 By: Deputy
11. FROM: County Counsel TO: Clerk of the Board oY Supervisors
is claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3). .
( ) Other:
Dated: dam- 7—O By: .Deputy County Counsel
III. FROM Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
Q(f This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order entered i its minute f r this date.
Dated: O . CKAJ� JOHN StJEETEN Clerk, By Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited
in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
IT
AFFIDAVOF MAILING
NG
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 Claim an addre d to the a' ant as shown above.
Dated: By: ' JOHN SWEETEN By Deputy Clerk
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 un'derstand 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 does 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.
L
e
LAW OFFICES OF
JAMES B. CHANIN
AVENUE
BERKELEY,CALIFORNIA 94705 RECEIVE®
(510)848-4752 .
_
FAX(510)848-5819 X�;
c7'
CLERK BOARD OF SUPERbdSOR$ .
CONTRA COSTA CO.
February 6 , 2001
Clerk of the Board of Supervisors
Contra Costa County
651 Pine Street, Room 106
Martinez, CA 94553
Re : Eric Childs v. County of Contra Costa
Dear Sir of Madame :
Enclosed please find a copy of the Government Tort Claim in
the above-mentioned case . Our office submitted this claim on
February 6 , 2001, requesting that a stamped copy be mailed to our
office .
Please stamp this copy showing the date it was originally
received by your office, and mail it to our office in the
enclosed self-addressed, stamped envelope .
Thank you very much for your time and attention to this
matter, and please do not hesitate to contact our office if you
have any questions .
Very truly yours,
LAIR F ICES OF JAMES B . CHANIN
Case atton, legal assistant
Enclosures
p - •
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o�
C�1
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6� N
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4�
r'
/ LAW OFFICES OF
JAMES B. CHAN IN
3050 SHATTUCK AVENUE
BERKELEY,CALIFORNIA 94705
(510)848-4752'•:'
FAX(510)848-5819
,r
RECEIVE®
FEB - .1200f
February 6, 2001
CLERK BOARD OF SUPERVISORS
CONTRA COSTA CO.
Clerk of the Board of Supervisors -�
Contra Costa County ✓� �,(p
651 Pine Street, Room 106V_'
Martinez,
Martinez, CA 94553 V �{ <
Re : Michael Davis v. County of Contra Costa l� C�
Dear Sir of Madame :
Enclosed please find the original and one copy of the
Government Tort Claim Against the County of Contra Costa .
Please file the original and return and stamped copy to our
office in the enclosed self-addressed, stamped envelope .
Thank you for your attention to this matter.
Very Truly Yours,
LAW O F CES OF JAMES B . CHANIN
Casey atton, legal assistant
Enclosures
JAMES B. CHANIN (SBN# 76043)
Law Offices of James B . Chanin
3050 Shattuck Avenue
Berkeley, California 94705
(510) 848-4752
Attorney for Claimant
CLAIM AGAINST THE COUNTY OF CONTRA COSTA
ERIC CHILDS )
Claimant, ) GOVERNMENT TORT CLAIM
Cal . Govt . Code §810, et seq. )
VS . )
COUNTY OF CONTRA COSTA ) ED
REC,�
}
FEB - l
CLAIMANT' S NAME: ERIC CHILDS
CLERK SOAF:►?OF SI;PERVISORS
CLAIMANT' S ADDRESS : 1621 Mariposa Street COPITRACOa�ACO.
Richmond, CA. 94804
CLAIMANT' S TELEPHONE NUMBER: (510) 524-6627
PLEASE NOTE: CLAIMANT IS REPRESENTED BY COUNSEL AND ALL
COMMUNICATIONS SHALL BE THROUGH HIS COUNSEL
ADDRESS TO WHICH NOTICES ARE TO BE SENT:
JAMES B . CHANIN, LAW OFFICES OF JAMES B . CHANIN, 3050
SHATTUCK AVENUE, BERKELEY, CALIFORNIA 95705 (510) 848-4752 .
DATE OF THE INCIDENT:
Beginning on or about December 7, 2000 .
LOCATION OF ACCIDENT OR INCIDENT:
Claimant was taken into custody at his home in Richmond,
California.
1
HOW DID THE ACCIDENT OR INCIDENT OCCUR:
On or about November 19, 1999, the Claimant was arrested
and charged with driving under the influence . The criminal
action filed in the Superior Court of Contra Costa County,
Richmond Division was entitled, People v. Eric Childs, Docket
No. 261252-1 .
i
On or about March 24, 2000, Claimant pleaded no contest
to Count 2 of the criminal complaint . As a result, Claimant
was sentenced to a three year term of probation.. One of the
conditions of his probation was that Claimant was required to
enroll in and complete the Contra Costa County Post Conviction
Drunk Driving Program (hereinafter, CCC Post Conviction DDP) .
Claimant enrolled in the CCC Post Conviction DDP. A copy
of the '.'Proof of Enrollment" form for said program is attached
and incorporated herein by reference as Exhibit 1 .
On or about July 3 , 2000 , Claimant completed the CCC Post
Conviction DDP. A copy of . the "Notice of Completion"
certificate evidencing Claimant' s completion of said program
is attached and incorporated herein by reference as Exhibit 2 .
Claimant complied with all the other terms and conditions
of his probation.
Nevertheless, on or about September 26 , 2000 , Claimant is
informed and believes and thereon alleges that the Contra
. Costa County Superior Court stated in its docket for that date
that Claimant failed to enroll in the CCC Post Conviction DDP .
A copy of the Clerk' s Docket and Minutes for September 26 ,
2000, is attached and incorporated herein by reference as
Exhibit 3 . -
As a result, Claimant is informed and believes and
thereon alleges that on or about October 6 , 2000, a no bail
warrant was issued for Claimant ' s arrest based on the false
information contained in the Court' s file stating that the
Claimant had not completed the CCC Post Conviction DDP. A
copy of the Clerk' s Docket and Minutes for October 6, .2000 , is
attached and incorporated herein by reference as Exhibit 4 .
Claimant does not have access to the information at this
time which would establish which specific Contra Costa County
employees, agents and/or servants were responsible for the
failure to properly document Claimant' s enrollment in and
completion of the CCC Post Conviction DDP. Whether the CCC
Post Conviction DDP program failed to properly notify the
Court of Claimant' s completion of the program or whether the
Superior Court staff failed to properly document or record
Claimant' s enrollment and completion of the program is
2
information which Claimant is informed and believes and
thereon alleges should be in the possession, custody and/or
control of the County of Contra Costa .
After the no bail warrant was issued on or about October
6 , 2000 , Claimant received no notice from anyone associated
with Contra Costa County, including the Superior Court, the
CCC Post Conviction DDP or anyone else, indicating that a
warrant had been issued for his arrest or otherwise alerting
Claimant that there was any problem with respect to the
confirmation of his enrollment in and completion of the CCC
Post Conviction DDP.
Thereafter, on or about December 7, 2000 , Claimant is
informed and believes and thereon alleges that the Contra
Costa County Sheriff' s Department conducted a large scale
drunk driving warrant sweep throughout Contra Costa County.
On or about the evening of December 7, 2000 , Claimant was
at his home watching television when members of the Contra
Costa County Sheriff' s Department came to his home as part of
the warrant sweep. At that time, Claimant was arrested
without reasonable or probable cause as a result of the
failure of Contra Costa County employees, agents and/or
servants to properly document his enrollment in and completion
of the CCC Post Conviction DDP.
On or about December 8 , 2000 , after the Claimant had
spent approximately 18 hours in the City of Richmond Jail, the
West County jail facility and had been stripped searched, the
Claimant was informed that his warrant had been "recalled" by
the Court . Despite the fact that the warrant had been
"recalled, " Claimant is informed and believes and thereon
alleges that he continued to be held in jail and was strip
searched after the time when the warrant had been recalled.
The Claimant was eventually released from jail when it
was determined that there was indeed no legal basis for his
arrest and imprisonment .
Claimant is informed and believes and thereon alleges
that the County of Contra Costa maintains customs, policies or
practices which cause persons, such as Claimant, to be
arrested without reasonable or probable cause as a result of
inappropriate or inaccurate record keeping and reporting
functions by persons working in and/or associated with the
Contra Costa County criminal justice system.
Claimant' s causes of action against the County of Contra
Costa and/or its employees as a result of this incident
include, but are not limited to : negligence, negligence per
se, negligent supervision, false arrest, false imprisonment ,
3
unreasonable search and/or unreasonable seizure, violation of
civil rights, violation of mandatory duties, infliction of
emotional distress and other claims or causes of action to be
determined as discovery continues .
DESCRIBE INJURY OR DAMAGE :
Emotional distress, pain, suffering, wage loss,
deprivation of civil rights, statutory damages, attorneys
fees, punitive and exemplary damages in amounts to be
determined according to proof .
NAME OF PUBLIC EMPLOYEE (S) BELIEVED TO HAVE CAUSED INJURY OR
DAMAGE :
Does 1-100, presently unknown County of Contra Costa
employees, agents and/or servants .
DEMAND FOR PRESERVATION OF EVIDENCE :
Claimant does hereby demand that the COUNTY OF CONTRA
COSTA including. its employees, agents, servants and/or
attorneys, maintain and preserve all evidence, documents and
tangible materials which is and/or may be relevant to the
subject matter of this Claim during the pendency of this
matter, including until the completion of any and all civil
and/or criminal litigation arising from the events which are
the subject matter of this Claim. This demand for
preservation of evidence includes, but is not limited to, a
demand that all police department and/or other public safety
communications tapes be preserved until the completion of any
and all civil and criminal litigation arising from the subject
matter of the events which are the subject matter of this
Claim.
AMOUNT OF CLAIM:
Claim is in excess of $10 , 000 . 00 . Jurisdiction is in the
Superior Court of the State of California for the County of
Contra Costa and/or United States District Court for the
Northern District of California.
DATED: February 6 , 2001 LAW OFFICES JAMES B . CHANIN
B
Y
ES B. CHANIN
Attorney for Claimant
4
PROOF OF ENROLLMENT 107
A Public Service Agency
NAME(LAST.FIRST.MIDDLE) PLEASE PRINT BIRTHDATE DRIVER LICENSE NUMBER
I 'A I
20565977
ADDIESIH+W I E"Ic (C'q 50 (STATE) - (ZIP CODE)
rA 04A014
1st OFFENDER MONTHS ❑ 5 MONTH RESTRICTION: 0 MULTIPLE OFFENDER
Drive to and from treatment program; to
3 MONTH RESTRICTION: [1 18 MONTHS
Drive to and from treatment and from employment;and during course of
program. employment. ❑ 30 MONTHS
Restrictions may begin after a mandatory 30 day suspension ends. ❑ 18 MONTHS OF 30 z MON.THS(IID RESTRICTION ONLY)
DATE OF ENROLLMENT VIOLATION DATEURTCODE DOCKET NUMBER
2 1 70
')A1252-1
PROGRAM 14Amt ADP LICENSE NUMBER
roriviction DDP f)7—()j)j—('pl —1
PROGRAM ADDRESS (STREET) (CITY) (STATE) (ZIP CODE)
?Q5 /&I St st:yppt Ri e-hmnnd CA Q 14 P)0 S
The following parties certify,under the laws of the State of California,that the foregoing is true and correct.
DATE PARTICIPANTS SIGNATURE TELEPHONE NUMBER
DATE AUTHOTAEDF50GRAM REPRESENTATIVE'S SIGNATURE PRINTED NAME TELEPHONE NUMBER
4/6, C C
Senior Crk 5101 'T" G ill
'-- I
INSTRUCTIONS To PART)CIPAW-� W
Mail QIVIVp L1 Senior
eDMV Mandatory Actions Unit, MIS J233, P.O. Box 942890, CONTROL NUMBER
Sacramento,CA 94290-0001,or submit DMV copy to,the nearest DMV office in your area.Before a restriction is processed,proof of
Financial Responsibility and payment of a reissue fee must be received. COURT COPY 051979
DL 107(NEW 1/99)
•
AX,
•}gl
RAFERC&FOO NA
NOTICE OF COMPLETION 183
CERTIFICATE07AAW,0FN0r0#1vDoafs
NAME (FIRST) (MIDDLE) (LAST) BIRTH DATE DRIVER LICENSE NUMBER
17%j C OULD:i 3-3-50 R0565977
ADDRESS (STREET) i tic l ictL A�. t (CITY) lnl (STATE) `'n (ZIP CODE)
plc}
940
has successfully completed a Driving-Under-the-Influence Program licensed by California Department of Alcohol and Drug Programs to provide the following service:
1st Offender Program 6 months
❑ Multiple Offender Program .❑ 12 months ❑ 18 months ❑ 30 months ❑ 18 months of 30 months(IID restriction only)
DATE OF ENROLLMENTDATE OF COMPLETION COURT CASE OR DOCKET NUMBER
1-13-1)0 7-3-042 2617.52-1
PROGRAM NAME ADP LICENSE NUMBER(REOUIRi
GCC 1'>l;st: Conviction DD1' ()7-CIUl-0 -1206
PROGRAM ADDRESS (STREET) (CITY) (STATE) (ZIP CODE)
205 41st St. _ _ ilia=nd (11A 94804
The following parties certify under penalty,under the laws of California,that the foregoing Is true and correct(perjury is punishable by Imprisonment,fine or both
DATE PARTICIPANTS SIGNATURE TELEPHONE NUMBER
DATE .,7-3--WCf AU F+I R)�ZED PROGRAM R PRES NTATIVE'S SIGNA !E_ T P�fpN [SUM EP
7-� i� lt.s.t . • •`i;✓_ ( -iZ% al�P�t� �Y r�i=,� �' rFiU} /4U�.{�
Instructions to Participant: Submit copy of this form to the nearest DMV,office Jn-your afear or,TO P copy,to.DMV Certificate Number
Consolidated Processing Area,P.O.Box 942890,Sacramento,CA 94290-0001E4?dOTE:°If this'is'a second'offense,
a$20 fee for removal of court restriction may be due to DMV. P` J��n]� ((�� qq
DL 101(REV.I Z%) PROGRAM COPY A.A 3:Z J'�F
SUPPLEMENTAL
MUNICIPAL COURT FOR THE BAY JUDICIAL DISTRICT
COUNTY OF CONTRA COSTA, STATE OF CALIFORNIA �-
CASE NO.
DEFENDANT(NAME) � �'�� .� `-' DATE
RMl.!,LZlZZly 7`227
t
1
7
6
7
8
s
g
1
5
SUPERIUR COURT, COUNTY OF CONTRA COSTA, STATE OF CALIFORNIA DOCKET NO.
40TICE, ENTENCE,SOMMITMENT FORM CLERK'S DOCKET AND MINUTES
DEFENDANT DEPT_DATE C TIME _
ADDS _— — DOB
ROC i —-—----
__PROB---__.--DEFENSE ATTORNEY____. _ TIME_ WAIVED
CUSTODIAL STATUS
CHARGES
PROCEEDINGS TES CERTIFIED CORRECT
COURT DEPUTY
JUDGE �_ -- —REPORTER CLERK
ASSIGN. COURT DEPUTY
TO DEPT. JUDGE_ __ —REPORTER --------CLERK _
APPLICABLE ENTRIES MARKED
❑ Deft.proceeds in PRO PE R ❑ Answers true name as charged w r l Bene nest t I jjue
P ❑ Deft.appears ❑in custody�Deft. not appearing R A= rt$
E ❑ With/by AttyJPub. Def./ADO A ❑ WaIves Ardreading of Complaint R ❑ Recalled ❑Set Aside ❑Remain Out
A El Deputy Dist.Atty. H El Handed copy of Complaint/Discovery N
R ❑ No PTA Release. ❑ No Vol.App.
A ❑ Court Probation Off. M ❑ Deft.duly arr. ❑ Video ❑ on Prob.Vio. T ❑ Hold until
N
c ElInterp. sworn/cath on file N ❑ Deft.waives are.on amended complaint. R ❑ Bail forfeit&continued 190 days El Bail Exon
E B
El cert. ❑ ElCerNon-Cert. Qualified per Rule 984.2 T A E ❑ Bail forfeiture set aside&reinstated
❑ Order Int.❑ Int. Coord. notified L g upon payment of fee$
❑ Referred To: PUBLIC DEFENDER w El Written Plea filed ❑Pleads Guilty,Ct.# c
A ty 0 ❑
R ❑ Referred To: PROB.Bail Study/PPR 1 ❑ Pleads No Contest, Found Guilty,Ct.# N
F ❑ Referred per❑288.1 PC❑1368 PC E ❑ Pleads Not Guilty,Ct.# 1 ❑
E ❑ Adult Pre-Trial/PC 1000 Diversion eligibility R N
Rs/ ❑ Jury Trial Waived/Demanded u
R ❑ Pub. Def. Conflict Filed;Appointed ADO p A ❑
A ❑ Report 20 for booking ❑ Time for Trial/Sent Waived/Not Waived N
L
❑ 977 waiver filed ❑170.6 PC filed/oral n ❑ Time for PX 10/60 Days Waived/Not Waived E ❑Vacate date of
❑ In re law notice given s ❑ Admit/Denies Priors/Refusal/Enhance s ❑ Def. must/need not appear
❑ Peo/Def. Motion totfor/cont. p❑ Court Probation granted for motyr
0❑ Submitted with argument❑without argument o❑ Adult Pre-Trial/PC 1000 Diversion granted
❑ Granted ❑ Denied ❑ Submitted ❑No Action Taken aE:] ProbatiorVDiversion/Reinstated/Modfied/Extended to
O❑ Grounds: T Original terms in full force and effect except as ordered.
N I
g❑ D.A. Motion to file amended complaint 0❑ D .givephraW rights to Revoc.Hg;Admits/Denies allegations
❑ Complaint amended on its face to add Ct.#�, N Prob. voked: Def.found in violation of probation
R a violation of section ❑ Probst ion
D :Terminated:SuccoMtuliy/Unsuccessfully/Denied
E ❑ Pursuant to 23103.5CVC ❑ Pay Prob.Vio.fine of$ ❑ Upon payment of fine/completion of jail sentence
R
g
El Strike the words felony and feloniously.Substitute the ❑ Crimi I Proceedings Reinstated/Dismissed
word misdemeanor wherever it appears in Complaint.
❑ Per CourVDA dismiss,Complaint/Ct.#
F❑ Pay a fine of$ ❑Rest.Fine of c ❑Be imprisoned days/months/years o❑ Obey all laws.
I ❑ Pay$10 cite fee/$25 Booking Fee/$ CJA Fee M ❑ days/montha/years credit n C3 Do not use any alcohol.Do not
N
E❑ Pay balance of fine/Din lieu of fine❑Susp.$after fine.M ❑ days/montha/years suspendedo go to places where alcoholic
s❑ Make monthly payments to CCU P.O.Box 1669 Martinez,CA 94553 T ❑Sentence to commence N beverages are the chief item of sale.
D
D Phone(510)646-1951 by E ❑Serve consecutive/concurent 1 ❑Attend—ANNA
R
D 11hours Volunteer work by Fee$ N El with ❑with any sentence meetings per week and present
T
E[3Re-refer/reinstate.to Level I/Level II/PCDDP s ❑Main Jail 11Electronic Home Detention N proof at each court appearance.
s❑ Referred to ORC for Attorney Fee Costs of$ ❑WAP Contact CAB immediately/within 15 days. s❑ Submit to search and testing
F❑ License Suspended/Revoked monthslyears ❑Day for day credit for time served in approved residential ❑ Destroy❑ Return weapon
E
E❑ DL310/DL309 Served❑ Advised 14607.8 CVC program.Proof by ❑ Stay away from
a❑Pay fine/comply or appear on at
OCT 062000 CCU NOTIFIE( WARRANTE .- /RECALLED IN COMPUTER �
❑REMANDED to County Jail: ❑Ordered released ❑On OR ❑Promise to Appear ❑Def.to be allowed phone calls
Bail Set in the amt.of$ ❑Court Courtesy ❑ State Prison Commitment Corlmitted to cus"uAl sentence is satisfied in full
TO THE SHERIFF;COM ITMENT:I hereby certify that this is a true copy of the Entry of Judgment or order n r ` e execution thereof.
❑See Lothe ' ute ag for additional proceedings.
DATED: (JUDGE OP THE SUPERIOR COURT;- GRIM.MINUTES(6/98)
1 PROOF OF SERVICE
2 I , the undersigned, declare that I am a resident of the
State of California, over the age of eighteen years, and not a
3 party to the within action; my business address is the Law
Offices of James B . Chanin, 3050 Shattuck Avenue, Berkeley,
4 California 94705 . On the date set forth below, I served the.
within documents :
5
GOVERNMENT TORT CLAIM AGAINST THE COUNTY OF CONTRA COSTA
6
by transmitting via facsimile the above-listed
7 document (s) to the fax number (s) set forth on the
attached list on this date before 5 : 00 p .m.
8
X by placing the document (s) listed above in a sealed
9 envelope with certified postage thereon fully prepaid,
in the United States Mail at Berkeley, California,
10 addressed as set forth below.
11 by causing the personal delivery of the document (s)
listed above to the person (s) at the address (es) set
12 forth on the attached list .
13 I am "readily familiar" with the firm' s practice for
collection .and processing of correspondence for mailing with the
14 U.S . Postal Service, and in the ordinary course of business
correspondence would be deposited with the U. S . Postage Service
15 the same day it was placed for collection and processing.
16 X (State) I declare under penalty of perjury under the
laws of the State of California that the aboveis true
17 and correct .
18 (Federal) I declare that I am employed in the office of
a member of the bar of this court at whose direction
19 the service was made .
20 Executed on Februay 6, 2000 , at Berkeley, California .
21
22 asey atton
23
Clerk of Board of Supervisors
24 Contra Costa County
651 Pine Street, Room 106
25 Martinez, CA 94553
26
27
28
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CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
BOARD ACTION:MARCH 6, 2001
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 I 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
R67313
� IEDpursuant to Government Code Section 913 and
915.4. Please note all "Warnings".
FEB 0 6 2009
AMOUNT: $2,736.20
COUNTY COUNSEL
CLAIMANT: OSCAR RAMIREZ
MARTINEZ CALIF.
ATTORNEY: DATE RECEIVED: FEBRUARY 5, 2001
ADDRESS: 1243 VICTORIAN CR BY DELIVERY TO CLERK ON: FEBRUARY 5, 2001
GREENFIELD CA 93927
BY MAIL POSTMARKED: HAND-DELIVERED
I. FROIVL• Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim..
PHIL BATCHELOR, Clerk
Dated: FEBRUARY 6, 2001 By: Deputy
H. FROM- County Counsel TO: Clerk of the Board of Supervisors
( his claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: Z $o By: Deputy County Counsel
III. FROn- Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
�f This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order n its mi t s for this date.
Dated: JOHN SWEETEN Clerk, By ° , Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited
in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVIT OF MAIIdNG
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 Claima , addre to the ial mant as shown above.
Dated: By: . ,JOHN SWEIJIEN By Deputy Clerk
CC: County Counsel County Administrator
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 does 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.
5
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 100a' 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 91553.
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: ClLim By Reserved for Clerk's filing stamp
0-sC.6.12
)
RECEIVED
Against the County of Contra Costa or > FEB - 6
2001
Dt LTA Mum 1("1PPk-L C-D(12'f,pi TTc WeDistrict) CLERK BOARD OF SUPERVISORS
(Fill in name)V 4,Nv t LLE k4VrJ►c-1PA`ICo0RT1WaLNvTGe.) CONTRA COSTA CO.
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district
in the sum of$ and-in support of this claim represents as follows:
Zr73e.Zo
1. When did the damage or injury occur? (Give exact date and hour)
Z WPrS PraQCS?£0 pnl p i—1 y-D 1 1j,�/ GREENF/eLDSCA Ar-T P PP9n,/vrP-METLy
12:vi hM X02 ACJ puTS-rA�NDiQ(a c.vat+_Qa.,/? FpfR- !�)ZO,Ooo buT OF CoN-reds, Costa.
&0 uNT-(�P1TT5 a0 aLq k41
2. Where did the damage or injury occur? (Include city and county)
WP-S AE212F_6'teb ItJ
M orJ-T6R-�`E �uN7 r
AvAUtvp-si -rue couN-ry JAIL TD &WA kT E�T2AD�TlO�,
3. How did the damage or injury occur? (Give full details; use extra paper if required)
w�S �QOCaf� P�i CpvN'r11 3Pvtk__L MnNMs2*J tovNTY) VNOWIAJ& LT WPClNT
M,E _ N�Vs�— "Nc> Cern/ TO CCIT � Cosi? Couw�. : D7EClO15Q
To ,Atm o�
TU C- or M-1 X03 p--r Psi 'F>0-r-r b, _
2017. Tp 3� +2�1 �5c�,'CIIP-� SA,NAE DA,:1 .
� Q .R ZoO1
BuNo . Aso ��TE� X511,00
Q W,1R22A ,rf ,cUfZ �S�Uoo.
.t
• 4.' What particular act or omission on the part of county or district officers, servants, or employees caused the
injury or damage? -TUC- cou Nl-y
� � 155 �� A W�2�p+rJ'r {=D t2 � W tTu ou j GU,�tN� Dlo� 0.N0 v lTa�S-[PtTISTlCS
w�� To-[P.w`I ��+-F>✓�26NT NEt(au'f, Daw L-►c.iW6(biAT, .wCleE To-r,-L0J 171-'FE�eF. T
5. What are the names of county or district officers, servants, or employees causing the damage or injury?
CC-)t-J'CteA ( os7A ,' , �y,CA,
PA lV\ 1 l.lx l�u N C{�AL t-bt)�T,w�W UT C.►Q e�c ,C.6-
6.
C.6-6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach
two estimates for auto damage.) Z PP lD t2t 0k' C0A ND 517.o0 CoNAatN-c-D —10
t'o r.kt—
1 Ao 1.1 C Ouwr`{ T O t?R.OU 6 M" X t's00 le.-V--IJ cc-
7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or
damage.) _1 pL,io lDolo DF= abviD ON G— FDR. �, Z10L7_ (7o p.NDJ,,5l7.00.
� � DsMc�+ M
,v�tSsEo Twn Zags o:F- wdQkf-� 1 � l � t5 l2 ,7o l ,z
8. Names and addresses of witnesses, doctors, and hospitals.
-S Ao.rl�DtZA- -t�->1---TR-J&S.—IZLI V t L-c o tZt p.cv C rz 6A9E5N:�:t&LZ- C-P. `330127
Ca Qp \SCuk;&Z2o i 1 aAC—f CJ,
9. List the expenditures you made on account of this accident or injury.
DATE TEAE AMOUNT
lu"(71 $q:oo 21D17•op
1'
14-d1 4f' o0
l—
Z,3-01 9 too .A',v'� 5p�tp
Gov. Code Sec. 910.2 provides "The claim must be
signed by the claimant or by some person on his behalf."
SEND NOTICES TO: (Attorney
Name and Address of Attorney )
j
(Claimant's Signature)
V Crz
(Address)
"C ti I--I a C-!'- c'Sol 2=7
Telephone No. Telephone NL`031 ) (07L4-'�5 17
******************************************************************************************
NOTICE
Section 72 of the Penal Code provides:
Every person who,with intent to defraud,presents for allowance or the payment to any state board or officer,or to any
county, city,or district board or officer,authorized to allow or pay the same if genuine,any false or fraudulent claim,bill,account,
voucher,or writing,is punishable either by imprisonment in the county jail for a period of not more than one year,by a fine of not
exceeding one thousand($1,000),or by both such imprisonment and fine,or by imprisonment in the state prison,by a fine of not
exceeding ten thousand dollars($10,000),or by both such imprisonment and fine.
erican Contractors Indemnity Company RECEIPT and STATEMENT OF CHARGES
•Airport Blvd.,9th Floor,Los Angeles,CA 90045(310)649-2663 _
POWER NO
Rec from: . ? .*If i ' * rro
/ ID
CA,/
NAME v'
ADDRESS
' ;
......... ... .
(�
Expenses Itemized in detai,such as Guard Fees,Recording Fees,Notary Fees,Long Distance Calls,
p (T v r actual unusual expenses)
. ;CHAR "•t `'
G
Q Tele rams,, ra el and other sua
°CHARGES .;.,:.
v 1-
Was collateral taken: ( )NO if Yes: ❑CASH L PROPERTY ❑OTHER ..,..:-.-.RE El E
V )
Name
N.
ofI BoACCQUNT,;:;';._ ^' �!`.:a�:'�:.•�
Q nd Icy - t!.
By
IL
MEMORANDUM OF BOND F URNISH&4MbtT BE COMPL pry •7;;.; nr); ?e . c,•:n
V DEFENDANT v _ / — DATE O IRTH /
W LAST NAME 1 C� FIRST MIDDLE
q
APPEARANCE DATE CK-J [ ' /TIME ( v v` COURT `l CITY C� -
,// COURT CODE
CASE NO. / J /.3J t CHARGES ` [ (� �'L�'�L_LBOND AMOUNT$
POSTED F04I I.�' DATE EXECUTED _v r f -�'STATE EXECUTED
Received Copy
REWRITE 13OND NO. ORIGINAL AMOUNT$ of above receipt D
i
American Contractors Indemnity Company RECEIPT and STATEMENT OF CHARGES
'Airport Blvd.,9th Floor,Los Angeles,CA 90045(310)649-2663
Rec ' edtrom:! POWER NO.
NAME
A ,DRESSNA
;<+ �J.. :J;•:
1 Q1F:= -
t3AIL�90` -
.� en PREMIi1M
ses
P (Itemized in d
stall, _
suc as Guard Fees,Recordin F ��
= Tele g ees,Nota :.
grams,Travel and other' sinus Notary Fees,Long Distance Calls
ual expenses). ,..: •-MISC:..-;:•,..:^;.; .,;�,� .�..,.:. �:,
CHARGES
- :.:, .TOTAL:;; �;. ..,.....'�x.-;•
Was collator CHARGES
al taken:(Y N if.Yes:
-
( es: ❑CASH p. `''l:'".c.7'
Name I REA TY
Ball
gid Agency .S,?,
By
MEMO BALANCE?` I, =1;::;>: +c_:•>" '':•:::.7i +..:;,5:
RANDOM OF BAIL B D FUR. ED(MUST BE PLETEp
I DEFENDANT
� 1\
TwME R C DATE OF BIRTH / 7✓
APPEARANCE DATEDOLE
ME
�MI,
♦ L �///l / />
I CITY
COURT CODE
CASE NO. c ( v� L/� 7 + ! " / /
I CHARGES �LrND AMOU
NT$PO F1
`� —
DATE EXECUTED �ft ( —( V STATE EXECUTED {" 1
RE%VR[TF40ND NO. e(aA
—� ORIGINAL AMOUNT$ I Recehred Copy t)
J C
n..� I`.. �of above receipt l
_. Slpnerun --I
....i i t t «! "}"{it+`.���7;- - !^•.[ 1' ; . ..iJi'''�,r 04 J..41.2.33f,?y._2 i
4ENIENCE,COMMITMENT FORM CLERK'S DOCKET AND MINUTES
iy• ,J', .> " 1.0 -00 I't
—DEPT. 5' DATE t•• ' �`€2•-.TIMEF'
--t_-:-------. / _— .S�..;;,�DOB U; s'1.1.r
� /7:
ADDRESS__ - tr" 9=v: — WAIVED
---.-----_-- FE EATTORNEY--...---. TIME
CUSTODIAL STATUS WARR
�-
CHARGES-__ L_A I—a a_Y,•rrk 'i''.ti=--- ----^--- '
PROCEEDINGS MINUTES CERTIFIED CORRECT
COURT w r-► ! DEPUTYI
JUDGE---.---"�'' —-- - --..---- ----------•REPORTER-------_,— CLERK
ASSIGN. COURT DEPUTY
TO DEPT._.-..__.___JUDGE____ ___..—__—._______.___ __REPORTER _ _—CLERK
APPLICABLE.r3NTRIES MARKED
A ❑ Qeft.proceeds in PRO PER A ❑ Answers true name as charged ❑ Bench/Arrest Warrant to Issue
P Deft. appears ❑in custody❑Deft.not appearing R n Ball at$
P . .
E ❑ With/by Atty./Pub. Def./ADO n ❑ Waives Arr/reading of Complaint R ❑ eR called ❑Set Aside❑Reinain Out
R ❑ Deputy Dist.Atty. G ❑ Han copy of Complaint/Discovery A ❑ No PTA Release ❑ No Vol.App.
A ❑ Court Probation Off. M eft.duly arr.❑ Video ❑ on Prob.Vio. T ❑ Hold until
N .
C ❑ Interp. sworn/oath on fife N ❑ Deft. waives arr.on amended complaint. a R ❑ Bail forfeit&continued 190 days ❑Bail Exon
E
❑ Cit. ❑Non-Cert. ❑Qualified per Rule 984.2 T A e ❑ Bail forfeiture set aside&reinstated
❑ Orr Int.❑ Int.Coord.notified L g upon payment of fee$
❑ Referred To: PUBLIC DEFENDER w c
A ❑ Written Plea filed ❑Pleads Guilty,Ct.#. D ❑
R ❑ _Referred To: PROB.Bail Study/PPR I N
F El Refe'rred per❑288.1 PC El 1368 PC. v 0 Pleads No Contest, Found Guilty,Ct.# T
E ❑ Pleads Not Guilty,Ct.# 1 ❑
R ElAdult Pre-Trial/PC 1000 Diversion eligibility R N
R El Pub. Def.Conflict Filed;Appointed ADO ❑ Jury.Trial Waived/Demanded U ❑
A C3 Report lo for booking L ❑ Time for Trial/Sent Waived/Not Waived N
S ❑ 977 waiver filed ❑170.6 PC filed/oral n ❑ Time for PX 10/60 Days Waived/Not Waived e El Vacate date of
❑ In re law notice given - s ❑ Admit/Denies Priors/Refusal/Enhance s ❑ Def. must/need not appear
❑ Peo/Def. Motion to/for/cont. P❑ Court Probation granted for mo/yr
0 El Submitted with argument❑without argument. 614 Adult Pre=Tdal/Pa..1400-0iversion granted
❑ Granted ❑ Denied ❑ Submitted ❑No Action Taken 9 E) Probation/Divers gn/Reinstated/Modified/Extended to
A ..:�.
o❑ Grounds: T Original terms in:tull force and effect except as ordered.
N l
.s❑ D.A. Motion to file amended complaint o❑ Deft:given/waived rights to Revoc.Hg;Admits/Denies allegations
o❑ Complaint amended on its face to add Ct.# N❑ Prob. Revoked: ❑Def.found in violation of probation
R a violation of section ❑ Probation/Diversion:Terminated:Successfully/Unsuccessfully/Denied
D
E ❑ Pursuant to 23103.5CVC ❑ Pay Prob.Vio.fine of$ ❑ Upon payment of fine/completion of jail sentence
R
s❑ Strike the words felony and
dffelQgiously.Substitute the ElCriminal Proceedings Reinstated/Dismissed
WOW ftisde Heanor wherever It appears inr
�hPef Court/ A dismiss,Com plal Ct.# 141-
F❑ Pay a fine of$ ❑Rest. Fine of c ❑Be imprisonedIF days/months/years . o❑ Obey all laws.
1R
❑ Pay$10 cite fee/$25 Booking Fee/$ CJA Fee M ❑ days/months/years credit El Do not use any alcohol.Do not
N
E❑ Pay balance of fine/❑In lieu of fine❑Susp. $after fine.M ❑ days/months/years suspended C0 go to places where alcoholic
S❑ Make monthly payments to CCU P.O.Box 1669 Martinez,CA 94553 T O Sentence to.commence N .beverages are the chief item of sale.
D
o Phone(510)646-1951 by E ❑Serve consecutivelconcurrent 1 ❑ Attend AA/NA.
R
D❑ hours Volunteer work by Fee$ N ❑with ❑with any sentencei meetings per week and present
T
R❑ Re-refer/reinstate to Level I/Level II/PCDDP. s ❑Main Jail❑Electronic Home Detention N proof at each court appearance.
SO Referred to ORC for Attorney Fee Costs of$ ❑WAP ContactCAB immediately/within 15 days. s❑ Submit to search and testing
F❑ License Suspended/Revoked months/years ❑Day for day credit f�r time served in approved residential ❑ Destroy❑ Return weapon
E
E❑ DL310/DL309 Served❑.Advised 14607.8 CVC program.Proof by ❑`Stay.away from
s❑Pay fine/comply or appear on at
❑REMANDED to County Jail: ❑Ordered released ❑On OR ❑Promise to Appear ❑Def.to be allowed phone calls
Bail Set in the amt.of$ ❑Court Courtesy ❑ State Prison Commitment ❑ Committed to custody until sentence is satisfied in full
TO THE SHERIFF:COMMITMENT:'I hereby certify that this is a true copy of the`Entry ol'Judgment or Order and is your authority for the execution thereof.
❑See other minute pages for additional proceedings.
DATED: (JUDGE OF THE SUPERIOR COURT) CRIM.MINUTES(8/98)
CR-3005
LJSee attached additional orders. :,'
SUPERIOR COURT, COUNTY OF CONTRA COSTA, STATE OF CAUFOANIA
PT'f' 'S)?[JRf; FT PE'RIOR Q;'YJRT
1"
IOTICE.,.SENTENCE, COMMITMENT FORM
DOCKET!L CLERK'S
f'lSC"'R C7�.j NA!'.TnrL 3.0
)EFENDANT_??—T�.r;+ �,r . -�- ----- STT i�P�7i�J--DEPT. `•,\ - DP�TE TIM _
tDDRES3_---. �,; iJ� =�,A:C=T------ -------- DOB
HEAR..A rt TFIC (� TIME__ WAIVED
IOC F` -- - ---DEFENSE ATTORNEY..- - --= - - —= ---
;USTODIAL STATUS TA P;m
-3 P.A.. rpt 9C 4g. C F.8 til
:HAPGES_ ---=------ =_-N 4r.. c —ljt
PROCEEDINGS ! S - '
n '+ r*;+ rTC''+T COURTi �' iu MINUTS TIFIfD�('OARECT
.. �' i_:.a :. l.:. �' ' _ r DEPUTY' 37 ,,
JUDGt_.------._^._----- -- ----------.-_____ -REPORTERj:�y e.,�Q_' CLERK
4SSIGN. COURT � ` / f'r�pEPUTY
r0 DEPT.__—__—JUDGE__..____::.__.-_...__.._•-.�— —_;_—_REPORTER °' CLERK
APPLICABLE ENTRIES MARKED
A ❑ D�W.proceeds in PRO PER A El Answers true name as charged ❑ Bench/Arrest Warrant to Issue
P 5b'6eft.appears ❑in custody❑Deft. not appearing R A Bail Set at$
P
E ❑ With/by Atty./Pub. Def./ADO ^ ❑ Waives Arr/reading of Complaint R ❑ Recalled ❑Set Aside ❑Remain Out
a ❑ Deputy Dist.Atty. N ❑ Handed copy of Complaint/Discovery N ❑ No PTA Release ❑ No Vol.App ;, --'•
N ❑ Court Probation Off. M ❑ Deft.duly arr. ❑ Video ❑ on Prob.Vio. T ❑ Hold until
c ❑ Interp. sworn/oath on file N ❑ Deft.waives arr. on amended complaint. e R ❑ Bail forfeit&continued 190 da s Bail Exon
E
❑ Cert. ❑Non-Cert. ❑Ouallffed per Rule 984.2 T A E ❑ Bail forfeiture set aside&reins ed
❑ Order Int.❑ Int. Coord. notified L R upon payment of fee$
❑ Referred To: PUBLIC DEFENDER w c
R ❑ Referred To: PROS.Bait Study/PPR
A ❑ Written Plea filed El Pleads Guilty, Ct.# 0 ❑
I N
E v ❑ Pleads No Contest, Found Guilty,Ct.# T
P ❑ Referred per 288.1.PC❑1368 PC E ❑ pleads Not Guilty,Ct.# 1 El
R
S/ ❑ Jury Trial Waived/Demanded u
R ❑ Pub. Def.Conflict Filed;Appointed ADO P A ❑
❑ Report 20 for booking L El Time for Trial/Sent Waived/Not Waived N
S ❑ 977 waiver filed ❑170.6 PC filed/oral n El Time for PX 10/60 Days Waived/Not Waived e ❑Vacate date of
❑ In re law notice given s ❑ Admit/Denies Priors/Refusal/Enhance s ❑ Def. must/need not appear
❑ Peo/Def. Motion to/for/cont. p❑Cou - batiorWanted for � mo/yr
o❑ Submitted with argument❑without argument U❑ Adul P fl- P¢ 000-Diver
sio
a � ,
T❑ Granted ❑ Denied ❑ Submitted ❑No Action TakerH ,S❑ Pro Iation/Diverslon/Reinstated/Modified/Extended to r
I A {, - I� „�:l
0❑ Grounds: T Original terms in full force and effect except as ordered. 1
N I f
S
❑ D.A. Motion to file amended complaint p❑ Deft.given/waived rights to Revoc.Hg;Admits/Denies.
-,
oComplaint amended on its face to add Ct.# ❑ Prob. Revoked: ❑Def,found in violation of probation f'' }'�'
R a violation of section ❑ Probation/Diversion:Terminated:Successfully/Unsuccessfully/Denied
D
E ❑ Pursuant to 23103.5CVCay Prob.Vio.fine of$ 11 Upon payment of fine/c,3r�lpletion of jail s ntence
R❑ Strike the words felony and feloniously. Substitute the Criminal Proceedings Reinstated/Dismissed �t
word misdemeanor wherever it appears in Complaint.
❑ Per Court/DA dismiss,Complaint/Ct.#
.6r
•IV , _�-
P❑ Pay a fine of$ ❑Rest. Fine of c ❑Be imprisoned days/months/years o❑Obey all laws. f�
1 ❑ Pay$10 cite fee/$25 Booking Fee/$ CJA Fee 0 ❑ days/months/years credit R❑ Do not use pny alcohol.Do not
M
E❑ Pay balance of fine/Din lieu of fine❑Susp.$_after fine.M ❑ days/months/years suspended C0 go to places where alcoholic'
❑ Make monthly payments to CCU P.O.Box 1669 Martinez,CA 94553 M EDSentenceto commence p bever4ges are the chief iterrt•of sale.
0 Phone(510)646.1951 by E ❑Serve consecutive/concurrent 1 ❑ Attend _AA/t�A
R
D❑ hours Volunteer work by Fee$ N (:1 with ❑with T any sentence meetings-Qe�voek and pl s n't-
E El Re-refer/reinstate to Level I/Level II/PCDDP s ❑Main Jail 13 Electronic Home Detention 0 �progf'it each court appearance.
S❑ Referred to ORC for Attorney Fee Costs of'$ ❑WAP Contact CAB immediately/within 15 days. ' l�.Subhl ;search and testing
F❑ License Suspended/Revoked months/years ED Day for day credit for time served in a1,prove esfdevial ❑ Destroy❑ Retumflve on
E❑ DL310/DL309 Served❑ Advised 14607.8 CVC program.Proof by i L/ ❑ Stay away 4 f;
s❑Pay fine/comply or appear on at
❑REMANDED to County Jail: ❑Ordered released ❑On OR ❑Promise to Appear ❑Def.to be allowed phone calls
Bail Set in the amt.of$ ❑Court Courtesy 0 State Prison Commitment ❑ Committed to custody until sentence is satisfied.in full
TO THE SHERIFF:COMMITMENT:I hereby certify that this is a true copy of the Entry of Judgment or Order and is your authority for the execution thereof.
❑See other minute pages for additional proceedings.
DATED: (JUDGE OF THE SUPERIOR COURT) GRIM.MINUTES(8/98)
Goa attarhad additional orders.
CR-3005
AMENDED CLAIM C - I
6
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
BOARD ACTION: MARCH 6, 2001
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".
FF9 0 5 2001
AMOUNT: $8,50C.00 COUNTY COUNSEL
MARTINEZ CALIF.
CLAIMANT: LARRY MONDY
ATTORNEY: DATE RECEIVED: JANUARY 31, 2001
ADDRESS: 536 HARVEY WAY BY DELIVERY TO CLERK ON: JANUARY. 31, 2001
BAY POINT CA 94565 .
BY MAIL POSTMARKED: TRANSMITTAL
I. FRONL• Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim..
PHIL BATCHELOR, Clerk
Dated: FEBRUARY 5, 2001 By: Deputy L4A37
41
H. FROr4- County Counsel TO: Clerk of the Board of Supervii6rs
( his claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: 2- ���� By��l'L Deputy County Counsel
III. FRONS Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. BOARD ORDER: By unanimous vote of the Supervisors present:
C4 This Claim is rejected in full.
( ) Other:
I certify that this is a true and correct copy of the Board's Order tered itsmi t s for this date.
Dated: .4,L JOHN SWEETEN Cleric, By , Deputy Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited
in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVIT OF MAILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United
States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully
prepaid a certified copy of this Board Order and Notice to Claiman , addre d to th timant as shown above.
Dated: By: JOHN SWEETEN By Deputy Clerk
CC: County Counsel County Administrator
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 does 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.
ClairrAo: 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 100th day after the
accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to
personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later
than six months after the accrual of the cause of action. Claims relating to any other cause of action must be
presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2. )
B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County
Administration Building,6551 Pine Street,Martinez. CA 94553.
lr if C!.2aim is ;against a district governed by the Board of Supervisors, rather than the County, the name of the
.. f. a.....
District should be filled in.
D. If the claim is against more than or.�:.r►ttblic ertit ,se::trate claims must i)e filed a2aittst each nub.lic.entity.
E. Fraud. See penalty for fraudulent claims, Penal Code Sec. '12 at the end of this form.
RE: Claim by. ) Reserved far Clerk's Filing Stamp
Against the County of Contra Costa
or
District)
(Fill in Name)
The undersigned claimant hereby makes claim against the County of Contra Costa or the above named
District in the sum of S 11106 and in support of this claim represents as follows:
1. 'When did the damage or injury occur:' (Give exact`)ate and flour)
2. Where did the damage or iujut-y occur? (Include City and County) -
4*3. Haw: tiid tli'e damage or injury occur? (Give full details;use extra paper if re red)
4. What particular act or omission on the part of count_ r distn offi' rs, servants, or emplovees caused the
injury or damage? �='
N WC4 N� Ariat I.� Lv Lct, vile
Mid J ,,JC .
(Over)
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