HomeMy WebLinkAboutMINUTES - 05152001 - C.14 e i 4
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CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
BOARD ACT10tlt May 15, 2001
Claim Against the County, or District Governed by )
the Board of Supervisors, Routing Endorsements, I 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. I notice of the action taken on your claim by the
11WAD Board of Supervisors. (Paragraph IV below), given
pursuant to Government Code Section 913 and
APR 13 2001 915.4. Please note all "Warnings".
AMOUNT: $100,000 COUNTY COUNSEL
MARTINEZ CALIF.
CLAIMANT: Leonar Garcia
ATTORNEY: Willard E. Scott DATE RECEIVED: April 12, 2001
ADDRESS: 347 W. 10th St BY DELIVERY TO CLERK ON: April 12, 2001
Pittsburg, CA 94565
BY MAIL POSTMARKED: April 11, 2001
I. FROM: Clerk of the Board.of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
JOHN SWEETEN Cler
Dated: April 13, 2001 By: Deputy
H. FROM County Counsel TO: Clerk of the Board of Supervisors
( i-�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: By: �� 4 Deputy County Counsel
M. FROM Clerk of the Board TO: County Counsel (1) County Administrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
BOARD ORDER: By unanimous vote of the Supervisors present:
This Claim is rejected in full.
( Other:
I certify that this is a true and correct copy of the Board's Order a ered in its minutes f r this date.
Dated Q JOHN SWEETEid Clerk, By puty Clerk
WARNING (Gov. code section 913)
Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited
in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an
attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so
immediately. *For Additional Warning See Reverse Side of This Notice.
AFFIDAVIT OF N AILING
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United
States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully
prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: By: JOHN SWEETEN, CLERK Bye
eputy Clerk
CLALA'I
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
BOARD ACTIO 11t May 15, 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 1 The copy of this document mailed to you is your
California Government Codes. 1 notice of the action taken on your claim by the
Board of Supervisors. (Paragraph IV below), given
pursuant to Government Code Section 913 and
LL4411�� ��JJ 915.4. Please note all "Warnings".
AMOUNT: $250,000 APR 13 2001
COUNTY COUNSEL
CLAIMANT: .Irineo Garcia MARTINEZ CALIF.
ATTORNEY: Willard E. Stone DATE RECEIVED: April 12, 2001
ADDRESS: 347 W. 10th St BY DELIVERY TO CLERK ON: April 13L, 2001
Pittsburg, CA 94565
BY MAIL POSTMARKED: April 11, 2001
I. FROM: Clerk of the Board.of Supervisors TO: County Counsel
Attached is a copy of the above-noted claim.
J E Cl�r
Dated: April 13, 2001 By: Deput
H. FROM County Counsel TO: Clerk of the Board of Supervisors
(,,�'This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The
Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of
claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: e/ 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).
N. BOARD ORDER: By unanimous vote of the Supervisors present:
y`\� This Claim is rejected in full.
( ) Other: _
I certify that this is a true and correct copy of the Board's Order entered in its min es f r this date.
Dated:j&�� ' S,a(� JOHN SWEETEN Clerk, By eputy 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 NIAHXI iG
I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United
States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully
prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above.
Dated: (� By; JOHN SWEETEN, CLERK By eputy Clerk
Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY
INSTRUCTIONS TO CLAIMANT
A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops
and which accrue on or before December 31, 1987, must be presented not later than the 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 onor after January 1, 1988, must be pres`ented'not-later
than six months after the accrual of the cause of action. Claims relating to any other cause of action must be
presented not later than one year.after the accrual of the cause of action. (Govt. Code §911.2. )
B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County
Administration Building,651 Pine Street,Martinez, CA 94553.
C. If Claim is against a district governed by the Board of Supervisors, rather than the County, the name of the
District should be filled in.
D. If the claim is against more than one public entity,separate claims must be filed against each public entity.
E. Fraud. See penalty for fraudulent Maims, Pena! Code Sec..72 at-the end of this-form.
RE: Claim by ) Reserved for Clerk's Filing Stamp
IRINEO GARCIA )
RECEIVED
Against the County of Contra Costa
APR..1 .2 2001
or
CLERK BOARD OF SUPERVISORS
District) CONTRA COSTA CO.
(Fill in Name)
The undersigned claimant hereby makes claim against the County of Contra Costa or the above named
District in the sum of$250,000-.O and in support of this claim represents as follows:
1. When did the damage or injury occur? (Give exact Date and Hour)
March 18, 2001 approximately 9-:00 p:m:.
- - - - -- --- - --- ---- ----------------------------------------------------------------- -- -
2.
Where did the damage or injury occur? (Include City and County)
Contra Costa County Detention Facility, Martinez, California.
- - - - --- ---
How did the damage or injury occur? (Give Hill details;use extra paper if requited)
While a prisoner at the Contra Costa County Detention Facility, Claimant's right
leg was broken, he received abrasions-and .contusions to his upper.,body-.when
he was struck or kicked by the deputy sheriff while he was handcuffed with his
hands behind his back.
- -- --- ---- ------- --------------------------------------------------------------------
4. What particular act..or omission on the part of county.or district officers, servants, or,employees caused the
injury or damage:'
Officer struck or kicked. the Claimant with such force that his leg was broken and
he received--other physical: inj,uries.
(Over)
LAW OFFICES OF
WILLARD E. STONE
2855 MITCHELL DRIVE,SUITE 109
WALNUT CREEK,CALIFORNIA 94598
(925)935-1711
WILLARD E.STONE FAX:(925)935-1051
GREGORY STONE. FAX:(.530)235-0942
5828 DUNSMUIR AVENUE
DUNSMUIR,CALIFORNIA 96025
(530)235-0605 RCLERKBOARD
CEIVED
March 21, 2001 12 2001
Clerk of the Board of Supervisors OF SUPERVISORSA COSTA CO.
Room 106
County Administration Building
651 Pine Street
Martinez, CA 94553
Re: Our client: Irineo Garcia - County of Contra Costa
Dear Madam Clerk:
I am enclosing a claim asserted on behalf of our client h neo Garcia concerning an
incident which occurred on March 17, 2001, while he was in custody at the Martinez
Detention Facility.
I would appreciate it if you would file the original claim, returning the copy to our
office in the envelope provided.
Thank you for your courtesy and cooperation, and in the event that you require any
further information, please do not hesitate to contact our Walnut Creek office.
Very truly yours,
Willard' . tone
WES:cs
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' APPLICATION TO FILE LATE CLAIM
BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
BOARD ACTION
Application to File Late Claim Y. NOTICE TO APPLICANT May 15, 2001
Against the County, Routing ,) The copy of this document mailed to you is your
Endorsements, and Board Action.) notice of the action taken on your application by
(All Section References are to the Board of Supervisors (Paragraph III, below),
California Government Code.) ) given pursuant to Government Code Sections 911.8 and
915.4• Please note the *WARNING" below.
Claimant: McKinley Johnigan K16634 3Fr-11RaWMM
Attorney: None APR 12 2001
Address: San Quentin State Prison COUNTY COUNSEL
MARTINEZ CALIF.
San Quentin, CA 94964
Amount: unknown By delivery to Clerk on April 11, 2001
Date Received: April 11, 2001 By =11r postmarked on April 10, 2001
I. FROM: Clerk of the Board of Supervisors TO: County Counsel
Attached is a copy of the above noted Applies to lai
DATED: April 12, 2001 JOHN SWEETEN , Clerk, By Deputy
-177 U
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
( )/The Board should grant this Application to File Late Claim (Section 911.6).
( tel The Board should deny this Application to File Late Claim (Sectio 911.6).
DATED: lam/ 7� 9 / Sf LVAN MAp'C' est
Deputy
County Counsel, By C� _
II. BOARD ORDER By unanimous vote of Supervisors present
(Check one only)
( ) This Application is granted (Section 911.6).
This Application to F11e Late Claim is denied (Section 911.6).
I certify that this is a true and correct copy of the Board's Order entered in its
minutes for this date.
DATE: OIV SWEETEN , Clerk, By Deputy
WARNING (Gov. Code 5911.8)
If you wish to file a court action on this matter, you must first petition the
appropriate court for an order relieving you from the provisions of Government Code
Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such
petition must be filed with the court within six (6) months from the date your application
for leave to present a late claim was denied.
You may seek the advise of any attorney of your choice in connection with this
matter. If you want to consult an attorney, u should do so immediately.
V. FROM: Clerk of the Board TO: 1 County CounselCounty Administrator
Attached are copies of the above Application. We notifed the applicant of the
Board's action on this Application by mailing a copy of this document, and a memo thereof
has ben filed and endorsed on the Board's copy of this Claim in accordance with Section
29703.
DATED: JOWq' SWEETEEd Clerk, By Deputy
V. FROM: 1 County Counsel 2 County Administrator TO: Clerk of the Board
of Supervisors
Received copies of this Application and Board Order.
DATED: County Counsel, By
County Administrator, By
APPLICATION TO FILE LATE CLAIM
'�%veeten
The Soard of Supervisors
Conti-a Jchn
COLIntv Adiminisiraiion'- E'Llildirh_: COUIVI ",zilmor
_51 Pine tiert. Room !06 Costa
i2c :04
Marfir,ez. Ca:;ior'lla 9457"!_"
County
John Gioia. ?s: District
Gayle S. Uilkeina.2nd Disinct
Donna Gerber,3rd District
Mark DeSaulnier.4th Distric;
Federal D.Glover.51h Distr;cf
RECENLO
APR 112001
ICLERK BOARD OF SUPERVISORS
CONTRA COSTA CO.
TO: McKINLEY JOHNIGAN, K16634
San Quenton State Prison
San Quentin, CA 94964
NOTICE TO CLAIMANT .
(Of Late-Filed Claim)
(Government Code Section 911.3)
The claim you presented to the.Board of Supervisors of Contra Costa County,
California, as.governing body of the County of Contra Costa on March 13, 2001, has been
reviewed by County Counsel and is being returned to you herewith because:
XX Your claim for an injury to person or personal property was not presented within six
months of the event or occurrence as required by law. (See Government Code sections 901
and 911.2)
Your claim relating to a cause of action other than injury to person, personal
property or growing crops was not.presented within one year after the event or occurrence as
required by law. (See Government Code sections 901 and 911.2)
Because the claim was not presented within the time allowed by law, no action was
taken on the claim.
Your only recourse at this time is to apply without delay for leave to present a late
claim. (See Government Code sections 911.4 to 912.2 and 946.6) Under some
circumstances leave to present a late claim will be granted. (See Government Code section
911.6)
McKinley Johnigan
Re: Notice to Claimant
Page Two
You may seek the advice of an.attorney of your choice in connection with this matter.
If you desire to consult an attorney, you should do so immediately.
Date: JOHN SWEETEN, Clerk of the Board
of Supervisors and County Administrator
By:
Deputy Clerk
Enclosure
Affidavit of Mailing
I declare under penalty of perjury that I am now, and at all times herein mentioned, have
been a citizen of the United States, over age 18, and that today I deposited in the United
States Postal Service in Martinez, California, postage fully prepaid, a copy of the above
NOTICE TO CLAIMANT (OF LATE-FILED CLAIM), addressed to the claimant as shown
above.
`t�Date: L o
De uty Clerk
1:'TORT,.R1S iC-%iGT..CLAI\IS',.LATE'Vohniean.%ipd
'• Cla':n it... BOARD OF SL-PER%ZSORS OF CONTRA COSTA COUNTY
L��T=._C:IONS TO CL.A1M-4-N-T
A. Claims relating to causes of actio.^. fc- de:: or for injury to person or to personal property or growing
crops and which accrue on or be.-bre Decl-7iber 31, 1987, must be presented not later than the 100h day
after the accrual of the cause of a:tie-. Cla ms relating to causes of action for death or for injury to
person or to personal property or gro-�-ing crops and which accrue on or after January 1, 1988, must be
presented not later than six months =.r t`a- accrual of the cause of action. Claims relating to any other
cause of action must be presented nc_ :ate-than one year after the accrual of the cause of action.
(Gov't Code 911.2.)
B. Claims must be filed with the Clerk `f the Board of Supervisors at its office in Room 106, County
Administration Building, 651 Pine S= Martinez, CA 94553.
C. If claim is against a district governed n-v the Board of Supervisors, rather than the County, the name of
the District should be filled in. I
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
L7ri
Against the County of Contra Costa or ) MAR 1 3 ?001
District) CLERK=c.:
(Fill in name) ) cc;�r;;„c;,_;;;};�.o.
The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district
in the sum of$Z.M N oN and in support o this claim.represents as follows:
1. When did the damage or in' occur? (Give exact date and hour) g 7
2. Where did the damage or .in'u occur?(I�clude city and county) M. R f WEZ G o�� Jq
/MA.Rri467,,. 6 . 9 553
3. How did the damage or injury occur' (Cr-•e full details; use extra paper if required) ]-�/p �E�aj�� �'uM
dN ME -rqe N Z• WAs � .0 -r o - F
. Y • �r o s R 41167 �f� Aso
A�r� ARk,vi�j M5R8 A SAN z�u,5n/T N Pe,�fN. , ,4ERC W.� N0f . .
'� SAN�uFnt�
7mK 13 P,c ruRE a>C Ma Mfr's WE11 h-s 7eeK .4 v`alio 7-4 ��.
THE. J11 E.s 7;�4r r E ��, �Y Foie MO
ri
`,�hat particular act or omission on the part of county or dist
ct officers, servants, or employees caused the
injury or damage' �N�t� ��JG/1 �5 �� To B/6 P RQf I�/ 8�1�✓��!1_A1
7tfEy 1A.1✓� G��s� /I/1G /O � ����/G d� /O��LG Df/fCE+IQ
tiA'hat are the names of county or district officers, servants, or employees causing the damage or inju;.?
MSR IV57- eOaNly .�(GR;6�. Z�1/T�. VAZ- ���,!� ZNv6Si;; Rfio� ��PARfit�te,��
N,�s �a,N o)�e4q /l���1E_J y
6. 'What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach
two estimates for auto damage.) C �1s� M9 7b 99 AWly Bi�Nd _.r.A/ L51f i/_
7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or
darnage.)
Aga r 5& drWTIAl &W1
8. Names and addresses of witnesses, doctors, and hospitals.
TXT uMs Al �v�Afe Wino SA W j5✓4R y� ""
-19446Rr�l 7-29 ANvtAQ 6, c2aWtl TA;L „ 5.4
�a&Nf;N. P�4;soW W45 �/ sl
L
h0660M A& A dcN ftjC rYVJaAJ
9. List the expenditures' ou
made on account of this accident or injury.
DATE TIlAE. AMOUNT
�-d
?-oo To z.-of - 2s Dao- Aye '
� / ro
-1-me ZKTuoti s, WP AWZAL Oil/ 945.zAW15 .1 Aki _-e Hl1 1N kis 0W
Gov. Code Sec. 910.2 provides"The claim must be
SE?`�NOTICES TO: (Attorney
��L ) signed by the claimant or by some person on.his.behalf."
Name and Address of Attorney
OK�Al1.�
(Claimant-s Signature)
017 )_5.4w Qd.i5AMinl, 51',4_/9 RR sc7N .
(Address)
M�Tt/�Iq P�it1e
Telephone No.. )Telephone No. 51 D- Z 4 5 . 15 Z
NOTICE
Section 72 of the Penal Code provides:
Every person who,with intent to defraud,presents for allowance or the payment td 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.
r
MCKINLEY, JO.HN?GAN
SAN QUENTIN STATE PRISON
SAN QUENTIN, CA. 94974
CLAIMAHT: IN PRO PER
CONTRA COSTA COUNTY BOARD OF SUPERVISORS
MCKIP?LEY JOIDTIGAN
PLAINTIFF
VS NO
DEFENDANTS
CONTRA COSTA COUNTY ET. AL.
REQUEST TO FILE LATE CLAIP4
CA. GOV. CODE 911 .4
TO: TATE CLERK OF THE BOARRJ? OF SUPERVISORS.
Cope^ now the cla;_mantMcKinley Joh_nigan herein requesting that the
above entitled Public embity grant him leave to file a .Tate claim
persuant to Ca. Gov. Code Section 911 .4
This ca.l4.m is based on the attached declaration and memoranda m of
law.
DATE: 0 BY:,G�! - �-
DECLERATION
I Mckinley Johnigan, Declares:
1 . That I am the person making this decleration.
2. That on August --7,- 2000 I was seriously injured by Contra. Costa
County Sheriffs Department.
3. That the injuries I sustained needed emergency medical care.
4. That I was unable to file a claim because of the gravity of the.
injuries.
5. That I was physically and mentally uncapaciated from filing
a claim against Contra Costa County within a six month period.
6. That my injuries include but not limited to being blind in
my left eye , lacerations under both eyes, ' multiple bruses on
my neck and back from being punched with closed fists
7. .That I am a CCCMS mentally in prison. .
8. That I take psychological medications for my mental illness.
I declare under the. penalty of perjury .that I .the foregoing is
true and correct. Executed on , 2001 at the
San Quentin State Prison, San Quentin California 94974.
s 1
Mckinley Joh 'ga
—MEMORANDUM—OF—LAW—
CLAIMANT HAS A RIGHT TO FILE
A LATE CLAIM
CA . Gov ' t § 646 States in Part : Late PresentAtion of a Claim is
Allowable if the Person is a minor , or insane person , A person
imprisoned on A Criminal Charge . The Claimant herein Meets the
Prerequisite of § 646 Because I am A Prisner in a Correctional
facility and I am A CCCMS mental ill Person . CA. Gov , t § 911 . 6 ( b ) ( 3 )
Permits the filing of a latr Claim under certain circumstances
which are , alleged injury , damage or loss , or mentally incapacitated .
Here in this is a instent matter the Claim filed to the Board of
Supervisurs was timely based on . the injury suffered by the Claimant
and also the fact of my mental ilLWess . The same formula for filing
A late Claim is echoed in CA . Govt § 946 . 6 ( c ) ( 3 ) . the Chaim that is
being propounded by the claimant upon the public entity of Contra Costa
County should be presented to the Board of Supervisor for the purpose
of hearing the factual allegations alleged by the claimant concerning
the severe beating thj#" the claimant went through by two unamed Sheriff
deputies that were acting within the scope of there employement when the
. beating took place . These Sheriff deputies were employed by the Contra
Costa Sheriff Department when the assault took place . The Board of Sup-
ervisor have jurisdiction over this matter .
CONCLUSION
The claimant herein has 13 still photographs of the assault that took place
as well as a VH-S recording of the incident . These photographs were taken by
correctional officers at San Quentin Prison on August 7 , 2000 .
DATE : -I � d � B Y : le
McKinley J an
4-- A
=.cerci .f
I'
Liiitiihl of ( onti-L Lo--la
Of f lfl` af 1111` ~Iil`1'l t
Warren E. Rupf
Sher!:?
McKinley Johnigan #K-16634
California Department of Corrections
San Quentin State Prison
San Quentin, CA 94964
Dear Mr. Johnigan:
This letter is to inform you that the Contra Costa County Sheriff's Office has completed the investigation:into
the complaint you filed against members of this Office regarding an incident that occurred on August 7,2000.
In your complaint, you alleged that two deputy sheriffs, without provocation, choked you to near
unconsciousness and repeatedly punched you in the face.
Internal Affairs Sergeant Veda Musto and Sergeant John Dodd conducted the investigation into your complaint.
Their investigation was reviewed by Lieutenant Wm.French,Commander Gregg Moore and UndersheriffK.athi
Holmes.
The conclusion reached is that your allegation of unlawful and excessive use of force is exonerated. That
means, the acts which erovided the basis for-the allegation did occur; however, the investigation revealed
that theact._s were Justified, lawful, and proper. I
There were separate issues related to the improper reporting of the injuries you sustained during the incident
of August 7,2000 and the failure of the duty sergeant to properly investigate and supervise the handling of the
incident. These allegations have been classified as sustained. That means, the investigation disclosed
sufficient evidence to clearly prove the allegation. Appropriate corrective action has been taken.
Due to the restrictions imposed by California Penal Code Section 832.7, we are unable to release any further
info,;,Zation ccnceming the deputies. These records are considered confidential and shall.not be disclose)to
anyone, or in any criminal or civil proceeding, except by discovery pursuant to the Evidence Code.
Should you have further questions, or if I can be of any further assistance, please do not hesitate to write to
me.
Sincerely,
a
WARREN E. RUFF, SHERIFF
Wayne Willett, Captain
Contra Costa Office of the Sheriff
Professional Standards and Resources
P.O. Box 391, Martinez, CA 94553
Post Office Box 391• Martinez, California 94553-0039
(925) 335-1500
..:r. ♦ 2r. -- �._L -.. ". :.�Ci.:i'•L... .�.. � :::k .:Li?'- :�,tC' t.::$�f: - �f;1'`�i
..a. - 1 ,ar;z .. ._._. .., .. 1 .: ✓.r_.._.-6i;.:::..;'::ta :�31..`.-+� _.�y - .Y..•/,satf.:5:: - M'w;�:!C:' .'4e a' :.Y:-:a`_'=...iyr-: as'�,:r `J.4.:$;� ':\,
MENT: -
`!DEPAIYI7 '.
S F CAI.IFO ..
'"'iNMAT'i/PAROLEE' ISABILITY;:YERa�• CATION: ::•., ,.......: :.:...:. ::..'.. ,::::`:=:.=:'..' .,.,.: ,"•. .;' . `':: ' ;: :-'. `..'.:;OF CORRECTIONS
CDC 1845(Rev 2/99)
CHECK ALL OF THE BOXES APPLICABLE.
INMATE'S NAIME: CIC NUMBER: INSTITUTION: HOUSINGASSIGNMENT: DATE FORM INITIATED:
Section A -D to be completed by a physician only
SL?ICTION A.- REASON FOR:INITIATION OF.FORM.:::: SECTION:B :C:ATEGORIES.:'QF'DIS:A'BILI'TI': : ' '::': :
Inmate voluntarily self-identified to staff ❑. BlindlViision Impaired ❑ Speech Impaired
❑ Observation by staff' ❑ Third party evaluation request ❑ Deaf/Hearing Impaired ❑ Other
F] Medical documentation or Central File information ❑ Mobility Impaired
SECTION C: ;DIS'"ILITIES IMPACTING PLACEMENT SE ON D:`DISABILITIES NOS'IIVIPACI`I)yG PLACEMENT:
1. PERMANENT EELCIAIR USER
A ❑ PERMANENTLY MOBILITY IMPAIRED(Lower Extremities)
2. M_•PERMANENTLY MOBILITY IMPAIRED(Lower Extremitiei)./ Walks 100 yards or up a flight of stairs without pause
usi ❑ without aids ❑ with aids crutches, prothesis, or walker
Cannot walk I00 yards or up a flight of stairs without pausing ( p ):
with the use of aids (crutches, prothesis, or walker). B. ❑ PERMANENT NONAMBULATORY MOBILITY IMPAIRMENT .
3. ❑ PERMANENTLY DEAF/HEARING IMPAIRED (e.g., arm or hand prostheses, or missing digit(s))
So severe they must rely on written communication,lip reading or signing as C. F1 PERMANENTLY HEARING IMPAIRED
their residual hearing,with aids,will not enable them to hear an emergency
t. warning,or effectively communicate. l With residual hearing at a functional level with--hearing aid(s).
4. Af PERMMCMZ5XJf,ID1D,'VISION IMPAIRED ! L -✓ D. ❑ PERMANENTLY BLIND/VISION IMPAIRED
Not correctable to central vision acuity of less than 20/200 Correctablee to central vision acuity less than 20/200 with
with corrective lenses. corrective lenses.
5. Q PERMANENT INDISCERNIBLE/NO SPEECH E. a PERMANENT INDISCERNIBLEINO SPEECH
No effective written communication. Communicates effectively in writing_
6. ❑ OTHER 11APACTING PLACEMENT (See Comments below)
SECTIONS A.throu h D COMPLETED BY:
Physician's Name(Print) .
❑ DISABILITY NOT VERIFIED.(Explain in comments section)
Physicians Signature Date Signed: ❑ VERIFIED DISABILITY IN:
❑ SECTION C ❑ SECTION D
. .. .
.... .....,.NTLA EME FA..C.T. ORS.AN.D.:...INO.RMATbECTION E: ADDITIOVAL .
Q.....::.:.:.... .: :......:::.:.....:...::::...
completion by correctional counseling staff'
List assistance needed with daily living activities: (i.e., eating, bathing, ❑NO ADDITIONAL INFORMATION AVAILABLE
dressing, etc.)
❑ Uses American Sign Language(A.S.L.)
❑ Uses Signing Exact English (S.E.E.)
❑ Communicates in writing ❑ Reads lips
Per 128C(s)dated: ❑ Reads braille ❑ Requires large print
Has the following documented health care needs:
DOCUMENTED MENTAL HEALTH NEEDS
❑ In-patientF1Sun Sensitive El
❑ Heat Risk/Alert ❑ Cannot be exposed to particulates in the air ❑ CCCMS ❑ .EOP ❑ MHCB ❑ DMH
Refer to 128C(s)dated: Refer to 128C(s)dated:
SECTION E COMPLETED BY:
NAME: TITLE: JDATE SIGNED:
,
.......:..:.::::.:::..:....:..
DISTRIBUTION:Original-General Chrono Section of Central File Pink-Health Care Services for Health Care Record. Yellow-Inmate/Parolee
MEDICAL REPORT OF INJURY OR UNUSUAL OCCURRENCE
NAME OF HOSPITAL DATE
G
THIS SECTION fKJM R NA F�j��T) OLD HOUSIN LOCATI NEW H USI IG LOCATION
FOROIrNMATE ,Z �1 /& /�W/Vt l,!
THIS SECTION AME L STJ 7 FIRST MIDDLE) SEX AGE IDOB(MO.,DA.,YR.) OCCUPATION
FOR STAFF/
VISITOR ONLY HOME ADD CITY STALE ZIP HOME PHONE
TIME OF OCCURRENCE PLACE OF OCCURRENCE. TIME SEEN MODE OF Afi$IVAL
BRIEF RESUNE IN PATI NT'S WORDS OF THE IRC T�ANCES OF THE INJUR OR UNUSUAL OCCURRENCE
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NAME OF WITNESSES,SUMMARIES OF THEIR STORIES,INSOFAR AS AVAILABLE
NURSE/MTA'S HISTORY OF INJURY/OCC RRENCE
KNOWN ALLERGIES J/ /� e DATE F;-AST TETANUS
(//Av' I ; /
VITAL SI S TIME MEDICAL OFFIf-ER TIME M AL OFFICER
NOTIFIED ARRIVE Lam/
COMMENTS OF I AL OFF R
G � '
DIAGM�,tTWVMPRES
L
JE40N'T
1 Qtoo
DESCRIPTION OF SIGNIFICANT CLINICAL LABORATORY AND/OR ROENTGENOLOGIC FINDINGS
DISPOSITION
ESTIMATED OR RECOMMENDED N MBWn7V7
ITION"STATUS
PROGNOSIS
/A
SIGNAT / E OF M DI AL OFFICER
CO 2 (Rev.9/77) `
STATE OF CALIPORHIA t,. DEPARTMENT OF CORRECTION:
RECEPTION'CENTER PHYSICAL EXAMINATION
In srlr•.1^IUN owre
AUG 0 e 2000
PAT IS L ENDERLD ❑AVERAGE HEAVY ❑OBESE Heys H�p_ /� WEIGHTOEFowrw lrE]YES (EXPLAIN)
TEMPERATURE PU ISR RES PIRwT1`0H --"'--."--'-----------""-'_'--_-
K I
KIN MARK MOLES,TATTOOS,NARCOTIC SCARS ((/EEX•/PLLLAAIIN) /v/
~� ------- ' -----------
---
c
--- - --------------- -------- --------------------------------------------------------
SEROLOGY HOMO PCY WBC
URINE: X-RAY
SG SUG ALB MICROS
DISTANT VISION 1 NEAR VISION HEARING AID
USED
UNCORRECTED CORRECTED UNCORRECTED CORRECTED �
RIGHT 20/' RIGHT 20/ ❑GLASSES RIGHT J/ RIGHT J/ RIGHT WV /15 ❑YES
LEFT 20/ LEFT 20/ ❑CONTACT I LEFT J/ LEFT JLEFT WV /15 i ❑
LENSES NO
BOTH 20/ BOTH 20/ BOTH J/ BOTH J/
ABNOR- DESCRIBE ABNORMALITIES
NORMAL MAL '1 ...
1. GENERAL APPEARANCE. . . . . ❑ �---'
2. HEAD AND NECK. . . . . . . . . . '�' _ ________________________
1. EYES. -- __✓-='�J�--------------..�_______
______ __ �� �__ ^_ti._
4. E.N.T. . . . . . . . . . . . . . . . . . ❑ /_^
5. CHEST/LUNGS. ❑ �i2�- ----------- __ / -_T -"_`---___---
7. ABDOMEN-HERNIA . . . . . _ . . .
❑ --- ----- - --------------- --- -----�=--- _'`---------� ------
8. GENITO-URINARY. . . . . . . . . . . �� —�9
ORTHOPEDICS (EXTREMITIES `
9• SPINE, MUSC. S"KEL • ❑ - �
10, LYMPH NODES . - . . . ❑ ------ r- /
11. NEUROLOGICAL. �� ------( .�•�" ,�, J
12. RECTAL/PELVIC . _ . . - . . . . . ----- ----------.
13. PSYCHIATRIC (MENTAL STATUS) ❑ ❑ / `��i l-�
14. PSYCHIATRIC CONSULT INDICATED ❑ NO ❑ YES
__________________________________________________________________________________._-_--_-_-__________------__--
15. OTHER
-------------------------------------------------------------------------
WORK RESTRICTIONS
1
--------------------------------------------- ----- --- --
TREATMENT/INVESTIGATION: ------------------------------------------ INPRES510
NECESSARY____ __�l :_%_ ----------
� -�- -3
ELECTIVE _____ __y _____________________________________ ••
COMMENTS NAME l • 1
-------------------------------------------------- ---------------
------------------------------------ --------
NUMBER
-------------------------------------------------------------------------
--------------------------------------
BIRTHDATE/AGE
S .3 z5�-
PHYSICIAN DATE ADMITTED
CDC 1968 (5/82) IF MORE SPACE IS NEEDED USE REVERSEAW 0 7 ZUW
DATE TII4IE
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SLS G s71
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INSTITUTION PHYSICIAN ROOM NO. CDC NUMBER,NAME(LAST,FIRST,MI)
PHYSICIAN'S PROGRESS NOTES
CDC 7230(7/90) G
STATE OF CALIFORNIA DEPART.IIEYT OF CORRECTIONS
k,_A-6ZE OF CALIFORNIA _ DEPARTMENT OF CORREC60NS
REQUEST FOR SERVICES
i
TO BE COMPLETED BY REQUESTER and FORW�A`RD/E/P TO UTILIZATION MANAG ENENT DEPT.
`� tt. �C:/ y .. ,
Patient'sName: CDC Institu«.(_n.
DOB: EPRD Date: Gender:
Principal Diagnosis. <- -e ICD-9 code:
Requested Service(s): CPT code(s):
Please check all that apply:
Diagnostic - Outpatient = Inpatient ❑ Elective = Initial ❑ Follow up !l
Contemplated TreatmentiSen,ice.
Emergent❑ Urgent, Routine a
For the purpose of retrospecrive review. if emergent or urgent please justify urgency:
Proposed Provider: Anticipated Length of Stay_
Expected Disposition (i.e.: outpatient follow up, return to institution,transfer):
Medical Necessity (briefly describe the clinical situation;the history of the illness,treatments used,-pertinent lab and imaging
studies;or que s to the consultant): /
C t C(
q--c. C-,, /1 .f-- J//� -t 1';-er r
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Estimated time for service delivery, recovery, rehabilitation and follow up:
Summary of Preliminary or Diagnostic Work up, Conservative Treatment Provided (if applicable, please
provide TB code, CD4, viral load, albumin, total protein and dates within last 3 months):
Comments: (diagrams, risk factors, prognosis, alternative management, etc.)
Ale,
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Embosser Plate
/1A 7
REUES G PHYSICIA S PRINTED NAME AND SIGNATURE:
UTILIZATION MANAGEMENT TRACKING# fy1
Authorized/denied/deferred by: Date:
CDC REQUEST FORM (draft) part A 6-18-99 draft
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Form 1114P BRIGGS,Des Moines,IA 50306 WO-247-2343 - COLLECTION SHEET
PSINTE�IN U.S.A
COLLECTION SHEET
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NAME and NUMBER: JOHNIGAN, McKinley K-16634 1-N-82 CDC-128-C
JOB LIMITATIONS: x 6 months.
1. Unstable gait.
2. Cannot walk more than 10 minutes at a time.
3. Cannot use (L) arm.
4. (L) eye pain with poor vision.
MEDICAL REASON: 1. (L) hemiparesis due to stroke.
2. Cane for ambulation.
3. Complaining of pain(L) eye due to accident.
4. Has eye patch on (L) eye.
Original:.:... ':. .... viewed CMO
Central File:. M. Trinh,IV1.D_
r tl
.C. :....:::. .. .. . .
Hear c`i Re o d aff
CiStPh sician�`.
Inmate
DATE:: 09/18/00 (T: 09/19 trm) San Quentin
Form 1114P BRIGGS.Des Mo:r?es,IA sU:wn eUU-ear-[,ire
PAINTED IN U.S.A. VVrrrrr'r.•�-- ---- -
F.
HF,�tTH:SC[a�BMN7 ,
f"
NAM:�� fU 1 C-",A Ij}}_A C�C_ ) �'t/ CDC`f#: �'1 (I HOUSING: C
(�This inmate has completed a routine mental health screening and is.-.
❑ Cleared-for general population(no restrictions). ❑ Referred for further evaluation. Referred for crisis cane.
❑ Able,but unwilling to participate in clinical assessment.
❑ This inmate was interviewed after ❑staff ❑self referral on 6 / ,and the following action was taken:
❑ Cleared for continued programming. ❑ Referred for further evaluation.
❑ Other:
❑ This inmate is non English speaking. Primary language:
44
0inkiaa's Name(Print) Phone/Ex CLm hues Slpuara. Date
CDC 129C
CDC F51RM 128C MHPCv2.0[5-1-971
Effective 6-1-97
NAME: '`_ ><' ` CDG ( INST: --� �.
HOUSING:
LAST FIRST MI if RC
THIS INMATE HAS COMPLETED A MENTAL HEALTH EVALUATION WITH THE FOLLOWING RESULTS(check box(s)below):
a) �❑ Does Not Meet Criteria for Inclusion in the Mental Health Treatment Population.
b) Ll Meets Inclusion Criteria for the MH Treatment Population (Check Level of Care[LOC] Below)
r'
QrNo ❑Yes Inclusion is for of Medical Necessity(Obtain Chief Psychiatrist Signature Below).
c) ❑.Presently included in MHSDS,new LOC below(Check LOC Below).
LOC: [Inpatient DMH ❑Crisis Beds(II ❑Enhanced Outpatient Program(EOP)/Cat J Clinical Case Management(CCCl Cat J
Level of Functioning Asssessment(GAF score): ' Psychotropic Medication Prescribed: des ❑No
Behavioral Alerts:
CLINICIAN'S LAST NAME(PRINT) PHONE/EXTENSION CLINICIAN'S S1NATURE DATE CHIEF PSYCHIATRIST or DESIGNEE SIGNATURE
Original to be placed In Central File within 48 Hrs.Copt es to: Correctional Counselor I,Unit Health Record
Reception Center: 't
MENTAL HEALTH SCREENING
J
NAME: Toa�#ti°! 412"'-1 Y-11^1 CDC#: � HOUSING• ' r
❑-'This inmod has completed a routine mental health screening and is:
y'1 Cleared for general population(no restrictions). ❑ Referred for further evaluation. ❑ Referred for crisis cane.
/`❑' Able,but unwilling to participate in clinical assessment.
❑ This inmate was interviewed after ❑staff ❑ self referral on / / ,and the following action was taken:
❑ Cleared for continued programming. ❑ Referred for further evaluation.
❑
Other-
This
therThis inmate is non EHglish speaking. Primary language:
Clinician's Name(Print) Phone!Extension Clinician's Signature Date
CDC I2EC
COLLECTION SHEET
a
a
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Reception Center-
MENTAL HEALTH SCREENING
MET
NA : `1e) k. n i I'S 4n: , y.t Y 4 e CDC#: (; HOUSING:
is inmate has completed a routine mental health screening and is:
❑ Cleared for general population(no restrictions). eferred for further evaluations ❑ Referred for crisis care.
❑ Able,but unwilling to participate in clinical assessment //1
❑ This inmate was interviewed after E]staff ❑self referral on / / ,and the fdllowing action was taken:
❑ Cleared for continued programming. ❑ Referred for further evaluation.
❑ Other. E G G",,y D.4 r)o /-,. t')A- �!.•i r Y' �C r I r �P
❑ This inn is non English speaking. Primary language: N
f E
Clinidan's Name(Print) Phone/Extension Cli"n'esignatare u Date
CDC I23C
Reception Center.
STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS
CDC FORM 128C MENTAL HEALTH PLACEMENT MHPCv2.0[5-1-97]
Effective 6-1-97
NAME CDC# — /�/ INST: HOUSING: / /V
LAST FIRST Jif RC
THIS INMATE HAS COMPLETED A MENTAL HEALTH EVALUATION WITH THE FOLLOWING RESULTS (check box(s) below):
a)�❑.Does Not Meet Criteria for Inclusion in the Mental Health Treatment Population.
b) L:1 Meets Inclusion Criteria for the MH Treatment Population (Check Level of Care[LOC] Below)
t' ❑No ❑Yes Inclusion is for of Medical Necessity(Obtain Chief Psychiatrist Signature Below).
c) ❑ Presently included in MHSDS, new LOC below(Check LOC Below).
LOC: ❑Inpatient DMH '❑Crisis Beds(MHCB) ❑Enhanced Outpatient Program(EOP)/Cat J 06rinical Case Management(CCCMS)/Cat J
Level of Functioning Asssessment(GAF score): _1 Psychotropic Medication Prescribed: es []No
Behavioral Alerts:
CLINICIAN'S LAST NAME(PRINT) PHONE/EXTENSION CLINICIAN'S SIGNATURE DATE CHIEF PSYCHIATRIST or DESIGNEE_SIGNATURE
Original. to be placed in Central File within 48 Hrs.;Copies to: Correctional Counselor I,Unit Health Record
5AI 2-1141
JOHNIGAN,MCKINLEY K-16634
�L DR: DUPRE PSYCH
736621 - 0 RPH : MCM MFG:
START : / / STOP:
*DC OLANZAPINE 10MG-PM* 0
***** DISCONTINUED ******
*.**** DISCONTINUED ******
START : 08/08/00 STOP: 09/05/00
NEXT REFILL DUE :
JOHN IGAN ,MCK.INLEY K-16634
1-N-082L DR : DUPRE PSYCH
744534- 0 RPH : ECS MFG:
START : 1 f STOP : r` /
*DC OLANZAPINE 10MG (ZYP* 0
***** DISCONTINUED *** **
*,k*** DISCONTINUED *** ***
START : 09/05/00 STOP : 10/11/00
NEXT REF I LL DUE : ...............
JOHNIGAN ,MCKINLEY K-16634
1-N-032L DR : DUPRE PSYCH
739670- 0 RPH : ECS MFG:
START : / / STOP : I r'
*DC SERTRALINE 50MG-PM*
DISCONTINUED ******
***** DISCONTINUED ******
START : 08/17/00 STOP : 10/11/00 '
NEXT REFILL DUE : .....
J.OHNIGAN , MCKINLEY K.-16634
1 -N-082L DR : DUPRE PSYCH
736622- 0 RPH : ECS MFG :
START : / I STOP : / rr
*DC DIPHENHYDRAMINE 50MG* 0
k:x*.** DISCONTINUED ******
***** DISCONTINUED
START . 08/08/00 STOP: 10/11 %00
NEXT REFILL DUE :
....._._............................................................
NOTE: SEND COPY OF PHYSICIAN'S ORDER FOR MEDICATION
TO PHARMACY AFTER EACH ORDER IS SIGNED.
Problem Physician's Order and Medication
llOlder Date Time # (Orders must be dated, timed,and signed.)
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