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Home My WebLink AboutMINUTES - 04112006 - C.19 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION:APRII, 11, 2006 Claim Against the County, or District Governe the Board of Supervisors, Routing Endorsemen NOTICE TO CLAIMANT ffland Board Action. All Section references are to and 8 2006 The copy of this document mailed to you is your California Government Codes. CO)JNTY COUNSEMotice of the action taken on your claim by the MARTINEZ CALIFBoard of Supervisors. (Paragraph IV below)., given Pursuant to Government Code Section 913 and AN AMOUNT THAT WOULD EXCEED THE 915.4. Please note all "Warnings". MINIMUM JURISDICTIONAL AMOUNT FOR A AMOUNT: CASE FILED WITHIN THE UNLIMITED DATE RECEIVED: MARCH .07, 2006 JURISDICTION OF THE SUPERIOR COURT CLAIMANT: JANA D. TODD BY DELIVERY TO CLERK ON:MARCH 07, 2006 DELIVERED BY FEDEX ATTORNEY: CHARLES J. .WISCH BY MAIL POSTMARKED: , DATE UNKNOWN LAW OFFICES OF.CHARLES J. WISCH• ADDRESS: 425 CALIFORNIA STREET, 17th FLOOR SAN FRANCISCO, CA .94104 FROM.: Clerk of the Board of Supervisors TO: County Counsel- Attached is a copy of the above-noted claim: i,AP.CF� 07; JOHN CULL I Dated: By: Deputy Il. FROM: County Counsel TO: Clerk of the Board of Supervisors PC1_-haIfy (0�his claim complies s�hbstantially with Sections 910 and 910.2. O 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). O Claim is not timely filed. The Clerk should return claim on ground that it was f led late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). (v)-'Other: C�.�tr?-� iy-1 i �r►e(L OL ` j eu-�w GCC Ly'/`I O r Gl — eC oad 7LJ1 Z a, � �+ Dated: �J' 7�� By: /�( �9�,�r�� Deputy County Counsel Ill. FROM: Clerk of the Board TO: County Counsel (I) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. OA.RD ORDER: By unanimous vote of the Supervisors present: ( This Claim.is rejected in full. ( ) . Other: 1 certify that this is a true and con-ect copy of the Board's Order entered in its minutes for this date. d Dated*- � /� OUO(m JOHN CULLEN, CLERK, By , Deputy Clerk WARNING (Gov. codes ction 913) Subject to certain exceptions, you have only six (6) months fi-om 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 1 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 l deposited in the United States Postal Service in Martinez, California, postage frilly prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. 0 Dated: J01-IN CUL.LEN, CLERK By__ Deputy Clerk 4 OFFICE OF THE COUNTY COUNSEL SE_-L SILVANO B.MARCHESI COUNTY OF CONTRA COSTA .j► -'_ .=-_ �e� COUNTY COUNSEL Administration Building '� •� 651 Pine Street, 91h Floor "_ --- e SHARON L. ANDERSON o; "- • CHIEF ASSISTANT Martinez, California 94553-1229 GREGORY C.HARVEY (925) 335-1800 VALERIE J. RANCHE (925) 646-1078 (fax) '�'. ® O Assis-mwS `TT'9 COU�� NOTICE OF UNTIMELINESS AS TO PORTION OF THE CLAIM TO: Charles J. Wisch Law Offices of Charles J. Wisch 425 California Street, 17`I' Floor San Francisco, CA 94104 RE: CLAIM OF JANA D. TODD Please Take Notice as Follows: In regards to the claim you submitted on March 6, 2006 via Federal Express overnight delivery, on behalf of Jana D. `Dodd, portions of the claim are timely and portions may be untimely. Any claims f6r allegations occurring prior to September 6, 2005 that you may be presenting against the County of Contra Costa governed by the Board of Supervisors would fail to comply substantially with the requirements of California Government Code Sections 901 and 911.2, because they were not.presented within six months after the event or occurrence as provided by law. Because any potential claims prior to September 6, 2005 would not have been presented within the time allowed by law, no action will be taken on airy of those potential portions of your claim. The claim was forwarded to the Board for action only on the timely portions of the claims. The only recourse at this time is to apply without delay to the County of Contra Costa ooverned by the Board of Supervisors for leave to present a late claim as to the claims which are untimely. .'gee Sections 911.4 to 912.2, inclusive, and Section 946.6 of the Government Code. Under some circumstances, leave to present a late claim will be granted. See Section 911.6 of the Government Code. SILVANO B. MARCHESI COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel Page 1 CERTIFICATI: OF SERVICE BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5, Evid. Code. tiff 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On March 21, 2006, 1 served a true copy of this Notice of Untimeliness as to a Portion of the Claim by placing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez. California addressed to Charles J. Wisch, Law Offices of Charles J. Wisch, 425 California Street, 17°i Floor, San Francisco, CA 94105, as set forth above. I am readily familiar with Office of County Counsel's practice o'collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on March 21, 2006. at Martinez, California. Kathleen O'Connell cc: Clerk of the Board of Supervisors (original) Risk Management Page 2 I CHARLES J.,WISCH, SBN 68050 LAW OFFICES OF CHARLES J. WISCH 2 425 California Street, 17th Floor San Francisco, California 94104 3 Tel (415) 788-1945 RECEIVED Fax(415) 788-1948 4 MAR07 Attorneys for Claimant Jana D. Todd,doing 2006 5 business as JDT Consultants CLERK BOARD OF SUPERVISORS 6 CONTRA COSTA CO. 7 8 BOARD OF SUPERVISORS A 9 COUNTY OF CONTRA COSTA 1' 10 (: 11 JANA D. TODD, DOING BUSINESS AS ) JDT CONSULTANTS, ) 12 ) CLAIM FOR INJURIES AND Claimant, ) DAMAGES 13 ) vs. ) 14 ) COUNTY OF CONTRA COSTA, ) 15 ) Respondent. ) 16 ) 17 18 19. TO THE BOARD OF SUPERVISORS, COUNTY OF CONTRA COSTA: 20 1. You are hereby notified that Jana D. Todd, doing business as JDT 21 Consultants ("Todd"), whose address is 1424 W. Holland Avenue, Fresno, CA 93705, claims 22 damages from the County of Contra Costa("respondent") in an amount that would exceed the 23 minimum jurisdictional amount for a case filed within the unlimited jurisdiction of the Superior 24 Court. 25 2. This claim is based upon the injuries suffered by Todd to her reputation 26 and business due to defamation committed by respondent and its agents as follows: 27 2.1 Todd is a licensed clinical social worker,performing professional 28 services in the field of social work,particularly working with children. Todd has a long history 1 1 of providing high quality professional services and, until the events set forth here, was well 2 respected in her profession. 3 2.2 On or about April 12, 2005, Todd commenced performing services 4 for respondent's Department of Mental Health at the request of Sharon Cuthbertson, 5 ("Cuthbertson"), an employee and agent of respondent. 6 2.3 Thereafter, Todd entered into a contract, and subsequently an 7 amended contract, with respondent to perform said services. 8 2.4 The services Todd was requested to perform, and did perform, are 9 a type of professional social work described as "Therapeutic Behavioral Services"("TBS"). TBS 10 are services mandated by state law that are provided to children through and under the auspices 11 of the mental health departments of each county in California. Todd was specifically contracted 12 by respondent to provide TBS services to children who, although residents of the County of 13 Contra Costa at the time they qualified for delivery of services through the county mental health 14 department, had been placed in residential situations outside of the county. 15 2.5 On information and belief, commencing not later than in or about 16 December 2005, respondent has intentionally and willfully defamed Todd. Said defamation has 17 consisted of false and unprivileged oral (and possibly written) statements (a) charging Todd with 18 conduct that, if true,would constitute a crime, (b)tending to injure Todd's business and 19 profession as a licensed clinical social worker by imputing to her business and professional 20 practices of such a character that those imputations tend naturally to lessen the profits she should 21 otherwise have earned, and (c) which, by their natural consequences have caused Todd to suffer 22 actual injury. 23 2.6 Specifically, respondent's agent and employee Cuthbertson has 24 falsely and willfully communicated to third persons that Todd, in performing services for 25 respondent: (a) "has overcharged dramatically,"which would constitute fraud and a criminal 26 violation of statutes and regulations applicable to California's Medi-Cal program, .(b) seeks to 27 maintain levels of delivery of TBS services that are not justified, also leading to overcharges for 28 those services, (c) lacks professional competence and requires"extra case management," 2 I (d) lacks professional competence and requires special "coaching" in order to conduct TBS, and 2 (e) is subject to "boundary issues"which, among professionals providing mental health services, 3 constitutes a serious challenge to a person's professional and even ethical competence. 4 3. The false and defamatory statements by Cuthbertson about Todd have 5 injured Todd's professional reputation and, on information and belief, have caused Todd to lose 6 substantial compensation that she would have earned from entering into contracts with other 7 California counties to deliver TBS to children served by the mental.health departments of said 8 counties. 9 4. The amounts claimed by Todd for damages and injuries are for.general 10 damages for in to her reputation, specific damages for lost business income, and all such 11 other damages allowed by law, all in amounts exceeding the minimum amount for cases filed 12 within the unlimited jurisdiction of the Superior Court. 13 5. All notices or other communications with regard to this claim should be. 14 sent to claimant addressed as follows: 15 Jana D. Todd dba JDT Consultants c/o Charles J. Wisch 16 Law Offices of Charles J. Wisch 425 California Street, 17th Floor 17 San Francisco, CA 94104 18 19 Dated: March 6, 2006 LAW OFFICES OF CHARLES J. WISCH 20 21 By Charles J. Wisc 22 Attorneys for Claimant Jana D. Todd, doing 23 business as JDT Consultants 24 1147.101 25 26 27 28 3 LAW OFFICES OF CHARLES J . WISCH 425 CALIFORNIA STREET, 1 7TH FLOOR SAN FRANCISCO. CALIFORNIA 94104 TEL (415) 788-1945 WISCHLAW a@CS.COM FAX (4 15) 788-1948 March 6, 2006 EI�ED 1147.101 VkEc BY FEDERAL EXPRESS MAR p l 2006 Clerk of the Board of Supervisors CLESIc BOARS of suPERvIsoRs 651 Pine Street, 1 st Floor CONTRA COSTA CO. Martinez, CA 94553 Re: Claim of Jana D. Todd dba JDT Consultants Dear sir or madam: Enclosed please find an original and three copies of the Claim for Injuries and Damages submitted on behalf of Jana D. Todd doing business as JDT Consultants. Please return a file-endorsed-copy in.the enclosed prepaid envelope. 1 Very trul ours, Charles J. Wisch Enclosures cc: Client(w/encl) CJW:c 1 1 � , o / 'v O � = � _ �Vit, ��t �£•� $ ��'// •'`�:rt?. ��,,r!.�i�_ ` .fin`�4�Sy" l0 tc S co 2 zs or �rMl a iy 1' Ce) U o u cg o' o y v `� p D ur•� `� Zp y�cc ca V CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY C� ./7 �B BOARD ACTION:APR.L, 11, 2006 D Claim Against the County, or District Governe ) the BoarD� d of Supervisors, Routing Endorsemei , NAR 0 8 2006 T NOTICE TO CLAIMANT and Board Action. All Section references are to Co�1NTY COUNSEL he copy of this document mailed to you is your California Government Codes. M RTINEZ CALIF.notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given NOTE: CLAIM AGAINST HEALTH CARE PROVIDER Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: UNKNOWN I DATE RECEIVED: MARCH 07, 2006 CLAIMANT: CECELIA HOPKINS-CHESTNUT AND BY DELIVERY TO CLERK ON: MARCH 07, 2006 JAMES CHESTNUT RECEIVED FROM RISK ATTORNEY: R. KENNETH BAUER BY MAIL POSTMARKED: MANAGEMENT LAW OFFICES OF R. KENNETH BAUER ADDRESS: 500 YGNACIO VALLEY ROAD, SUITE 300 WALNUT CREEK, CA 94596 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULL.E er Dated: MARCH 07, 2006 By: Deputy 11. FROM.: County Counsel TO: Clerk of the Board of Supery sons ( ) This claim complies substantially with Sections 910 and 910.2. (Wfl,lis Claim FAI LS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board.cannot act for 15 days (Section 9101.8). ( ) 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: I Dated: 3'- 1 3- O(.p By: Deputy County Counsel iII. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). .IV. PARD ORDER: By unanimous vote of the Supervisors present: ( aK This Claim is rejected in full. O Other: i I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Date Y/ 0&4W0__ JOHN CULLEN, CLERK, By , Deputy Clerk i WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months fi•om 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 pet jury 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. I p Daied: ��fa, !4D�_ JOHN CULLEN, CLERK By Deputy Clerk i OFFICE OF THE COUNTY COUNSELSILVANO B.MARCHESI COUNTY OF CONTRA COSTA • ter' -=_ � COUNTY COUNSEL Administration Building SHARON L. ANDERSON 651 Pine Street, 91h Floor '.° CHIEF ASSISTANT Martinez, California 94553-1229 s GREGORY C. HARVEY (925) 335-1800 0` �_�;+�''U1�\ ®�;- ��Z VALERIE J. RANCHE (925) 646-1078 (fax) �a' a�' - O ASSISTANTS ��Sra cov ' NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: R. Kenneth Bauer Law Offices of R. Kenneth Bauer 500 Ygnacio Valley Road, Suite 300 Walnut Creek, CA 94596 RE: CLAIM OF CECELIA HOPKINS-CHESTNUT JAMES CHESTNUT Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [X] 1. The claim fails to state the name and post office address of the claimant. [X] 2. The claim fails to state thepost office address to which the person presenting the claim desires notices to be sent. [X] 3. The claim fails to state the dlate, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [X] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10,000). If the claim totals less than ten thousand dollars ($10,000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. A-% r R. Kenneth Bauer Re: Claitn of Cecelia& .Tames Chestnut Page Two [X] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code, § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code, § 910.6. [ 18. Other: SILVANO B. MARCHESI COUNTY COUNSEL By: 01a Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (Code Civ. Proc., §§i 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) 1 am a resident of the State of California, over the age of eighteen years, and not a part- to the within action. My business address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On March 14, 2006, 1 served a true copy of this.Notice of Insufficiency and/or Non-Acceptance of Claim by placing" the document in a sealed envelope with postage thereon filly prepaid, in the United States mail at Martinez, California addressed to R. Kenneth Bauer, Law Offices ofd R. Kenneth Bauer, 500 Ygnacio Valley Road, Suite 300, Walnut Creek, CA 94596, as set forth above. I am readily familiar with Office of County CUUnsel's practice of collection and processing of correspondence For mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. I declare under penalty of perjury under the laws of the State of California and the United States of America that the above is true and correct. Executed on March 14, 2006, it ,rtinez, California. Ka Teen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 LAW OFFICES OF R. KENNETH BAUER 500 YGNACIO VALLEY ROAD SUITE 300 WALNUT CREEK, CALIFORNIA 94596 (925) 945-7945 FAX(925) 940-9632 February 24, 2006 Sunthara Hay, D.O. 2745 Moet Lane San Ramon CA 94583 Re: Cecelia Hopkins-Chestnut Dear Dr. Hay: Enclosed herewith. please find a Notice of Intention to Commence Action Against Health Care Provider on behalf of Cecelia Hopkins-Chestnut and her husband, James Chestnut . This office has been contacted by Ms . Hopkins-Chestnut and Mr. Chestnut concerning the referenced medical treatment, and the enclosed notice is being served at this time because we are concerned that their statute of limitations may expire in the near future. We have not yet had an opportunity to review their case to determine if a lawsuit will, in fact, be filed, but we are obligated to protect their right to do so by serving the enclosed notice. Sincerely, LAW OFFICES OF R. KENNETH BAUER R. Kenneth Bauer RKB: lkb 1 R. Kenneth Bauer, Esq. , SBN 118620 LAW OFFICES OF R. KENNETH BAUER 2 500 Ygnacio Valley Road, Suite 300 Walnut Creek, California 94596 3 Telephone: (925) 945-7945 Facsimile: (925) 940-9632 4 Attorneys for CECELIA HOPKINS-CHESTNUT 5 and JAMES CHESTNUT 6 NOTICE OF INTENTION TO COMMENCE ACTION AGAINST HEALTH CARE PROVIDER 7 8 CERTIFIED MAIL - RETURN RECEIPT REQUESTED 9 TO: Sunthara Hay, D.O. 10 27.45 Moet Lane San Ramon CA 94583 11 Re: Cecelia Hopkins-Chestnut 12 This letter shall serve as notice, in accordance with section 13 364 of the California Code of Civil Procedure, that Cecelia Hopkins- Chestnut and her husband, James Chestnut, intend to file an action 14 against you for professional negligence ninety (90) days from this date. The legal basis of this action will be the negligent manner 15 in which you prescribed, and directed Ms . Hopkins-Chestnut to use, Efudex for treatment of her cervical dysplasia commencing in July, 16 2005 . 17 The claimant will allege and prove that Ms. Hopkins-Chestnut has sustained permanent losses and injuries as a proximate result of 18 your professional negligence, including, among other things, pain and suffering, medical expenses, lost income and emotional dis- 19 tress, 'and that Mr. Chestnut has sustained a loss of consortium. 20 Dated: February 24, 2006 LAW OFFICES OF R. KENNETH BAUER 21 22 23 By: ennet Bauer 24 25 26 27 28 1 County of Contra Costa RECEIVED County Administrators Office Risk Management Division MAR 0 7 2006 2530 Arnold Drive Suite 140 I ' CLERK BOARD OFSUPERVISORS Martinez, California 94553 CONTRA COSTA CO. Phone: 5-1443 Fax 5-1421 March 7, 2006 To: Clerk of the Board From: Ron Harvey Risk Manager Subject: Cecelia Hopkins-Chestnut Please process the attached Notice of Intention as a claim. If you have any questions feel free to call. I ti CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 11, 2006 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 Co ) 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". MAR 0 8 2006 COUNTY COUNSEL DATE RECEIVED: MARCH 08, 2006 AMOUNT: $550.47 MARTINEZ CALIF. CLAIMANT: ASHLEY DISTRIBUTION SERVICES, LTD. BY DELIVERY TO CLERK ON:MARCH 08, 2006 BY: DEANISE KONTER ' ATTORNEY: UNKNOWN BY MAIL POSTMARKED: FEBRUARY 09, 2006 ADDRESS:. ONE ASHLEY WAY ARCADIA, WI 54612. FROM: Clerk of the Board of Supervisors TO: County Counsel' Attached is a copy of the above-noted claim. JOHN CULL , C r Dated: MARCH 08, 2006 By: Deputy II. FROM: County Counsel. TO: Clerk of the Board of Super visors ( 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). O Claim is not timely filed. The Clerk shouId 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: /3-.0 to By: Deputy.County Counsel .1.1.1. 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. $DARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in Rill. ( ) Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. o Dated:A r// oeAD4 JOHN CULLEN, CLERK, By ,.Deputy Clerk WARNING (Gov. code se ion 913) Subject to certain exceptions, you have only six (6) months fi-onthe 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 all attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that .today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order-and Notice to Claimant, addressed to the claimant as shown above. n , Dated: l�/� °�'�� JOHN CULLEN, CLERK B vDe Deputy Clerk — — -- 5 ----- p Y a I.14.14.14: �YDistribwion Services.LTD. One Ashdcy way *Arcadia,\VI 54612 1'Iione:(608)323-3083*(500)576-1920 February 8., -1006 RECEIVED Contra Costa County Public Works Attn: Dave Rezza MAR 0 8 2006 2530 Arnold Drive, Suite 140 Martinez, CA 94553 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. To Whom It May Concern: J : �� --7 O On September 7. 2005 on Highway 680 in Walnut Creek, CA your driver Chris Cellini. (crew 51) hit our vehicle and caused damage to the driver side mirror. I have enclosed a copy of the photos and the repair bill. Ashley Distribution Services, Ltd. is requesting payment for these damages in ilii amount of$550.47. Please make checks payable to: Ashley Distribution Services, Ltd. Attn: Deanise Konter One Ashley Way Arcadia, WI 54612 Or if you choose to turn this in to your insurance company please contact me at the number below. If you have any questions please:call me at 800-477-2222 ext. 6506. Sincerely, Deanise Konter Safety Department RECEIVE0 MAR 0 8 2006 CL'E'RK BOARD OF SUPERVISC' S CONTRA COSTA CO. .i 02/07!2006 16:37 16083 64 ASHLEY DISTRIBIWN PAGE 01 L (i. 8913802512 Truck Shop 130 Vogel Way Arcadia,WI 54612 Phone(608)323-6962 Fax(608)323-6164 Date: 02107106 Bill To: Ashley Distribution One Ashley Way Arcadia WI 54612 (608)323.6506 Mirror Damage--Accident--Repair Cab Extender Driver:Erin Seibel :.41Cal7NU`i�S1ri�`�;`::z:�M7i��)�k::4'al::,t':;:�,, f+`!,. . ,.:. �R ,,:•::;.);�..... ..:. ::Iwi'�G "C!?QI�"::`::` ::;.:`:TE�tM 792118 111,112 97205 September 10,2005 Colton Due on receipt Aty S t�S GfZ '1` 1.00 20756209 Mirror P S 436,26 $ 436.26 1.00 20535605 Bracket P S 19.17 .$ 19.17 2.00 Labor $ 47.52 S 95.04 $ - $ $ S $ - a . TOTAL PARI-S . S 455.43 TOTAL LA60R $ 95.04 SHIPPING&HANDLING TOTAL DUE $ 550.47 THANK YOU FOR YOUR BUSINESSI vv r JV ly 1 ley *� a '.A 1 i G • i J � i 1 i i a � 3 P �r' ...rte:v--•.._- ,.^ =t } ; j.. :z Ft�fi 1. M Yl.. t X., i • m N +' om 0 NNcam_` r `l 2t �. a1 N Sd311Nn 1x1- V d' T L O C:5 or U �N/ pd ca N co U- 4 Q � Gcr) co , cr, o � X , , fi , CO ' J ' , U � � a o N � � 7 � , a a . N � , d' , , CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY C /� • BOARD ACTION: APRIL 11, 2006 Claim Against the County,.or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section ref s 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 MAR 0 g 2006 Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". C��O��UNTY COUNSEL AMOUNT: $2,081.27 + $50.00-rile .A platbATE RECEIVED: MARCH 08, 2006 CLAIMANT: ROGER VARON N . BY DELIVERY TO CL:ERiC ON:MARCH 08, 2006 ATTORNEY: UNKNOWN BY MAIL POSTMARKED: MARCH 07, 2006 ADDRESS: 2713 MORGAN DRIVE, #29 SAN RAMON, CA 94583 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULL 1 Dated: MARCH 08, 2006 By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Sniper isors (Alis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant.The Board cannot act For 15 days (Section 910.8). O Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). ( ) Other: Dated: By: m Deputy County Counsel 111. .FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2). O Claim was returned as untimely with notice to claimant (Section 911-3). IN/ BOARD ORDER: By unanimous vote of the Supervisors present: (✓) This Claim is rejected in full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. 0 Dated ,Ori/ / oZOW4 JOHN CULLEN, CLERK,By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the rnail to file a court action on this claire. See Government Code Section 945:6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney; you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1 am now, and at all times herein mentioned, have been a citizen of the United States, over age 1$; 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: nil / 9?4% JOUN CULLEN, CLERIC By __ _Deputy Clerk . BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) .� B. Claims must be filed with the Cleric of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street,Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more .than one public entity. separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ■■ammonsoon Now Oman mean aaoamom mango aaaaaoeeoaaaaaaaoaasaiaonEgo a[ RE: Clain By: Reserved for Clerk's filing stamp RECUVED Against the. County of Contra Costa or ) L- MAR 0 8 2006 ) CLERK�V10ARO QE SUPERVISORS D1StrICt) _`O;@TR.a COSTA Co. (Fill in the name) ) The undersigned claimant hereby makes claim auIst the County of Contra Costa or the above-named district in the sum of 0 Aland in support of this claim repres nts as follows: 1. When did the damage or injury occur? (Give exact date and hour) ,5�a4-� -2, o 6, A 2. Where did the d age r inju y occur? Incl de city and cou ty) lea l�e,�te5 �� 5cnool _ 9 �- G�rEv�a J. How did the damage or injury o cur? (Give full details;use ex a aper if required) aG� Alk ca u- usex-G kirk e� c- 1.230 vvk u r VeeW P CLCD, �q S P c( �cc v1 loct,�,,c � �-}� wi q �' A r by vr\der' 4. What particular act or omission on the part of count), or district officers, servants, or employees caused the injury or damage?, CSU.� �.`�er �, �}a5 1p�` K o—J+ a4 w 14M 5�� ulS0.S �t �i-� vu Cet r. 8 5 What are the names of county or district officers; servants, or employees causing the damage or injury? Ls r ,. 6. What damage or injuries do your clahn resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage:) g �- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) C ('�-u, V\ �u b l; In � o o�ul S�� --s e;e e�-,'wt�x+� acive4 S. Names and addresses of witnesses, doctors, and hospitals: '�. Q Vk eA, 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT ■■a0asssasssssaaaassaaaaaaaa0aassaaassaassasROME assssassasssaaasaassassassasasasssssi .Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attornev) � Name and address of Attorney (Claimant's Signature) a-715 Y TC3 a v1 Dir, (Address) Telephone No. )Telephone No. vl aZ��-�— `[ rz-] ■■saasssaaasaaasaaa3aaasssssasaassassaasasassman ssaasaaaasaaaaaaaaaRon MEN OEM swum ssssi PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any clairn filed with the County under the Tort Claims Act, is subject to publicc disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■museum smass spossum sa■s■ 0aamassaaasaaasssaawas assaassaarasasasasaaaassssausaNONE ssasl NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), 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 imprisomnent and'fine. 02/27/2006 at 12 : 52 PM Job Number: 15163 CROWN CHEVROLET CADILLAC OLDS ISUZU License # :BAR#AA2466N 7544 Dublin Blvd Dublin, CA 94568 (925) 828-6500 Fax: (925) 828-4174 PRELIMINARY ESTIMATE Written By: MATT MCDERMOTT Adjuster: Insured: ROGER VARON Claim # Owner: ROGER VARON Policy # Address: 2713 MORGAN DRIVE #29 Deductible: SAN RAMON, CA 94583 Date of Loss: Day: (925) 487-2126 Type of Loss: Point of Impact: 6 . Rear Inspect Location: Insurance Company: Days to Repair 2000 CHEV MONTE CARLO SS 6-3 . 8L-FI 2D CPE RED Int : VIN: 2G1WX12KXY9354936 Lic: RVPHOTO CA Prod Date: 05/2000 Odometer: 75280 Air Conditioning Rear Defogger Tilt Wheel Cruise Control Intermittent Wipers Keyless Entry Steering Wheel Controls Body' Side Moldings Dual Mirrors Roof Console Traction Control Fog Lamps Rear Spoiler Clear Coat Paint Power Steering Power Brakes Power Windows Power Locks Power Mirrors AM Radio FM Radio Stereo Cassette Search/Seek Anti-Lock Brakes (4) Driver Air Bag Passenger Air Bag 4 Wheel Disc Brakes Cloth Seats Bucket Seats Automatic Transmission Overdrive Aluminum/Alloy Wheels ------------------------------- ----------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1 REAR BUMPER 2 Repl Bumper cover SS model w/sport 1 1317 . 02 1 . 7 2 . 6 pkg• 3 Add for Clear Coat 1 . 0 4 Add for spoiler 0 .4 5# R&I TRANSFER 7 SPOILER RETAINERS 1 . 0 6# FLEX 1 8 . 50 T 7# TINT 1 X 0 . 5 ------------------------------------------------------------------------------- Subtotals =_> 1325 . 52 3 . 6 3 . 6 . 1 Q2/27/2006 at 12 : 52 PM Job Number : 15163 PRELIMINARY ESTIMATE 2000 CHEV MONTE CARLO SS 6-3 . 8L-FI 2D CPE RED Int : Parts 1317 . 02 Body Labor 3 . 6 hrs @ $ 72 . 00/hr 259 .20 Paint Labor 3 . 6 hrs @ $ 72 . 00/hr 259 .20 Paint Supplies 3 . 6 hrs @ $ 31 . 00/hr 111 . 60 Sublet/Misc . 8 . 50 ----------- ----------------------------------------- SUBTOTAL $ 1955 . 52 Sales Tax $ 1437 . 12 @ 8 . 75000 125 . 75 ---------------------------------------------------- GRAND TOTAL $ 2081 . 27 ADJUSTMENTS : Deductible 0 . 00 ---------------------------------------------------- CUSTOMER PAY $ 0 . 00 INSURANCE PAY $ 2081 . 27 NOTE : MATERIALS INCLUDE ALL BUT. NOT LIMITED TO SANDPAPER, MASKING TAPE, MASKING PAPER, PAINT REDUCER, PAINT, PRIMER SEALER, THINNER, PLASTIC, ACTIVATORS, COMPOUNDS, GLAZES, WAX AND GREASE REMOVERS . PARTS PRICES ARE SUBJECT TO INVOICE . FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS : D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES : B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS : ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE RPR=REPAIR RT=RIGHT. SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLS : #=MANUAL LINE ENTRY *=OTHER [IE . .MOTORS DATABASE INFORMATION WAS CHANGED] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE . MQVP=MANUFACTURER' S QUALIFICATION AND VALIDATION PROGRAM. OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME UNIQUE PRICING OR DISCOUNT. 2 Q2/27/2006 at 12 : 52 PM Job Number: 15163 PRELIMINARY ESTIMATE 2000 CHEV MONTE CARLO SS 6-3 . 8L-FI 2D CPE RED Int : Estimate based on MOTOR CRASH ESTIMATING GUIDE. Unless otherwise noted all items are derived from the Guide DR1CG00 Database Date 01/2006, CCC Data Date 01/2006, and the parts selected are OEM-parts manufactured by the vehicles Original Equipment Manufacturer. OEM parts are available at OE/Vehicle dealerships. OPT OEM (Optional OEM) parts are OEM parts that may be provided by or through alternate sources other than the OE/Vehicle dealerships. OPT OEM parts may reflect some specific, special, or unique pricing or discount. Asterisk- (*) or Double Asterisk (**) indicates that the parts and/or labor information provided by MOTOR may have been modified or may have come from an alternate data source. Tilde sign (-) items indicate MOTOR Not-Included Labor operations. Non-Original Equipment Manufacturer aftermarket parts are described as AM, Qual Repl Parts or Comp Repl Parts which stands for Competitive Replacement Parts. Used parts are described as LKQ, Qual Recy Parts, RCY, or USED. Reconditioned parts are described as Recon. Recored parts are described as Recore. NAGS Part Numbers and Benchmark Prices are provided by National Auto .Glass Specifications. Labor operation times listed on the line with the NAGS information are MOTOR suggested labor operation times. NAGS labor operation times are not included. Pound sign (#) items indicate manual entries. Some 2006 vehicles contain minor changes from the previous year. For those vehicles, prior to receiving updated data from the vehicle manufacturer, labor and parts data from the previous year may be used. The Pathways estimator. has a complete list of applicable vehicles. Parts numbers and prices should be confirmed with the local dealership. CCC Pathways - A product of CCC Information Services Inc. 3 , e =; 5 t , , i , :1 t i t �4 , � o t y ccs t , , CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 11, 2006 Claim Against the County, or District Govei-ned by ) the Board of Supervisors, Routing Endorsements, ) NO'i.'ICE TO CLAIMANT and Board Action. All Section refere q11 re to California Government Codes. The copy of this document mailed to D you is your notice of the action taken onour claim b the Board of Y Y MAR 14 2006 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY COUNSEL Section 913 and 915.4. Please note all AMOUNT: TO BE DISCUSSED MARTINEZ CALIF "Warnings,". CLAIMANT: DARRELL CONKLE ANDI SHEILA CONKLE BY POWER OF ATTORNEY MARCH 1.4, 2006 ATTORNEY. UNKNOWN DATE :RECEIVED: ADDRESS: 836 CARQUINEZ WAY BY DELIVERY TO CLERK ON: MARCH 14, 2006 MARTINEZ, CA 94553 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C .Dated: MARCH 14, 2006 j By: Deputy I1. FROM: County Counsel TO: Clerk of the Board of.Supeivisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially witli Sections 910 and 910.2, and we are so notifying claimant. Tile Board cannot6ct 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: 3"r't'o—O(o By: / :Deputy County Counsel I.11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely, with notice to claimant (Section 911.3). IV. ARD ORDER: By unanimous vote of the Supervisors present: (► This Claim is rejected in frill. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. 0 DatedJr/J ��Ot JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) 1 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 fit 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 1 declare under penalty of per jury 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 i 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: �'i�'r�� JOHN CULLEN, CLERK By Deputy Clerk "BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT °A: A claim•relating to a oause.of ou fondest or for 4uryto person.or to personal property.or..;; growing clops shall be piesente¬later.than six months ager the acctual..of:t)a cause..of eC.ion. A claim relating tq en other:cause.of action shall be.'presented riot later ihaa.oae year after the:acerae!of the cause of..action: (Gov:Code:§91 LI). B. Cleans must be filed -wig the Cleric of tbz Board of Supervisors.wax its`office in:Room; 106; County A � ini „on Buiidiag, 651 Pine'Strest.Mkdam CA.9,45531:. uvCIfcmis e¢aMssai .dryBthan tne:Gounty,the:: name of the District should be filled in.. D. If the cWln:is;agai more tliaa one public e=ty; separate claims mus be filed egzinsf,each public coaly. E: pram;. See penalty for.fraudulens claims,Penal.Code Sect-72 at the`i n d this •i'W.a8S.R013660..0499wee000w ens wen.■.lmeJ69r8NO5.O:ONert6.•111ii:•6mPD111 99*691192..l - RE:..: Claiui:By: . Reserved for`C1esk's.iilirig.staztip:` :DARRELL CONKLE AND HIS WIFE SHEILA CONKLE,BY �RECEIUED.POWER OF ATTORNEY ): I t Against.the County 9f:Coatra'Cdsta or ) : MAR 1 4. 200 ' District). . . BOARD. F SUPERVISOR$ i (Fill iii the nam9).. . corvrRA COSTA Co. ):: The.undersignedclaimant hesrby, es clii6 aiwi the County of�Cantra.:Cesw or the.above-named.. district in the sum of:$ To Eig ois6usslai and is support of this chili represents as follows; ; I. When did the daaisge or iz}juryocctu? (Give execrdate andboor) JAN.24;2006-FEB.8,2006 I 2: Where did the di6a.ge or IMWVoccur? (Inc _I ludo city cad county) CONTRA COSTA REGIONAL.MEDICAL CENTER, MARTINEZ;.CA 3:.:. . Row did'tlie damage or ito 0.ccur. (Give foil detals:use extrEi paper if.rEquned) SEE ATTACHED 4, What:particular:.act.or omission on the peat of.counrf dj d*-ct-off colmsi serye=' OT employees: caused the in or e? SEE ATTACHED 5 What are:the mines of euny.br diitriCt ffiC1CTs.savants,or employeds causi=ig`the damage or:iujury? SEE ATTACHED, 6: �Thact dam*.::or injuries da Yomciai�+ resulted? (Grine iull.event of injuries. njuries `or.:darueges z1aimed. -Attach two esti=Ws ft auto damage:) SEE ATTACHED. 7, Haw was the amount. claimed l:above computed? (Include the` i:i.t#aicd .=' Dunt.a:" dny prospective iniury.or dame j: N/A 8. Names and addresim-of witness ,.doospitalC THE COMPLAINT FILED WITH THE OMBUDSPERSON AT CC RMC (ATTACHED),CONTAINS SOME OF.'THE NAMES,HOWEVER UPON COMPLETION OF THEIR REPORT,OTHER NAMES SHOULD COME TO LIGHT: SEE ATTACHED FOR A LIST OF OTHER WITNESSES. _ 9: List the expeucbuas you made ob,account of ttus accadetrt or injtry:. ATE" AMOL�1T c MEDICAL EQUIPMENT FOR HOME USE,24 HOURS:IN.HOME" MME(2 WEEKS) � cAa2e�.l✓ems ) 3 �-�-� (,,,�...PZ�. ,.. w■■snseff...rngsNow*.ov■■■■gravel I�s�s■�:■��■�.'::�■�i"�.s�ois.rsa■w..sosswsa■r.�as:o.res:o.0si Gov,Code Sec. 910;2 provides``The.claim:shall be . signed by thc.claiinarrt or bysome.person on hist behalf s . . rro cEs tt� • Nmne and:address:of A (Claimimt's.Sigttiature) 836 CARQUINEZ WAY. j MARnNEZ;.CA94553 Telephone.No. Telep>~one.No.. 925-228-1 616. . go an.wes a Nei was 1.1 PUIIC RECORDS NOTICE: . Ple=be"M' ed that.thls clairn'forai;or.agy ciaiin filed with the Courcy under the Tats C aims Ac:; is svbjem to public disclosure under tba-.Caiif=la Pub liC Rac rds Act...(Gov: :Cod_,`55 '6500..et;seq.) Fi"iermore,:any attachrzien ,addeadun,s;or suppleme.nsas w ed w the claim form,includins nedical"r+ecords,are atso subject to public disclosure: ■•■d■.■•■damage 9.ss@s■■.■.■'■. .. .■■.■....■nso....■saBoom man■■meannesp■r■was as'aa■*66■■.,„ -ii Onc : Suction 72 of the Peiial Co&provides: Everp:psraon:who;:with intent to dcfrauc;.presents for allowance or or payment to.any'statt:board'.or.officer--or to-any county,:city; or district board or filter; aitthorized.to allow,0 pay the same if genulne,.any.false..or fraudulent:cJaim,.bitl,:acmunt:Voucher,o�wrlting;is punishable either by impri3. mem in'iho.County ja11 kr a ,period of not more.then:one,:yew,ebs a fine.of not exceeding.one thousahtdollarp'(S1,000.00)j.or'by bb:h such it!tprisoimetft ead'finey.or by impri;onm. 'I .m tl� MSX,priuoa..by a Ene-cf;not extBedtag sen th0ussi�d dollars 510;004);or by:both.such'ilapribonitialt and. ine , ( �. • := I I Attachment to Claim 8. Names and address of witnesses, doctors,and hospitals: 2. 3 4. 5. 6. 7. 8. FULL AND UNLIMITED POWER OF ATTORNEY TO WI-IOM 1T MAY CONCERN: I, DARRELL CONKLE, do hereby appoint Sheila Conkle, to be my Attorney in Fact, to sign and receive all documents, of any nature and kind,and to do all things in my stead as if I were present and acting in person. Darrell Conkle Date CALIFORNIA A1,11--PURPOSE ACKNOWLEDGMENT l State of i County of Q f On�� a before me, � Date Name and Title of Officer(e.g., Jane Do ,Notary Public') i —0Ct >r personally appeared Name(s)of Signer(s) ) ❑ personally known to me Y_-Proved tome on the basis of satisfactory evidence i to be the person( whose name() is/are-subscribed to the ) within instruments!acknowledged to me that he/shefte -- executed the same in his/herfth&authorized capacity(ies), and that by his/het/their signature on the instrument the person(,or the entity upon behalf of which the person) _ JENNFM SM(pEBM acted, executed the instrument. a COMM.#1619220 m NOTAWPUBUC-CAuwRNIA V WITNESS my hand and official seal. C7 CONTRA COSTA COurmr -+ lly C- m1.Evhm IJw 5.2" Signature of Notary Public OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document t Title or Type of Document: FU k 1 CAM W1 1111 c C)� a�A��Iev Document Date: Number of Pages: \ Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: ❑ Individual ❑ Individual ❑ Corporate Officer ❑ Corporate Officer Title(s): Title(s): ❑ Partner—❑ Limited ❑ General ❑ Partner—❑ Limited ❑ General ❑ Attorney-in=Fact ❑ Attorney-in-Fact ❑ Trustee ❑ Trustee ❑ Guardian or Conservator ❑ Guardian or Conservator ❑ Other: Top of thumb here ❑ Other: Top of thumb here Signer Is Representing: Signer Is Representing: 0 1996 National Notary Association•8236 Remmet Ave.,P.O.Box 7184•Canoga Park,CA 91309-7184 Prod.No.5907 Reorder:Call Toll-Free 1-800-876-6827 CONTRA;COSTA REGIONAL MEDICAL CENTER:&-CONTRA-COSTA HEALTH CENTERS PATIENT COMPLAINT/GRIEVANCE • QUEJA.DEL PACIENTE Name.. Nombre: DARREL.LCONKLE - Rhone # # :de Telefono: 925-228 1616, AddreSS.' D.IreCC10n:.: 836.CARQUINEZ WAY, MARTINEZ,CA 94553 ... . ,_,...; Medical: Record #: :24451.87 Date of Birth: SaCial 'Seciirity -r 563-4&7846 Fe de nadinie161937 Date.of`treatment/visit:: ..Date complaint filed • La fech' 1./24106-2/8/06 �Fecha dei trataniiento: de: presentacion de la queja:. Where did i.0 11�. 0...00Cur? • 1.06. �E..00UrrIQ el.l(1C1(�eflte?. C A.COSTA:REG. MED. CNTR . Brietty describe complaint.: Provide details of complaint with%specific information --ch.as: names; dates,:sequence of;events, etc. Attach asrhkh additional information -as'is necessary, Describe btdVeniente la queja: Provea deWlgs de la..queja con information especffica tomo nom, res; fechas, h3 secuerncia de,hech�os; etc: Incluya toda-la inforrnaciori aiiicional gue sea riecesaria: 1. PATIENT, DARRELL CONKLE, ADMITTED 1/24/06(EARLY AM),COPD,:WITH COMPROMISED BREATHING. TREATED.IN ER,..PLACED ON BIPAP AND RECOVERING WELL;.:UNTIL, 2. 1/25/06(C09:00 PM)ERRONEOUSLY DIAGNOSED AND TREATED,FOR ALCOHOL WITHDRAWAL,. ENDAGERING RECOVERY, AND LEADING TO, 3. UNNESSESSARY INTUBATION,.FURTHER ENDAGERING RECOVERY;:AND, 4. .CONTINUED.TO.BE TREATED..WITH'A COMBINATION OF ANTtPSYCHOTIC.AND ANTI-ANXIETY DRUGS, INCLUDING HALDOL, ATIVAN, RESPERDAL, AND BUSPAR, RESULTING IN A COMATOSE. ... -UHRESE.OARLVE-C-Ol:1,DILON THAT WOULD LAST_UNTIL�[3/O {$'DAYS) 5: PATIENT DID NOT RECOVER.CONSCIOUNESS UNTIL-THESE DRUGS WERE FINALLY REMOVED ON f 2/3/06. PROGNOSIS THAT THE PATIENT WILL RECOVER TO PREVIOUS FUNCTIONALITY; QUZE.T.IONABLE.... *PLEASE SEE ATTACHED SUMMARY.AND.TIMELINE OF EVENTS 'Whats action are you requesting? Quos meddas:quie�e quetomemos?. 1: A COMPLETE INVESTIGATION INTO THIS MATTER,'INCLUDING PERSONS RESPONS113LE FOR.MISS- DIAGNOSIS AND TREATMENT: 2. A COMPLETE EVALUATION OF ALL MEDICATIONS PRESCRIBED, EVALUATING THE POTENTIAL.NEGATIVE AFFECTS OF THE INTERACTION.OF THESE DRUGS. A_REVIEW OF'COJ�MUNICATIONS'WITH THIS FACILrrY MY EXPERIENCE WAS THAT.CRITICAL INFORMATION WAS NOT PASSED-ON TO THOSE WHO NEEDED IT. 4: '.-��.�66EBIFRE-ESTA-uLisNEA�-",o#i1BiuNG-RE -Ki*G-4r.RzF#c464-RROEE4MR6--DE-ISIONS iN A NON-EMERGENCY SITUATION WITHOUT A LICENSED:PHYSICIANS APPROVAL: '5 RESVCTS'OFTHE-IN'CfDEWlr'REPORT_�_LOtl-Vr-rA'K,ArND-RES , B7�1f�O 1 Signature:of person submitting complaint: Did employee Firma,:dela.persona`que presents la_queja: ".cornplete form?. lf:other than.patient; indicate-relatiorishizSPOUSE,:WIFE of PA nI�MT Q yes Q._rio Signature of employee receiving:complaint:. Y our-complaint will be thoroughly investigated and you will.receive an answer within:thirty days: `Thank you for bringing this to:our attention: We:strive to provide quality care:., Sq ue a sera investi �ada ri urosamente usted ee bir:una res uesta(Je rtfo de trelr,ta`dray: q.. J g 9 . Y, .. P .. 1.a anroripnamne nnr hahamna.infnrmaiin ria ceto.catentn hrrie oafni rnne:on:nrnwbar o6rlarin 7+p nalifiori Timeline/Summary of Events Darrell Conkle suffers from severe COPD, but has been able to live a normal life with the help of medication and daily breathing treatments(inhalers & nebulizer). He has been able to completely care for himself, eat,walk, drive, shop, keep medical appointments, etc, alone and without aid. He was hospitalized 4/ 12 years ago for a severely compromised breathing episode, and except for that hospitalization has been completely functional. Dr. Applegate had previously prescribed Prednisone, for Darrell to take when he had any serious symptoms of compromised breathing. January 20, 2006, Friday, a fire destroyed the house next door,killing both of the occupants. January 21 & 22, Saturday and Sunday, Darrell was having breathing problems due to the smoke from the fire. He began using the Prednisone on Saturday. January 23, Monday, I spoke with Dr. Applegate, telling him about the fire, that Darrell was having breathing difficulties and that he was using Prednisone. Dr. Applegate confirmed that Darrell was doing exactly what he should be doing. that he should increase the dosage, and that if needed, Dr. Applegate would see Darrell in Clinic on Tuesday, January 24. January 24, Tuesday, early am, Darrell,was very weak, only able to walk by holding the wall and having severe breathing difficulty. I immediately took him to ER. Dr. Applegate was called to ER, and Darrell was placed,on a BiPAP. Intubation was discussed.at this time, but dismissed, as not necessary. Dr. Applegate felt that Intubation should only be done if absolutely necessary and no other treatment option was possible. Darrell responded well to the BiPAP, and he was stabilized by around 10 am the same morning. Darrell was moved to the Critical Care Unit for observation, he continued to improve,was alert and talking. The staff was very satisfied with his recovery and that Intubation had not been needed. Dr. Applegate stated that our home had to be completely sanitized of all imbedded smoke before Darrell could return home, I arranged to have this done. January 25, Wednesday, Darrell continued to improve. 1 spoke with Drs. Applegate and Tzvielii,they indicated that they were going to move him out into the mainstream on Thursday, by-passing IMCU, as he was doing so well. 1 I saw him at 4:00 pm, Darrell, was doing exceptionally well, and wanted to come home 1 returned to he hospital around 6:00 pm, l spoke to the nurse on duty, she asked if Darrell suffered from any type of confusion, particularly Sundowners Syndrome, I verified that he did, and had suffered with this for many years. However, it should be re- stated that even though Darrell suffers from occasional spells of confusion, he was 100% functional. She also stated he was being given Ativan, and was concerned that Ativan may be causing his confusion. They had called the Dr. to see if he may want to prescribe another drug as Darrell was due to receive Ativan again at 7:30 pm.. Darrell was doing very well, and talked again of going home, he was hopeful he could be released on Thursday instead of being transferred. At this time he was totally coherent, rational and speaking clearly. That night at approximately 9:00 pm I received a telephone eall from a resident physician, Dr. Jennie Riley. She stated she had just Intubated Darrell because of`alcohol withdrawal'. This is the first, but most critical, miss-diagnosis' and treatment. I told her that Darrell drank socially, and was not an alcoholic. She further stated that she had asked Darrell (a man they had already determined was suffering from confusion) if he drank—he stated he enjoys a cocktail every evening before dinner. The medical records indicate this diagnosis and subsequent Intubation was made at 1900 hrs. (7:00 pm). I was with Darrell, in his room at this time, no mention of this was made to me, had it been, I could have easily explained Darrell's symptoms, that it was not alcohol withdrawal,but normal anxiety for him, as was determined at the 1/27/06 Multi Disciplinary Rounds meeting. Additionally, the `Alcohol Withdrawal Guideline" states"Admitting physician should make initial evaluation....., and decide on appropriate level of care" (medical records page 113A ) I asked Dr. Riley if she had informed Dr. Applegate or contacted him prior to performing this procedure. She stated she had not and would inform Dr. Applegate the next morning. This critical procedure should not have been done in a non-emergency situation, without contacting Darrell's primary physician, Dr. Applegate and/or myself. I immediately contacted the Supervising Nurse,Nancy and the Charge Nurse, Kip. Nancy contacted Dr. Applegate and was told by Dr. Applegate that he was concerned and 2 CONTRA COSTA 9EALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER ALCOHOL WITHDRAWAL SaLDERS, PAGE 2 OE 2 ALCOHOL WITHDRAWAL GUIDELINES 1. Assess your patient's risk: a) High risk patients include: 1) patients with a history of alcohol withdrawal seizures or delirium tremens who are actively conFuming alcohol; 2) patients with an initial CIWA score > 15. b) Mild-moderate risk patients include: 1) patients with a history of alcohol dependence who are actively consuming alcohol. Daily alcohol use with a positive CAGE screen should be considered a patient at mild-moderate risk. High risk patients should be considered for prophylaxis treatment and should receive symptom- triggered treatment. Do not begin prophylaxis in patients with INR>1.5,AST>200 or with clinical evidence of decompensated cirrhosis (ascites, esophageal varices, hepatorenal syndrome, SBP or hepatic encephalopathy). Mild-moderate risk patients should receive symptom-triggered treatment. 2. Monitoring of CIWA-Ar score (Clinical Institute Withdrawal Assessment for Alcohol): a) CIWA <8 = not yet in withdrawal; CIWA >8 = withdrawing; CIWA >25 = needs telemetry monitoring. b) For patients in severe withdrawal (CIWA >25), admit to IMCU or ICU. Assess total six hour use of benzodiazepine (required during first 6 hours of hospitalization) and extrapolate to 24 hour needs. If needs are greater than the equivalent of lorazepam 24mg per 24 hours, start lorazepam gtt at dose equivalent to estimated 24 hour needs/24 hrs. c) Goals: CIWA <8; stable CIWA >24 hrs d) Admitti h sician should make initial evaluation of CIWA in the ED and decide on appropriate level of care. e) RN should make initial evaluation an documentation of patient's CIWA upon arrival to the floor/unit. House officer should be called if.initial CIWA is >15, 3. Level of care: a) Consider ICU admission for patients with uncontrolled severe symptoms,CIWA >25 or with co-morbid cardiovascular or pulmonary disease b) Consider IMCU admission for patients in active withdrawal with comorbid medical conditions or who have worsening hemodynamic status attributed to active withdrawal or comorbid medical illnesses (e.g., SBP > 180 or HR >120). 4. Continuity of care: a) Reassess and write new orders daily with attempt to taper by approximately 25%each day if CIWA stable >24 hrs. b) Do not extend prophylaxis longer than 72 hours unless CIWA is unstable. c) Consider haloperidol for treatment of agitation, disorientation or hallucinations when autonomic symptoms are well controlled (e.g., minimal tremor, diaphoresis)with benzodiazepines. Observe for the development of extrapyramidal symptoms (e.g., dystonia, akathesia, parkinsonism). Do not use in active ETOH withdrawal CIWA>8. d) Consult Social Work for referrals to outpatient treatment (e.g., alcohol rehabilitation programs, AA, etc.) The order from utilizes prazepam unng acute withdrawal and diazepam for prophylaxis. It is appropriate to use either agent in either context, and individual providers may prefer to write their own orders. However, mixing agents is not recommended,and the same agent should be used for both ATC and PRN dosing. In addition, use of lorazepam (shorter-acting) is preferred fer the elderly and for patients with liver dysfunction. If the patient has onset of withdrawal symptoms requiring treatment, estimate benzodiazepine requirement to achieve CfWA < 8 and start ATC dosing. USE OF THE "CAGE" MNEMONIC ( >2 of 4 = positive screen ) Cutdown Have you tried to cut down on your drinking? Annoyed or angered Have others,annoyed or angered you by criticizing your drinking? Guilty Have you ever felt guilty about your drinking? Eye-opener Have you ever used alcohol to steady your nerves or to reduce the effects of a hangover? ALCOHOL WITHDRAWAL GUIDELINES MR437 (e-05) Side 2 V V CONTRA COSTA HEALTH SERVICES C L R CONTRA COSTA REGIONAL MEDICAL CENTER D A P R C L L 925 228- 1616 V!.l ALCOHOL WITHDRAWAL ORDERS C I 1 / Ih/ 1437 MAC1)0f' 4L01 DDVID I 1 /24 /06 11 INITIAL CIWA SCORE S�, is. CIWA-Ar Score < 8 �°'1 ❑ WITHDRAWAL PROPHYLAXIS Medication: Diazepam ❑ PO ❑ IV push (Max dose: 60 mg per shift) Mild Risk, h/o self-limiting withdrawal ❑ 5 mg ❑ mg ❑ q 6 hours x 4 ❑ And,x 1 PRN CIWA> 8, notify MD and initiate symptom-triggered treatment of active withdrawal. Moderate Risk, h/o w/d requiring meds ❑ 10 mg ❑ mg ❑ q 6 hours x 4 ❑ And,x 1 PRN CIWA> 8, notify MD and initiate symptom-triggered treatment of active withdrawal. Severe Risk, h/o w/d seizure/delirium ❑ 15 mg O mg ❑ q 6 hours x 4 ❑ And,x 1 PRN CIWA> 8, notify MD and initiate symptom-triggered treatment of active withdrawal. �-- TGA-Ar Score 0-25 Modified Sedation-'Agitation Scale PTOM-TRIGGERED TREATMENT OF ACTIVE WITHDRAWAL 3 Dangerous agitation (Pulling at ET tube,trying to remove catheters, ent at risk for withdrawal or currently in mild to moderate withdrawal) climbing over bed rail, striking at Nursing: Assess initial CIWA on arrival to floor/unit. staff, thrashing side-to-side) IIf CIWA<8, assess CIWA eve 2 hs x 3: If CIWA remains<8, 2 Very agitated (Does not calm, every despite frequent verbal reminding assess CIWA every shift of limits; requires physical restraints, V If CIWA> 8 at any assessment, initiate treatment below and biting ET tube) GV 1 Agitated (Anxious or mildly agitated, reassess CIWA and sedation q 1 hr until CIWA<8.then q shift. attempting to sit up, calms down on . Call MD if CIWA> 14 or,if CIWA> 10 for more than four hours. verbal instructions) 0 Calm and cooperative (Calm, Medication: Lorazepam ❑ PO AIV push ❑ IM (Max dose: 32 mg/shift) awakens easily,follows commands) Mild w/d CIWA 8-13 2 mg ❑ mg q 1 hr PRN CIWA> 8 -t Sedated (Difficult to arouse, awakens to verbal stimuli or gentle Moderate w/d CIWA 14-20 3 mg mg q 1 hr PRN CIWA> 14 shaking but drifts off again,follows simple commands) Marked w/d CIWA 21-25 �4 mg ❑ mg q 1 hr PRN CIWA> 21 -2 Very sedated (Arouses to physical stimuli but does not communicate CIWA-Ar Score > 25 or follow commands,may move TREATMENT OF SEVERE WITHDRAWAL spontaneously) -3 Unarousable (Minimal or no Nursing: (�EF-Continuous SP02 monitoring response to noxious stimuli,does not. Assess vital signs and sedation every 2 hours communicate or follow commands) Assess CIWA every 1 hour until CIWA< 14,then every 4 hours until CIWA<8, then call MD to reassess. ('Assess sedation scale 15 minutes after each IV bolus. For sedation scale> 3, assess vital signs, hold medication, notify MD. Intubation tray to bedside Medication: Lorazepam2 mg IV push. CD4 mg IV push (Max dose: 64 mg per shift) every 15-30 minutes, titrate to sedation scale o -1 for first 6 hours, then notify MD to evaluate. Call MD for sedation scale of-2 or -3. ?:�TBanana Bag: MVI adult 10 mL IV, CDMagnesium Oxide 400 mg PO bid hiamine 100 mg IV, Folate 1 mg IV in the first ❑ Magnesium Sulfate 1 gram IVPB over 1 hour x doses bag of IV fluid daily. z�.iLC� ❑ Potassium Chloride 10 mEq IV drip every 1 hour x doses IV fluid \3S Rate I.5 G mL/hr ❑ Potassium Chloride Controlled-Release PO RN to call pharmacy daily, as necessary,to update current IV fluid rate. Reassess your patient when there is any change in status or every 24 hours. Benzodiazepine orders must be rewritten every 24 hours.Attempt to taper,benzodiazepine dose ea c day by 25% if CIWA score is stable. Noted by Date Time Physician Si-nature Date Time _-1 ^ 1. 1 ^k-_ rc oh—A All mHOL WITHDRAWAL ORDERS somewhat upset that this procedure had been done, and that Dr. Applegate would contact me in the morning, after he had made some inquiries. I returned to the hospital around 10:00 pm and was alarmed, finding my husband totally unresponsive and comatose, unable to move,open his eyes, speak, and completely unaware of his surroundings. January 26, Thursday, Darrell unresponsive and comatose. I spoke with Dr. Applegate, asking him why Intubation had been allowed,when Darrell was making such a remarkable recovery. He responded that he did not know at this time, but that Dr. Riley would have to have a `Respiratory Reason', that she had performed a Blood/Gas test, but he did not know the results. He stated that Dr. Riley alone made this decision. (The medical records indicate that Dr. Yates may also be involved with this decision/procedure) We also spoke about the `alcohol withdrawal' diagnosis she had made, Dr. Applegate stated he had never observed and that there was nothing in any medical records indicating `alcohol abuse'. Dr. Applegate has been treating Darrell for 4 '/z years. He requested I be present at a meeting that was to take place Friday,January 27, at 10 am, to include all parties who are involved with Darrell's care and treatment. The Respiratory Therapy staff indicated that they too were surprised that Darrell had been Intubated, as he had responded so well to the BiPAP. That evening a nurse on duty,told me that they were trying to reduce the dosage of Ativan, but that when they did, he would exhibit symptoms of`alcohol withdrawal', she further indicated that the diagnosis of`alcohol withdrawal' was in his chart and discussed.in Report. I stated that I thought this miss-diagnosis had been addressed and corrected by Dr. Applegate. At this time another nurse, RN, Lou Vitan, interjected, stating"Sheila if you don't quit coming down here and aggravating us we are going to refuse to treat your husband." (This statement was reported to Nancy the Supervising Nurse,Nancy took a written report of the incident and stated she would investigate the matter.) Please note, Darrell continued to receive drugs related to `alcohol withdrawal". January 27, FridaL Darrell comatose and unresponsive. Prior to the meeting,Drs. Yates and Tzvieli were in Darrell's room. Dr. Yates had her hands on Darrell's feet, and stated"Your husband has just had a seizure". Again,a diagnosis done without any 3 forethought or investigation,had Dr. Tzvieli not been in attendance, he may have been miss-treated for this also. Dr. Tzviueli stated, if`Dr. Yates thought that Darrell had had a seizure,perhaps she should order an EEG. Attended the meeting Dr. Applegate had called. Dr. Applegate stated that Darrell had been doing well on the BiPAP, but now that he had been Intubated,we needed to decide what was the best course of treatment, and to get him Extubated from this procedure. It was determined that he would be Extubated immediately, this was done. Darrell was placed back on the BiPAP,however, he remained comatose and unresponsive. January 28 &29, Saturday & Sunday, Darrell is comatose and unresponsive. During this period his vital signs,were for periods, up and down, very unstable. No one seemed to know what to do,or what was causing his deterioration. Darrell's condition would remained unchanged for the next 6 days, comatose, unable to respond or open his eyes January 30,Monday. The process of taking him off of the BiPAP was begun, he was only able to remain off of the By-Pass and on Oxygen only for a very short time, 30 minutes, Dr. Applegate says he is stymied, does not know what is causing him to be unresponsive, and does not know at this time what Darrell's mental state will be if he ever comes out of the state he is currently in. No one at this time has suggested a review of the numerous anti-psychotic,anti-anxiety drugs being given to him, if they are the correct drugs or if the combination of these drugs were having a debilitating affect. (Ativan, Haldol, and Buspar) January 31,Tuesday,The process of removing him from the BiPAP continues, with his staying off longer. Still comatose and unresponsive. February 1, Wednesday, he was able to remain off of the BiPAP all day. He was now somewhat responsive, able to shake his head yes and no, trying to open his eyes, and has limited movement of just his arms and legs. However,unable to speak, able to just make sounds,unable to feed himself.. He is still on an assortment of drugs,that may be contributing to his comatose condition. February 2, ThursdM, he is to be moved to IMCU, as his lungs were improved, and he is no longer in a life threatening condition. However,he remains comatose and 4 unresponsive,. I spoke with Dr. Graham, and Dr. Graham indicated he was going to take Darrell off of Haldol, unless Darrell became so agitated,that he was a danger to himself. Further,that they were taking him off Ativan,and that he was going to prescribe Resperdal. I was still concerned about the drugs that were being administered to Darrell and spoke by telephone to Kip, he agreed that if Darrell became agitated that they would call me before administering Haldol,Ativan, or any other sedative and that he,Kip, would give this information to all of the staff. Darrell was moved that night to IMCU. See attached Complaint for details concerning the administration of Haldol by Maria Banko. FebruM 3, Friday. I went to the hospital immediately upon learning that Darrell had been given Haldol at midnight,(the staff completely disregarding my agreement with Kip and his subsequent communication to them),arriving around 7:30 am. Darrell is still totally unresponsive, and unable to communicate, except to try to make unintelligible sounds. 1 requested to see Dr. Applegate, and told him how very unhappy and concerned I was with Darrell's care and treatment, and that this cannot continue, that something has to be done. Dr. Applegate scheduled a meeting at 10:00 to discuss Darrell's condition and treatment. During this meeting it was revealed that Darrell had not only had Haldol at midnight, but again at 4:00 am. After everyone had a chance to speak, Dr. Applegate stated that `it is apparent the graveyard hours are Darrell's Waterloo." I requested,at this time,that Darrell be removed from all anti-psychotic, anit-anxiety, sedatives and other mind altering drugs, that he continue to receive blood pressure, breathing and heart medications only. Further, it was determined in this meeting that Dr. Grahams decision to prescribe Respital was incorrect and that it was to be discontinued.immediately. Dr. Serbin,who had ordered the Haldol originally, stated it had been administered incorrectly,that it was not being administered per his orders. It was decided that they would take Darrell off of all of these medications immediately,but, Dr. Applegate recommended that a family member would have to stay with Darrell at all times, to make sure no prohibited drugs were administered, due the negligence of the night shift nursing staff. February 4 & 5 Saturday & Sunday, Darrell made some improvement,we could make out some of what he was trying to say, he made some attempt to feed himself, his 5 vital signs stabelized. I or my son Mark stayed with him; Friday, Saturday, Sunday and. Monday. February 6, Monday, it was determined that he was improving enough that he could be moved out into the mainstream, Darrell was now feeding himself and able to talk, was receiving physical therapy and trying to walk with the aid of a walker. Darrell now has little bladder or bowel control, and needs to be cleaned regularly to prevent skin irritation. Dr. Applegate stated that a family member should still stay with him during the night. Darrell was moved to 5C, a room that would accommodate a family member staying with him, that evening. This improvement, after removing all of the drugs he had been given, leaves little doubt that the combination of miss-diagnosis of`alcohol withdrawal',unnecessary Intubation and the irresponsible prescribing and administration of drugs caused his deterioration. To date I have never receive a `respiratory reason' for the Intubation. February 7, Tuesday, Darrell could walk a little with the aid of a walker. It is decided that he will be released,tomorrow Wednesday February 8,2006,at 12:00 noon. The Social Worker spoke with me several times regarding her concern about my ability to care for Darrell at home and strongly recommended he be transferred to a convalescent home. Home is very important to Darrell, and after discussion with my family it was determined we would care for him at home,that his improvement would be impaired in a convalescent home.. Dr. Applegate later confirmed that releasing him to his home,was the best course of treatment for Darrell. Darrell still has little or no bowel control. Physical Therapy gave me a list of equipment that would be needed to care for him at home,toilet seat,walker and a shower stool, and that they,Physical Therapy, would order these items for me. Physical Therapy also requested I arrive around 10:00 am on Wednesday, 2/8/06, so they could demonstrate the exercises he would need to do at home. February 8, Wednesday, I arrived at 10:00 am, Sherrie, Head of Discharge, informed me that insurance would not pay for the required equipment and stated I would have to obtain these from a Medical Supply store. This, information, provided now,just 6 hours prior to discharge. She then determined she will order the equipment and have it delivered to our home, and that I could pay for it at that time. As Darrell still has no bowel control, he had had an accident during the night, and has been lying in feces for many hours. Charles the nurse on duty, had not observed this, nor taken steps to clean up. I cleaned Darrell and dressed him, it was now 2:30 pm and Darrell is waiting in a wheel chair for Discharge Orders. Our son,Mark has been waiting at home to carry Darrell from the car to the house(Darrell has very limited walking capacity)since 12:00 noon. Sherrie Head of Discharge,returned and gave me two telephone numbers of Medical Supply stores, not having ordered the equipment as promised. Darrell will not have the needed equipment at the time of discharge. We are now waiting for his prescriptions from the Pharmacy. 1 asked Dr. Mohr if she could call them and tell them that I would return, after Darrell has been ccleased to pick them up,Darrell is now very tired, and has been waiting for over 3 hours to be released. She did this, and I went to move the car to the exit where they would be bringing Darrell down, and waited and waited. When 1 called to inquire about the delay I was told they were still waiting on the prescriptions,no one knew of Dr. Mohr request. Darrell was finally released at around 4:00 pm. Unable to walk and with no bowel control. We engaged a 24 hours rise fQr 2 weeks to assist in his care. It is unlikely he will recover to his previous functional capacity. Sheila Conkle Dated: _ 7 FROM LEGAL- ,TECF: SERUICES INC FAX NO. 6158859414 Mar. 12 2006 09:42AM P3 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS PATIENT COMPLAINT/GRIEVANCE DO NOT PLACE IN CHART Data of Complaint -_ Timc.. D Patient ❑ Visitor ;Other SPOUSE OF PATIENT I low Complaint Received: Writtr-,n ElPhone D tn-Person ❑CCHP Complaint Taken ID:imprint with 10 card or include name.record nwnbcr, p BY dse of birth, aftess and phone number- SITE' umber.SITE- -- 13 i❑ 213•Surge.rySuite TO ❑50Surgiml 1 C1 DWtmy 30 r BHC 32 J PHC 1 T ) 2C-PACU 29 ❑5D-Pediatrics 0 Grounds/Hallways 631 0 CHC 33 mi. 3 �__)3D.-Critical Care Unit 23 C)Laboratory 37.0 AHC 38 ❑Say Point 5 X 3E-)ntermediate Care 14 lD 38-Emergency Debt' ;;1. C'Lobby 39 C 1+lRCH 2 ❑4A-Medical 9 ❑:3C-Psych ER Services ;lEi ❑Pharmacy e r] 4B-fJledicaI i5 C' Martinez,FPC/Spec Clinic ;:t° C.J Rehab Therapy 50 Mental Health 7 0 4C-Psychiatric 19 O Cardiopulmonary 51 0 Public Heatlh + a ❑4I71 Psychiatric 20 C-7 Diagnostic Irnyring 2'I ❑Other 52 ❑Homc Nealth 6 Ll 5A&B-Perinatal/Newbom 63 Other ;4 :D 5C-PostPartlMed/Surg _ DEPARTMENT CODE - 201❑Appointment Unit 206 O Financial Counseling 2 1 1 „?Mentaf Health 215 0 Public Health 202 L.-) CCHP Staff 2070 Housekeeping 21 Z 0 Nuraing 217❑Registration 203 Q Dental 208❑laboratory 213'--!Pharmscy 220❑Business Office Staff 204 CD Diagnostic lrraging 209 r Medica(Records 91 s❑provider 221 CDTherapy 205 D Emergency Dent 210❑Medical Social Services Q Family Prauitiorrer(2s0) 222❑No Specific Dept.lnvelved ❑ Speoraiut 1),811 219❑Other , CHECK APPLICABLE PROBLEMS ACCEPTABILITY + AGGE SIJULIlY PROBLMS 401 v Cincellcd Clinics QUAL 11Y OF CARE/PROVIDER 301 ❑ Ememency Coverage 403 `❑ ComfoWst:rroundings 501 CX Courtesy/Cloncern for patient 332 Handicap 404 ❑ Commurfta'Jon Problems 502 GX Diagnosis/Treatment Concerns 303 -) Hours of Operation too iimisd 105 ❑ mscriminzmon 508 0 Treatment Erplanazion 3C-4 ❑1 (,(caning Time Appointment 407 M, Scope of Se vice too limited 5050 Unhappy w0 lack of MD continuity. 305 ❑ Trarlsporratior- 402 C] _RmffAtvttzd= lgorr-provide s) 5G4 ❑ Other Quaiity of Caro issues 306 Q Urgent Care Coverage 409 ❑ Translation Problems Provider Name 307 ❑ 19 iting Room Time for Services 414 ❑ Other Acceptability tssu 309 tJ advice Nurse Telephone Une 415 ❑ Benefrt/Ccv,arage changes too bu-cy/not answera;d 416 ❑ Patient'Requested Forms/not mmpieted MISCELLANEOUS 311 �❑ RppoiritmentUnit Phone s17 C ?alien[Notification Problem 801 ❑ AddreswThone Change Line busy 418 ❑ Confidentiality;privacy 802 ❑ General Correspondence 3T2 ❑ Parking Problem i'f.A AISA31LL PRDSEEMS 805 ❑ Complaint about another patient 313 L, Unable to Reach Provider 703 ❑ Lost Valuctlew?ropery 807 C.; Change/Update Information 314 ❑ Unable to Reset tion-Froviders 704 ED Out of Plan st:n.=s 80a fes, IAC Policy Problem308 ❑ Other Access Issues 706 ❑ Other Claims or Wring Issues 806 ❑ Other Bron-classiliabte issues OMBUDSPERSON / DEPARTMENT MANAGER FOLLOW—UP i PRJNT name'of employee resolving complaint.: OR f� PRIM'name of employee complaint referrwro: dote; _I I Follow-up performed: i Response wt-030dayP CYes ONO. DATE COMPWNT RESOLVED: FRAM L(rGAL.TECi? SERVICES INC FAX N0. : 615e659414 Mar. 12 2006 09:42RM P2 CONTRA COSTA REGIONAL MEDICAL CENTER CO vTRA COSTA HEALTH CENTERS PATiIENT C®Pill PLAINTIGRIEVA1110E - QEDUA DEL PACIENITE Name • Nombre: DARRELLCONKI E _ Phone 4 de Telefono: ^ 925.228-1616 Address • Direcci6n: 836 CARQUINEZ WAY, MARTINEZ,CALIFORNIA 94553 Medical Record : 2445187 Date of Birth: Social SeCLIrity T ____.56- -46-7896 �echa de nacimi1/16/1937 Date of treatment/visit: Date complaint filed - La fecha Pecha de tratamiento: 1/.,?�3/06-2/8/06 de presentacidn de la queja: CONTRA COSTA REGIONAL Where did incident occur? • 406nde od:urria el incidence? MEDI1CALCENTER Briefly describe complaint. provide details of complaint with specific information such as names, dates, sequence of events, etc. Attach as much additional information as is necessary. Describa brevemente Is queja. Provea detalles de la queja con informacion especffica como nombres, fechas, to secuencia de hechos, etc. Induya toda la informacion adicional que sea recesaria. COMPLAINT: FbE,MARIA BAN G, RN 2/2/06-2/4/06 - MARIA 13ANd0 ADMINISTERED THfi DRUG HALnOI.,AFTER SHE HAD BEEN INFORMED THE DRUG HAD BEEN DISCONTINUED. - INSERTED HERSELF INTO THE PATIENTS CARE, AFTER SHE HAD BEEN REMOVED FROM THE PATIENTS CARE. - EXHISTCED RUDE AND UNPROFESSIONAL BEHAVIOR 'SEE ATTACHED SUMMARY What action are you requesting? • 6Que medidas quiere que tomemos? I- THAT MARIA BAN RECEIVE DISIPLIHARY ACTION FOR HER UNPROFESSIONAL CONDUCT. 2. HE PROCEDURES AT-MIS FACILrTY BE REVIEWED CHANGED. INSTRUCTING THE NIGHT (GRAVEYARD)s"iFT,To NOT SEDATE PA'nF-HTS UNNESSISSARILY AND/OR AGAINST ORDERS.SO THEY (THE NURSES) ARE HOT DISBURSED DURING THEIR SHIFT. Signature of person submitting complaint_ Did employee Firma, de la persona que presenta la queja: - eompleteform? If other than patient, indicate: relationship: SPOUSE/W11FE OF PATIENT J yes Q na Signature of employee receiving complaint_ Your complaint wilt be thoroughly irivestigated and you will receive an answer within thirty days. Thank you for bringing this to our attention_ We strive to provide quality care. Su queja sera investigada rigurosamente y u-ted recibira une respuesta dentro de treiMa dfas. f a a�+rorle�.amne.rinr hp1'�ornn2 inrnrmsI;n.-Ira aef� �ctirftn hlnc ncf�rrsrnnc An nmvoarri�i�orin rIo rolitiari FROM LEGAL TECH SERUICES INC FAX NO. 6158859414 Mar. 12 2006 09:43AM P4 Summary of Events—Re: Complaint, Maria Barju As of February 2,Darrell Conkle,who'had been a patient at Contra Costa Regional Medical Center, since January 23,2006,was still in a comatose and unresponsive condition_ Drs. Graham and Mohr were now been assigned to his case,due to rotation. On February 2,2006,Dr.Graham and I had a discussion about Darrell's condition and he determined Ativan and Iialdol would be discontinued. Darrell was scheduled to be transferred to 1.MCU that evening. I was concerned,that with the move, and given that communication between hospital staff had been a problem,that Dr.Grahams' orders might not be communicated and heeded. At 10:30 pm I contacted Kip,the Charge Nurse,and requested that he inform all of the personnel on the night(graveyard)shin, involved with Darrel I's care,of Dr.Grahams' orders and further requested that if Darrell became agitated to call me and I would he at the hospital in less than 15 minutes to calm. him down. Kip assured me he would do this. I was not contacted that night. On February 3,2006,around 6:45 am,1 contacted the hospital to check on Darrell's condition. The nurse on duty,Maria Baro,at fust refused to give me any information., but then did reveal she had given Darrell Haldol at 1....00 midnight. 1 went immediately to the hospital,arriving around 7.30 am,at this time Andy had replaced Maria Balo as Darrell's nurse. He was aware Haldol had been administered at midnight,but did not want to talk about it,upon seeing i was upset. A meeting with Dr.Applegate and the staff involved with Darrell's care was called at 10:15 am,and at this time it was revealed that Darrell had been given Haldol at midnight and again at 4:00 am. Kip stated he had informed Maria Banl�of Dr_Grahams orders and of my request to be contacted instead of administering Ativan,Haldol,or other. sedatives to Darrell. Maria Banko disregarded this and administered Haldol twice in less than 5 hours,the first time less than 1 hour after she came on dirty. Our son, Mark Thompson,and I stayed with Darrell that night to prevent a reoccurrence. Maria Barb was again the nurse on duty. She completely ignored me,and did not speak to me until I asked her if Kip had relayed the information the night before regarding not giving Darrell Haldol, Ativan,or other sedatives,and to call me instead if he became agitated—Maria stated"I don't recall". I requested Maria Banlgb be removed as Darrell's nurse and another nurse assigned. This was done. Our son Mark stayed tfle night, 11:00 pm 5:30 am. On February 4,2006,when I arrived at the hospital at 5:30 am to relieve Mark,Maria B o answered my call robe admitted—She said nothing,hung up and did not open the door.lballed back and Sheila,the clerk,opened the door_ Shei lei told me Maria wanted me to wait in the hall as she, Maria, was busy. it is unclear why she ordered me to wait in the hall,she was no longer Darrell's nurse,and was not in his room performing any duties. Breakfast was served around 7:30 am,to other patients.Tthis was the first time Darrell was to have food and was going to need help to eat. I waited for 30 or more minutes and then asked where Darrell's breakfast was. Maria Baro stated she had taken it and set it on the counter at the far end of the nurses station. The breakfast was now cold and inedible,again Maria Banlpb was not Darrell's nurse,so it is, again,unclear why she inserted herself into this situation or why she found it necessary to delay his breakfast. Maria Band has exhibited unprofessional conduct throughout our contact with her. ' CLAiM. BOARD OF SUPERVISORS OF CONI'RA.COSTA COUNTY BOARD AC'T'ION: APRIL 11, 2006 Claim Agains ie County, or District Governed Uy .) the Board of Supe 'sons, Routing Endorsemeits, ) NOTICE TO CLAIMANT and Board Action. Al ection references are to ) The copy of this document mailed to you is your California Government Co s. notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 1 0 2006 915.4. Please.note all "Warnings". COUNTY C SEL MARCH 10 2006 AMOUNT: . $3,000.00 MARTINEZ CA DATE RECEIVED:. CLAIMANT: BY DELIVERY TO CLERK ON:MARCH 10, 2006 BRUCE R. CHRISTENSEN - - HAND DELIVERED ATTORNEY: ; UNKNOM4 BY JL P.OSTM.ARKED: ADDRESS: 5019 ALHAMBRA VALLEY ROAD MARTINEZ, CA 94553 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CU. E rk Dated: MARCH 10, 2006 By: Deputy It FROM.: County Counsel TO: Clerk of the Board of Supervisors (` -This claim complies substantially with Sections 91.0 and 910.2. (L4"liis 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). O 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). (,KOther: PC 1 t e� v r —l,q t 11 ke. CL -- DO r10 ��Py►/,� I P-�l Dated: �—/J�'�P By: /n Deputy County Counsel I. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). [V. ARD ORDER: By unanimous vote of the Supervisors present.: ( This Claim is rejected in full. ( ) Other: I. certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. " o Dated: 6rll //� o�D�o JOHN CULLEN, CLERK., By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months fi-om 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 MAILING I declare under penalty of per jury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today [,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. o Dated: r��a'2�� JOHN CULI;.EN, C:LE.RK By__ --Deputy Clerk PUBLIC; : JUfdF<ti ---• - BOARD OF SUPERVISORS OF CONTRA COSTA COUTY rvu N YNSTRIIC7IONS TO CL�A�IMA A. A claim relating to a cause of action for death of for injury to person or to personal property or growing crops shall be presented not late: than six months after the aa=4 of the cause of action. A claim relating to any othrr cause of action, shall be presanted not later than one year after the accrual of the cause of action. (Gov. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, Co=y Administration Buildiag, 651 Pine Street, Mattinez,CA 94553. C. if claim is against a district governed by the Board of Supervisors, rather than the Count►, the � name of the District should be filled,in, D. if the claim is against more than one public eni ty, separate claims must be filed against each public eauty, E. Fraud• See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form.' 6408068410poor ewe aago►@gob Oyu aOra @$too$gob No#*rotor to/of a of Iwo a ofNovi fall■oof*of RE: Claim By: Reserved for CIerk's filing stamp �.c� �-• C`�rn 5��Se� � SD f4i Ib, �riU�, �� r . 1 RFCFlVFD Against the County of Contra Costa or ) MAR 1 U 2006 District) CLERK BOARD CF SUPERVfSORS (Fill in Ilse same) ) CONTRA COSTA CO, The undersig mad claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ 3,rte, cU and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact data and hoer) 2. Where did the damage or injury occur? (Include city and county) Sz1y AI :t .ct(tLJ p , Axv,� I�.,� ; OA-. od-)1t CtSa. 3. Now did the damage or irjury occur? (Give full details; use extra paper if required) 4. What particular act or omission on the part of county or district officers, servarts, or employees caused the injury or damage? p M,Ju� 4•(S<-c:CAJ 0 ay dream«cam 'rU a e�i-e.S� C,Lov��!>� rb p(y-&.( rtt, 5 What are the games of couutp or disl`iet 61TIcen, servants, or cmyloyees causing the J3am�ge ar in}try? -.-JHIY. `_], e11�IF�..:IJ•CCFi7"1 "' `� JNU.tiJ✓� f . 3 6, What darn+age or injuries do your clam restated? (Give full extent of :r-juries or damages claimed. Attach two estimates for auto c=ase,) I o ccsqc rte. How web the amount claimed above coRtptsted? 'Lvalude the estimated unour t of any prospeed ve injury or damage.). P S 8. Nwries and addresses of,%ftesses,doctors,end hospitals, �� `:� {�' z zu`,,` tt,, 9, List the expenditures you made on aacouat of*Is accidea,or injury' 1�1r1VTVir DATE Itaslss��st�It��s+�s•��■ets��s��tMoas•ats$■o Wasps tVON■/1*as 600■0s��liss■■■■•7�•t� j Gov. Code Sec, 9l 0.2 provides"The claim shall be signed by the claimant or by some person on his behalf," i SEND NQT' LE—S M. 4ttorme-y) 1 r _ Name and address of Attorney ) j (Claimant's signature)V;V. rr,�••.�� r.r.r (Address) r4 I --ch - 11�� Telephone 1�0. )Telephone No. _ —(Ci IS-) Z- 2— - & U •s�ssa•■as■■rss�••■•ss*as■ts4s1ssatsst■■■s••s■ss••s•sv•ss■••■satrtsssa•sssrllt■s■•�ssl I :PUBLIC PMCORDS NOTICE, Please be advised that this claim form,or any claim filed with the County under the Tort Claims Act, is sukject to public disclosure undtr the California Public Records Act. (Gov. Code, 5§ 6500 et seq.) Furthermore, any attachments,addendums, or supplemens attached to the claim ferm, including medical records, in Also subiect to public disclosure, *■s■r■■s••vessels$$■poets$Goes■506644046••eases st■ptw•••■f•l NOTICE: Sscrion 72 of the penal Code provides. Every person who, with intent to defreud, przsents for allowance or for payment to any rate board or officer, or ca ary cowity, city, or district board or officer, authorized to allow or pay a,.e same if genuine, any false or fraudulent claim, bill, accourp voucher, or writing, is punichable either by imprisonment.in the County jail Cor a period of not more than one year, by a fine of not exceeding ore thousand dollars ($1,000.00), or by both such impr'tsonratnt and fine, or by irnprisimment in the.vate prison, by a fine of not exaceding ten thousand dollars ($90,000), or by bobs such i:mprisonri)Mt and fine, :.CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: APRIL 1112006__ Claim Against the County, or District Governed by ) the Board of Supervisors, Routing .Endorsernents' ). NOTICE TO CLAIMANT and Board Action. AllSection 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 MAR 1 0' 2006 915.4. Please note all:"Warnings". AMOUNT: $48,368.02 . COUNTY COUNSEL MARTINEZCALIF. DATE RECEIVED: MARCH 10, .2006 CLAIMANT: CONTRA COSTA - JBWCP BY DELIVERY TO CLERK ON: MARCH 10, 2006 ATTORNEY: SANDRA M.:.KLIMASZEWSKI HAND DELIVERED LAW OFFICES OF SASSANO & is LUSHER BY MAIL POSTMARKED: _ ADDRESS: 3685 MT. DIABLO BOULEVARD', SUITE 202 LAFAYEITE, CA 94549 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. MARCH 10, 2006 JOHN CULLEN, Clerk Dated: s By: Deputy II. FROM: County Counsel TO: Clerk;of the Board of Supervisor- (vKThis claim complies substantially with Sections 91Oand 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 fled late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). O Other: Dated: 3— (P By: Deputy County Counsel iI1. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with no:tice to.claimant (Section 911.3). IV. BARD 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 Oi•der entered in its minutes for this date. Dated:Jl f��// D _ JOHN.CULLEN, CLERK, By Deputy Clerk _ WARNNG(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. It'you want to consult an attorney, you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I ani 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. 0 Dated: �� .BD JOHN CULLEN, CLERK By Deputy Clerk Law Offices of Reca!ved: 31 7/06 10:28AM; 9259300550 ->- La SASSANO & ftEISCHER -MAR. 1. 2446 10: 28AM cl:TRISTARGTo COUNTY CLERV OF THE SANDRA M. KLIMASZEWSKI Attorney at Law BCURI)OF SUPERVISORS OF CONT rN§TRTJC_T10N'S TO CLAI 3685 Mt.Diablo Boulevard Suite 202 Lafayette,Ca.94549 A. A claim relatiDg,to a cause of action fbi death or for 1 phone(925)962-6999 growing crops shall be presented. riot later than six rr sklimaszewski@sassanotaw.com fax(925)962-6990 action. A claim relating to arty other cause of action after the ae=al of the cause of action. (Gov. Code §911.2.) B. Claims must be fil6d 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 districtgo overned 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 thia one public entity, separate claims must be filed against each Public elitily. E. rLaq A. See penalty for fra duleht claims,Penal Code Sec.72 at-the end of this fame. %A-smogs Essex**a 0 waserre 5 Ottawa I#@ of 06964ON games P 0 of#a as so a 0 a VIA&aransaaws a s eggs. RE: Claim By: Reserved for Clerk's filing stamp Contra Costa-JBWCP RECEIVED Against the County of-Courra Costa or MAR .i 0 2006 County ,of Cojhtra costa District) CLERK BOARD OF SUPERVISORS COLITRA COSTnA CO. (Fin in the name) The Undersigned-olaiiiilnit hereby mAes claim against.the County of Contm Costa or the above-named disTHctinthe sun of 48 ,368 ()2 arid in support of this claim repxesents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 9-13-05 at 4:34 P6 I. Where did the damage or injury.o6cur? (include city and county) f . 725 . Court. Strebt�.jn Marti n( F�Z Ca 1 ornia re_or ill �e jUy 6cc,111 :(di_ f 3. How did thd d, full details;use extra eri reQuiied),....,.. & dd.endum.. .... .. e.e,,:a 4. at p6iticiilar act,or"oimssion on the P41 of:co inity or,district officers, sefvanls, or employees 41LSei the LIXY Or d C ., 9 d. aMage. Unknowia disocveryongoing, see addendum attached W1iat are01 the names of county or district officers, servants, or emp] yees causing the dainagre or injury? Unbknown, dis,covery: ongping. . . 3/ 7/06 10:28AM; 9259300550 -- Law OTC Matthew R- Sassa"O; Page 3 aAAR. 7. 2006 10: 28AM cOTRISTARs-rp couwfy CLERK OF THE NO, 8726 P, 3/3i 902 6 )What damage or injuries do your claim resulted? (Give ftill extent of injuries or darnages claimed. Attach two estimates for auto damage.) Claimant has expended $481368.02 in workerslcomperistition benefits with $3, 024 .00 in Temporary Disability and $17, 195 . 35 in medical, 1, How was the amount claimed above computed? (Include the estimated aniount of any prospective injury or damage.) It was computed based on bills forwarded by health care providers S. a Names and addresses of witnesses, doctors, and hospitals; T 1 . Judith Cohen, 726 Las .Trampas, Lafayette, California 94549 2 Conway $hrewsber;Vy, 241 18th Strret, Richmond, CA , 9. 14AT diceexpaiditares you made on aocovni of this accident or injury., DATE T AMOUNT Refer to attached benefit printout documenting workers cowzenSativri 46*od@Vwm*nw WWI Is a a%waftaftwovel 141 91091offuslu sisal of as Ian a among a fast to Ila ams!or No tog WWI$ Gov, Code See, 910.2 provides "The claim shall be signed by the claimant or by some person on his behalf SEND NOTICES.TQ- (Attorneyl : ) Name and address of Attorney (Claimant's Sigua=4 2 U j6r5 Mr- .1 0410 4 (Address) Telephone No, -6519 )Telephone No. swat*1 0 110811fo**&*am ms=Kugogvo if VWVdVmV%I*$of No as#we**6009 45911141141 go#61111 a Insist!"a a no a as) PUBLIC RECORDS NOTICE, Please be advised tbar this clafin form, or any claim filod with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act-(Gov..Code, §§ 6500 et seq.) Furthermore, any attachments,addendunis,or supplements attached to the claim form,,including medical records,are also subject to public disclosure. of 99 onto ARRM Was 9*0f*4*80W-ft0f ffWVO•a*vvrrravout NOME: Section 72 ofthe Pena'Codeprovi&s: very person who, with intent . � to defraud,presents for allowance or for payment to any state board or officer, or to any-county,. . . city, o.r district board or officer, auibarized to allow or pay the same if.genuine, any false or fraudulent claim, bill, account volidwr, or writing, Is.,puniqbaWe either by iml?Monment in tate County jail for a by a-flii6.-ofl 0 _evcee 11iff imprisonment and fine, pr by unprisontileslt ID tile smtebrisoll-, by a fin- of not eXceeding Sell thoiisand dolhrs 016,006),or by both such imprisonment and-fine, Contra Costa JBWCP v. County of Contra Costa Claim - Addendum 3. continued: EMPLOYEE,while descending courthouse steps,tumbled to bottom stair and sustained injuries to his head and right arm. 4. continued: County did not comply with Code re: Specifications for stairs. No traction devices provided on stairs. Special highlighting/designation should have been provided for lower stairs. 5. continued.: Further investigation ongoing re: names of officers and employees responsible for.incident. 6. continued: Additional benefits paid subject to proof. 7. continued: Estimated additional $15,000 to$20,000 for future carpal tunnel surgery based on medical reports. 8. continued: Deputy Pasth.rak completed incident report doctor information: 1 . Dr. John Schivally 2. Dr. Michelle Liu 3. Muir Orthopedic Specialists _ 4. California Eye Clinic Received: . 3/ y /O�,yy :z, M• 9259300550 -> Law OTC macTnew ii. 5assano; rage ef K4 R. 1. 2006 11 : 26k,: i STAR NO. 8274 p. 2/4 F� '� Payment Listing Page:1 of Run Time 11;10:38 Miller, Roy 05141743 From Through Check# Check Date Method Vendor nlscount Amount Indemnity TEMPORARY DISABILITY 02/152006 02282006 347046 02/242006 Check Claimant 0.00 252.00 02/01/2006 02/14/2006 345853 02/10/2006 Chack Claimant. 0.00 252.00 01/18/2006 01/312006 344891 01/27/2006 Check Claimant 0.0o 252.00 01/04/2006 01/17/2006 343793 01/13/2006 Check Claimant 0.00 252.00 12/21/2005 01/03/2006 342668 12/302005 Check Claimant 0.00 252.00 12/07/2005 12/20/2005 341645 12/162005 Check Claimant 0.00 252.00 11232005 12/062005 . 340269 12/022005 Check Claimant 0.00 252.00 09/142005 11/222005 339418 11/182005 Check Claimant 0.00 1,260.00 Totals for TEMPORARY DISABILITY 0.00 3,024.00 . Totals for Indemnity 0.00 3,024.00 Recovery 0.00 Medical ATTENDING PHYSICIAN 10/21/2005 10/21/2005 346793 0222/2006 Check MUIR ORTHOPAEDIC SPECIALIS' 0.00 74.20 10/19/2005 10/19/2005 346631 02212006 Check MODERN MEDICAL INCORP. 52.50 162.50 1212012005 12/20/2005 $46636 02/21/2006 Check CALIFORNIA EYE CLINIC 23.40 47.60 01/09/2006 01/09/2006 Paper Transaction CALIFORNIA EYE CLINIC 4,731.00 0.00 10/132005 10/13/2005 343801 01/132006 Check JOHN MUIR HEALTH NETWORK 89.02 104.98 12/152005 12115/2005 343555 01/112006 Check MUIR ORTHOPAEDIe SPECIALIS' `29.03, 69.13 12/092005 12/092005 Paper Transaction MUIR ORTHOPAEDIC SPECIALIS' '36.70 0.00 09/14/2005 09/14/2005 Paper Transaction CALIFORNIA EYE CLINIC 418.00 0.00 09/14/2005 1129/2005 343199 01/052006 Check CALIFORNIA EYE CLINIC 539.20 264.80 10/01/2005 10/02/2005 343200 01/06/2006 Check JOHN MUIR TRAUMA PHYSICIAN 107.50 . 182.50 10/03/2005 10/07/2005 343201 01/06/2006 Check JOHN MUIR TRAUMA PHYSICIAN 325.77 517,23 12/08/2005 12/08/2005 343214 01/06/2006 Check MUIR ORTHOPAEDIC SPECIALIS 29A3 69.13 11/29/2005 11/292005 343215 01/062006 Check MUIR ORTHOPAEDIC SPECIALIS 29.03 79.65 11/11/2005 11/11/2005 PoperTransacdon MUIR ORTHOPAEDIC SPECIALIS' 31.36 0.00 09/222005 09/302005 341435 12/14/2005 Check JOHN MUIR TRAUMA PHYSICIAN 972,31 827.69 09/13/2005 09/212005 341436 12/14/2005 Check JOHN MUIR TRAUMA PHYSICIAN 1,093.14 184.86 10/21/2005 10/212005 341452 12/142005 Check MUIR ORTHOPAEDIC SPECIALIS' 165.10 317.33 11/15/2005 11/152005 341453 12/14/2005 Check MUIR ORTHOPAEDIC SPECIALIS' 15.97 64.66 11/11/2005 11/112005 341454 12/14/2005 Check MUIR ORTHOPAEDIC SPECIALIS' 48.63 33.41 11/17/2005 11/17/2005 341455 12/142005 Check MUIR ORTHOPAEDIC SPECIALIS' 15.97 64.66 11/112005 11/11/2005 341456 12/142005 Check MUIR ORTHOPAEDIC SPECIALIS 15.97 64.66 10/052005 10/052005 340616 12/06/2005 Check JOHN W.SCHIVALLY,D 67.11 159.89 10272005 10/272005 340643 12/062005 Check MUIR ORTHOPAEDIC SPECIALIS 13.65 17.90 09/142005 09/14/2005 Paper Transaction MICHELLE LIU,M.D. 1,588.00 0.00 09/17/2005 09/19/2005 338871 11/15/2005 Check JOHN MUIR TRAUMA PHYSICIAN 161.25 273.75 09/15/2005 09/16/2005 338872 11/15/2005 Check JOHN MUIR TRAUMA PHYSICIAN 146.52 245.48 09/20/2005 09/23/2005 338873 11/15/2005 Check JOHN MUIR TRAUMA PHYSICIAN 234.51 396.49 Totals for ATTENDING PHYSICIAN 10,978.67 4,222.50 HOSPITAL 09/142005 09/1412005 338882 11/15/2005 Check JOHN MUIR MEDICAL CENTER 101,801.31 9,545.88 Totals for HOSPITAL 101,801.31 9,545.68 MED REIMS CLMT; DRUGS, SU 01/082006 01/09/2006 344325 01202006 Check Claimant 0.00 52.45 Totals for MED REIMB CLMT;DRUGS,SUPPLIES 0.00 52.45 BILL REVIEW-Medical 12/20/2005 12/20/2005 346682 02/212006 Check Tristar Managed Care-Bill Review 0.00 3.28 10/192005 10/192005 346682 02/21/2006 Check Tristar Managed Care-Bill Review 0.00 13.13 10/18/2005 10/212005 346682 02/212006 Check Tristar Managed Care-Bill Review 0.00 39.38 12/282005 12/26/2005 344284 01/19/2006 Check Tristar Managed Care-Bill Review 0.00 17.10 10/13/2005 10/13/2005 343845 01/132006 Check Tristar Managed Care-Bill Review 0.00 11.69 Confidential Run By: V. 0 70 Matthew R. Sassano; Page 3 - N0. 8274. F. 3!4 - - - - - � Payment Listing Page:2 of 3 Miller, Roy 05141743 From Through Check# Check Date Method Vendor Discount Amount Medical BILL REVIEW-Medical 10/13/2005 10/132005 343845 01/13/106 Check Tristar Managed Care-Bill Review .0.00 1.38 12/15/2005 . 12/15/2005 343626 01/11/2006 Check Tristar Managed Care-Bill Review 0.00 0.29 12/15/2005 12115/2005 343626 01/112006 Check Tristar Managed Care-Bill Review 0.00 3.90 12/09/2005 12/09/2005 343626 01/11/2606 Check Tristar Managed Care-Bill Review 0.00 5.00 12/06/2005 12/0612005. 343626 01/11/2606 Check Tristar Managed Care-Bill Review 0.00 0.29 12/06/2005 12/06/2005 343626 01/11/2006 Check Tristar Managed Care-Bill Review 0.00 3.90 12/13/2005 12/13/2005 343259 01/06/2006 Check Tristar Managed Cane-Bill Review 0.00 0.29 12/1312005 12/13/2005 343259 01/062006 Check Tristar Managed Care-Bill Review' 0.00 3.90 12/08/2005 12/08/2005 343259 01/0612006 Check Tristar.Managed Care-BIII Review 0.00 0.29 12/0812005 12/08/2005 343259 01/06/2006 Check Tristar Managed Care-Bill Review 0.00 3.90 1129/2005 11129!2005 343259 01/06/2006 Check Tristar Managed Care-Bill Review 0.00 0.29 11129/2005 111292005 343259 01/06/2006 Check Tristar Managed Care-BIII Review 0.00 3.90 10/03/2005 10/072005 343259 01/062006 Check Tristar Managed Care-Bill Review 0.00 45.61 10/012005 10/02/2005 343259 01/062006 Check Tristar Managed Care-BIII Review 0.00 15.05 09/14/2005 11/292005 343259 01/06/2006Check Tristar Managed Care-Bill Review 0.00 75.49 I 09/142005 09/14/2005 341868 122020051, Check Tristar Managed Can:-Bill Review 0.00 14,252.18 11/22/2005 1122/2005 341498 12/1412005. Check Tristar Managed Care-Bill Review 0.00 0.26 11/22/2005 11/22/2005 34149B 12/1420051 Check Tristar Managed Care.Bill Review 0.00 2.09 11/172005 11/17/2005 341498 12/14/2005 Check . Tristar Managed Care-Bill Review 0.00 0.26 11/17/2005 11/17/2005 341498 12114/2005 Check Tristar Managed Care-Bill Review 0.00 2.09 11/15/2005 11/15/2005 341498 12/14/2005 I Check Tristar Managed Care-Bill Review 0.00 0.26 11/15/2005 11/152005 341498 12/14/2005 Check Tristar Managed Care-BIII Review 0.00. 2.09. it 11/11/2005 11/112005 341498 12/14/2005 i Check Tristar Managed Care-Bill Review 0.00 0.26 11/11/2005 11/11/2005 341498 12/14/2005 Check Tristar Managed Care-Bill Review 0.00 2.09 11/11/2005 11/112005 341498 12/142005 ; Check Tristar Managed Care-Bill Review 0.00 4.38 !I . 11/11/2005 11/112005 341498 12/14/2005 I Check Tristar Managed Care-Bill Review 0.00 0.26 111112005 1111112005 341498 12/1412005 Check Tristar Managed Care-Bill Review 0.00 6.66 !I 10/21/2005 10/212005 341496 12/14/2005 Check Tristar Managed Care-Bill Review 0.00 2.45 10212005 1021/2005 341498 12114/2005 1 Check Tristar Managed Care-Bill Review 0.00 21.74 09/22/2005 0913012005 341498 12/14/2005 Check Tristar Managed Care-Bill Review 0.00 108.68 09/132005 09/21/2005 341498 12/14/2005 (Check Tristar Managed Care-Bill Review 0.00 153.04 11/011/2005 11/0812005 340864 12/062005 Check Tristar Managed Care-Bill Review 0.00 0,26 j 11/08/2005 111082005. 340864 12/06/2005 Check Tristar Managed Care-Bill Review 0.00 2.09 11/01/2005 11/0112005 340864 12/06/2005 Check Tristar Managed Care-Bill Review 0.00 0.26 11/01/2005 11/01/2005 340864 12/05/2005 Check Tristar Managed Care-Bill Review 0.00 2.09 10127/2005 10/272005 340864 12/06/2005 Check Tristar Managed Care-Bill Review 0.00 0.14 10/27/2005 10/2712005 340864 12/06/2005 Check Tristar Managed Care-Bill Review 0.00 1.63 10/27/2005 10/272005 340864 12106/2005 Check Tristar Managed Care-Bill Review 0.00 0.66 10/122005 10/122005 340864 12/062005 Check Tristar Managed Care-Bill Review 0.00 6.13 10/052005 10/05/2005 340664 12/0612005 Check Tristar Managed Care-Bill Review 0.00 4.44 10/052005 10/05/2005 340864 12/06/2005 Check Tristar Managed Care-Bill Review 0.00 6.91 09/23/2005 09/23/2005 340864 12/06/2005 Check Tristar Managed Care-Bill Review 0.00 1,289.73 0922/2005 0922/2005 340864 12/06/2005 Check Tristar Managed Care-Bill Review 0.00 998.03 09/20/2005 092312005 338962 11/152005 Check Tristar Managed Care-Bill Review 0.00 32.63 09/17/2005 09/19/2005 338982 11/15/2005 Check Tristar Managed Care-Bill Review 0.00 22.58 09/15/2005 09/16/2005 336982 11/15/2005 Check Tristar Managed Care-Bill Review 0.00 20.51 Totals for BILL REVIEW!-Medical 0.00 17,195.35 MEDICALINURSE MANAGEMEr i 01/03/2006 01/242006 346823 02/22/2006 Check Tristar Managed Care Nurse Case 1 0.00 2,024.82 12/0212005 12/312005 344675 01/242006 Check Tristar Managed Care Nurse Case 1 0.00 1,419.89 11/03/2005 11/30/2005 341869 12/20/2005 Check Tristar Managed Care Nurse Case 1 0.00 1,535.88 i 10/042005 10/312005 338963 11/15/2005 Check Tristar Managed Care Nurse Case 1 0.00 4,063.68 09/18/2005 09/232005 338983 11/15/2005 Check Tristar Managed Care Nurse Case 1 0.00. 786.92 Confidential Run By: 1 ..��. _ maw OTC Mathew R 5assano;. rage -+ NO. 8274 P. 4/4 Payment Listing Paye:3 of 3 ftun Time:11:10:36 Miller, Roy 05141743 From Through Check# Check Date Method Vondor Discount Amount Medical MEDICAUNURSE MANAGEMEP 09/16/2005 09/30/2005 338983 11/15/2005 Check Tristar Managed Care Nurse Case 1 0.00 9.50 Totals for MEDICAUNURSE MANAGEMENT 0.00 9,840.69 MEDICAL TRANSPORATION 09/132005 09/13/2005 340619 1210612005 Check AMERICAN MEDICAL RESPONSE 0.00 106.33 Totals for MEDICAL TRAN5PORATfON 0.00 106.33 PHYSICAL THERAPY 10/18/2005 10/21/2005 346630 02/212006 Chock MODERN MEDICAL INCORP. 157.50 487.50 12/062005 12/062005 343554 01/11/2006 Check MUIR ORTHOPAEDIC SPECIALIS' 29.03 69.13 I 12/13/2005 12113/2005 343213 01/06/2066 Check MUIR ORTHOPAEDIC SPECIALIS' 29.03 69.13 1122/2005 11/22/2005 341457 12/14/2005 Check MUIR ORTHOPAEDIC SPECIALIS . 15.97 64.66 d 11/01/2005 11/01/2005 340641 12/062005 Check MUIR ORTHOPAEDIC SPECIALIS' 15.97 64.66 10/27/2005 10/27/2005 340642 12/06/2005 Check MUIR ORTHOPAEDIC SPECIALIS 2.63 85.01 11/0812005 11/08/2005 340644 12/06/2005 Check MUIR ORTHOPAEDIC SPECIALIS' 15.97 64.66 t Totals for PHYSICAL THERAPY 266.10 904.75 EQUIPMENT&APPLIANCES 10/12/2005 10/12/2005 Paper Transaction MODERN MEDICAL INCORP. 231.80 0.00 10/21/2005 1021/2005 341449 12/142005 Check DEMAR MEDICAUSUPPORT CAR 0.00 62,00 10/12/2005 10/1212005 340567 12/06/2005 Check MODERN MEDICAL INCORP. 43.75 188.05 . Totals for EQUIPMENT&APPLIANCES 275.55 250.05 HOSPITAL OUT PATIENT 09/23/2005 09/23/2005 340617 12/06/2005 Check JOHN MUIR MEDICAL CENTER 9,212.34 4,326.81 0922/2005 09222005 340618 12/06/2005. Check JOHN MUIR MEDICAL CENTER 7,128.81 1,647.61 Totals for HOSPITAL OUT PATIENT 16,341.15 5,976.42 NURSING SERVICES(HOME HI 101182005 10212005 Paper Transaction MODERN MEDICAL INCORP. 650.00 0.00 Totals for NURSING SERVICES(HOME HEALTH) 650.00 0.00 DIAGNOSTIC TEST(CT/MRI) 121262005 12/28/2005 344262 01/19/2006 Check ONE CALL MEDICAL,INC, 68.40 273.60 I Totals for DIAGNOSTIC TEST(CT)MRI) 68.40 273.60 Totals for Medical 130,361.18 48,368.02 o Recovery 0.00 Totals for Claim 51,392.02 Recovery 0.00 I f ' R I J 3 1,1 Il J Confidential Run By: j CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY �. BOARD ACTION. APRIL:11, 2006 Claim Against the County, or District Governed by ) the Board of Supervisors, .Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section r The co of this document mailed to California Governineilt Codes. j! v copy you is your notice of the action taken MAR 14 2006 on your claim by the Board of Supervisors. (Paragraph [V below), COUNTY COUNSEL given Pursuant to Government Code MARTINEZ CALIF. Section 913 and 915.4. Please note all AMOUNT: AN AMOUNT IN EXCESS OF THE JURISDICTION OF THE SUPERIOR COURT "Warnings". CLAIMANT: MARK A. RANDLE ATTORNEY: KERRIE WEBB DATE RECEIVED: MARCH 14, 2006 LAW OFFICES OF KERSHP>n1; MARCH 14 2006 ADDRESS: CUTTER & RATINOFF BY DELIVERY TO CLERK ON: 980 9th STREET, STE. 1900 SACRAMENTO, CA 95814 BY MAIL POSTMARKED: MARCH 10, 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is'a copy of the above-noted claim. MARCH 14., 2006 JOHN CULLEN, C k Dated: By: Deputy I[. 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). O Other: Dated: —/�O (�Co By: Deputy County Counsel Ill.. FROM. Clerk of the Board TO. County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. OARD'ORDER: By unanimous vote of the Supervisors present: (v This Claim is rejected in full. ( ) Other- 1 certify that this is a true acid'correct copy of the Board's Order entered in its minutes for this date. c Datedrif �i JOHN CULLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions,you have oirly 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 W arnurg See Reverse Side of This Notice. AFFIDAVIT OF MAILING 1 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: �� °i��id J014, C[!LLE-N, CL.ER-I< 13 Deputy Clerk y� , — y —. P Y FCLERKB EIVED CLAIM AGAINST PUBLIC ENTITY 1 4 .2006 [Gov. Code §905.2, 910, 910.21 OF SUPERVISORS CONTRA COSTA CO. TO: Contra Costa County Board of Supervisors Attention: Clerk of the Board 651 Pine Street Martinez, CA 94553-1229 Mark A. Randle hereby makes a claim against the Contra Costa Regional Medical Center, 2500 Alhambra Avenue, Martinez, California 94553, and makes the following statements in support of the claim: 1. Mark A. Randle, 82 Trident Drive, Pittsburg, CA 94565. 2. Notices concerning the claim should be sent to Kerrie Webb, of the law offices of Kershaw, Cutter& Ratinoff, LLP, 980 9`h Street, Suite 1900;Sacramento, CA 95814. 3. On September 20, 2005, Claimant sustained permanent injuries when his healthcare professionals at Contra Costa Regional Medical Center failed to properly secure him onto a gurney, and caused or allowed him to fall into an empty whirlpool bathtub. 4. At the above time and place, Claimant was a patient at Contra Costa Regional Medical Center, and was being treated for sacral decubitus ulcers. Among other things, Claimant received whirlpool therapy for treatment of his sacral decubitus ulcers. At the above time and place, Claimant had completed a whirlpool therapy treatment, and was not properly secured onto a gurney when his healthcare professionals began to move the gurney, causing or allowing him to fall. Claimant is informed and believes that Contra Costa Regional Medical Center, and its employees and agents, failed to exercise the standard of care and;skill ordinarily and reasonably.required of physicians, surgeons, 1 hospitals, nurses, therapists, etc., in-that; without limitation, said practitioners failed to properly secure him onto a gurney, and caused or allowed him to fall into an empty whirlpool bathtub. 5. As a result of the negligence of the Contra Costa Regional Medical Center, and its agents, employees and other persons whose identities Claimant is presently unaware, Claimant sustained permanent physical and emotional injuries including, but not limited to severe damage to his pelvis, left hip, left leg, and lower back, as well as other damage and other personal injuries that are unknown at this time. 6. The names of the public employees causing the claimant's injuries are unknown at this time. 7. The claim is made in' an amount in excess of the jurisdiction of the Superior Court. Dated: March 9, 2006 KERSHAW, CUTTER& RATINOFF, LLP �KERRI EBB Attorney for Claimant 2 '.1 ` 1 '1 . i t 1 o � .o .o o� o N w, 1 N a� c 10 r, %0 %�co Cc, or- us W UAa� .o � " � � 1 ol I;L i sr, 1 W� I J © 0 1 � � 1 1: N O u- r� P v r V d 1 N L �✓y P f� O P CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY C. BOARD ACTION: APRIL 11, 2006 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 California Government Codes. ) you is your notice of the action taken on your claim by the Board of Supervisors. (Paragraph IV below), MAR 15 2006 given Pursuant to Government Code Section 9.13 and 915.4. Please note all AMOUNT: $1,171..36 COUNTY COUNSEL. "Warnings MARTINEZ CALIF, CLAIMANT: UNITRIN KEMPER FOR: SAM BENNEIT BY: ATTORNEY: MATHIEU ." SCHWARTZ . DATE RECEIVED: MARCH 15, 2006 UNKNOWN ADDRESS: P.O. BOX 6660 BY DELIVERY TO CLERK ON: MARCH 15, 2006 FOLSOM, CA 95763-6660 RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT FROM.: Clerk of the Board of.Supervisors TO: County Counsel Attached is a copy of the above-noted claim. . MARCH 15, 2006 JOHN CULLEN leJ Dated: By: Deputy`' Il. FROM: County Counsel TO: Clerk. of the Board of Sty6ervArs. This claim complies substantially with Sections 910 and 910.2. (V('his Claini 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 Cor leave to present a late claim (Section 911.3). ( ) Other: Dated: ?i, By: - -1 --vDeputy County Counsel Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 911.3). 1V. ARD ORDER: By unanimous vote of the Supervisors present: (v),This Claim is rejected in full. O Other: I certify that this is a true arid'correct copy of the Board's Order entered in its minutes for this date. O Dated -d ell//xi4tillro JOHN CULLEN, CLERK, By Deputy Clerk WARMNG NG (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally sewed or deposited in the mail to rile 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 (,declare under penalty of perjuwy,that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; 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. o Dated r�/�� . JOI-IN CULLEN, CLERK By Deputy Clerk OFFICE OF THE COUNTY COUNSEL E--L SILVANO B. MARCHESI COUNTY OF CONTRA COSTA COUNTY COUNSEL Administration Building 651 Pine Street, 9th FloorSHARON L. ANDERSON Martinez, California 94553-1229 �; ' CHIEF ASSISTANT 1e (925) 335-1800 �' %_�s'ri � GREGORY C. HARVEY (925) 646-1078 (fax) �� ' d 'l VALERIE J. RANCHE ' �_ 3� " ASSISTANTS rA coar�� NOTICE OF INSUFFICIENCY AND/QR NON-ACCEPTANCE OF CLAIM TO: UNITRIN KBMPBR P.O. Box 6660 Folsom, CA 95763-6660 RE: CLAIM OF Your Insured: Sam Bennett Your Claim No: 7.86 A62 10859 N 786 MPS Please Take Notice as Follows: The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910.2, or is otherwise insufficient for the reasons checked below: [X] 1. The claim fails to state the name and post office address of the claimant. [X] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [X] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [ ] 4. The claim fails to state the name(s) of the public employee(s) causing the injury, damage, or loss, if known. [ ] 5. The claim fails to state whether the amount claimed exceeds ten thousand dollars (`610,000). If the claim totals less than ten thousand dollars ($10.000), the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective i»jury, damage or loss so far as known, or the basis of computation of the amount claimed. [ ] 6. The claim is not signed by the claimant or by some person on his or her behalf. Unitrin Kemper Re: Claim of Your Insured: Sam Bennett Page Two [X] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit your claim on the enclosed form, including all the required information. Gov. Code. § 910.4. Please be aware that you have only a limited period of time in which to file an amended claim. See Gov. Code. § 910.6. [ ] 8. Other: SILVANO B. MARCHESI COUNTY COUNSEL By: Monika L. Cooper Deputy County Counsel CERTIFICATE OF SERVICE;BY MAIL (Code Civ. Proc., §§ 1012, 1013a, 2015.5; Evid. Code, §§ 641, 664) I am a resident of the State of California, over the age of eighteen years, and not a party to the within action. My N siness address is Office of the County C6unsel, 651 Pine Street. 9th Floor, Martinez, CA 94553-1 229. On —, I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of'Claim by placing the document in a sealed envelope with post�ae thereon fully prepaid, in the United States mail at Martinez, California addressed to Ugitri Ketnper,.P.O.-Box 6660, Folsom, CA 95763, as set forth above. I am readily familiar with Office of County Counsel's practice of collection and processing of correspondence for mailing. Under that practice, it would be deposited with the U.S. Postal Service on that same day with postage thereon fully prepaid in the ordinary course of business. 1 declare under penalty of perjury under the I ws of the State. of California and the United States of America that the above is true and correct. Executed on at Martinez. California. 01.Kathleen O'Connell cc: Clerk of the Board of Supervisors(original) Risk Management Page 2 OV) UNITRIN 1 Kemper 9sp I \AUTO AND HOME �-' February 3,2006 Attn:Penny BailyFc fi V Contra Costa County Risk;Management. `v �c�jj q 2530 Arnold Drive,Suite 140 Martinez,CA 94553 8�0os D Re: Our Insured: Sam Bennett ..--own Our Driver: Jesiryl Bennett Our Claim No: 786 A6 210859 N 786 MPS n Date of Loss: August 9,2005 I I aQ V/j Your Reference: B420 Plate Number: 1062412,California VIN Number: 1FV6HJDA91DH31574 Supervisor: Bike Giles :FIs.Baily: Our investigation leads us to conclude that your insured is legally responsible for this accident.Your insured hit our insured's vehicle. As a result of ounpayment,we are entitled to recover the damages which we have paid to repairs our insured's vehicle. I have enclosed the documents to support the amount of our payment as follows. Total Bill: $671.36 Collision Deductible: 500.00 Total: $1,171-36 C� Please forward a draft payable to Kemper Insurance in the amount of$1,171.36. Please mail to: Y PO Box 6660 "14q / ,,`T(( Folsom,C A 95763. q If you have any question please contact our subrogation department. Sincerely, Mathieu Schwartz Claim Representative III Kemper Independence Insurance Company 800-822-8426 x 2534 (916) 294-2500 (800) 822-8426 (916) 294-2600 Fax P.O. Box 6660 Folsom, CA 95763-6660 www.kemperautoandhome.com CALH MPS FOCUS • 02/03/06 PAYMENT SELECTION MPHS01 CLAIM# 786 A6 210859 N 786 NAME BENNETT*SAM D.O.L. 08/09/05 CHECK # ISSUE PAYEE PAYMENT PAYMENT DATE AMOUNT STATUS 514 0916069 09/19/05 SAM BENNETT 671 . 36 ACTIVE F0000014A PLACE CURSOR IN FRONT OF DESIRED ITEM AND PRESS ENTER 09/16/2005 AT 05:31 PM 786A6210859N7860101 31963 KEMPER AUTO AND HOME GROUP SACRAMENTO REGIONAL CLAIM OFFICE P.O.BOX 6660 FOLSOM, CA 95763 ' (800)822-8426 ESTIMATE OF RECORD WRITTEN BY: DAVIDA. GALLAGHER 09/16/2005 05:31 PM ADJUSTER: LINDSEY MATESSINO (800)822-8426 INSURED: SAM BENNETT CLAIM #786A6210859N7860101 OWNER: SAM BENNETT POLICY #RB 828627 ADDRESS: JESIRYL BENNETT DATE OF LOSS: 08/09/2005 AT 01 :50 PM 5052 SN PABLO DAM RD #46 + EL SOBRANTE, CA 94803 • TYPE.OF LOSS: COLLISION DAY: (510)758-7348 POINT OF IMPACT: 12. FRONT INSPECT JESIRYL BENNETT DAY: (510)758-7348 LOCATION: 5052 SN PABLO DAM RD #46 HOME EL SOBRANTE, CA 9480-3- REPAIR 3 DAYS TO REPAIR FACILITY: LICENSE # 2004 HOND CIVIC VP 4-1 .7L-FI 4D SED BLUE INT:BEIGE VIN: 2HGES16354H576225 LIC: 5KHE339 CA PROD DATE: ODOMETER: 26594 AIR CONDITIONING REAR DEFOGGER TILT WHEEL INTERMITTENT WIPERS TINTED GLASS BODY SIDE MOLDINGS DUAL MIRRORS CLEAR .COAT PAINT METALLIC PAINT POWER STEERING POWER BRAKES DRIVER AIR BAG PASSENGER AIR BAG CLOTH-SEATS BUCKET SEATS AUTOMATIC TRANSMISSION OVERDRIVE ------------------------------------------------ ------------------------------ NO. OP. .-. DESCRIP_TI.ON QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- 1# INSPECTED CAR ON 9/15/05 1 2 FRONT BUMPER--- 3 R&I R&I BUMPER COVER 1 .2 4* RPR BUMPER COVER 1 .5* 2.6 . 5 ADD FOR CLEAR COAT 1 .0 6 GRILLE 7* REPL GRILLE BLUE PEARL 1 90 .27 0 .6 0 .0* 8 HOOD 9* RPR HOOD 1 .5* 2.6 10 ADD FOR CLEAR COAT 1 .0 11# SUBL HAZARDOUS WASTE REMOVAL 1 3.00 X 12# RPR TINT PAINT 0 .5 13# REPL COVER CAR 1 3.00 0 .2 14# REPL FLEX AGENT 1 6 .00 15# ESTIMATE COPY LEFT FOR CAR 1 OWNER 9/15/05 1 09/16/2005 AT 05:31 PM 786A6210859N7860101 31963 • ESTIMATE OF RECORD 2004. HOND CIVIC VP 4-1 .7L-FI 4D SED BLUE INT:BEIGE ------------------------------------------------------------------------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT ------------------------------------------------------------------------------- -------------------------------------------------------------------------------- SUBTOTALS =_> 102.27 5.5 7 .2 PARTS 99.27 BODY LABOR 5.5 HRS a$ 65.00/HR 357 .50 PAINT LABOR 7 .2 HRS a$ 65.00/HR 468.00 PAINT SUPPLIES 7 .2 HRS @$ 30.00/HR 216 .00 SUBLET/MISC. 3.00 ----------------------------------------------------- SUBTOTAL S 1143.77 SALES: TAX S 315.27 a 8.7500% 27 .59 _ . . . TOTAL: COST OF REPAIRS S 1171 .36 - - - - ADJUSTMENTS: -_ DED.UCTIBLE 500 .00 ; .:.TOTAL ADJUSTMENTS $ 500 .00 ----- NET COST OF REPAIRS $ 671 .36 THIS IS NOT AN AUTHORIZATION TO REPAIR. ALL =`SUPPLEMENTS REQUIRE=PRIOR APPROVAL . PLEASE CONTACT D.AJJGALLAGHER a 510-677:-6440 REGARDING ANY NECESSARY CHANGES. D.A.GALLAGHER STAFF APPRAISER KEMPER AUTO & HOME_---- —------ ' 2 09/16/2005 AT 05:31 PM 786A6210859N7860101 31963 ESTIMATE OF RECORD 2004 HOND CIVIC VP 4-1 .7L-FI 4D SED BLUE INT:BEIGE FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=APPROXIMATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NON TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY, INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO. GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT 0/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PART COMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE AND REPLACE.RPR=REPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/-=WITH/- ,SYMBOLS: ;#=MANUAL LINE ENTRY *=OTHER CIE. .MOTORS DATABASE INFORMATION WAS CHANGED.] **=DATABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER.'S QUALIFICATION AND VALIDATION PROGRAM. ESTIMATE BASED ON MOTOR CRASH ;ESTIMATING GUIDE.. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM -THE GUIDE ARG4440 DATABASE DATE 07/2005, CCC DATA DATE 07/2005, AND THE PARTS---SELECT;ED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT: MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS. ASTERISK (*) OR ;DOUBLE ASTERISK (**) INDICATES THAT THE PARTS AND/OR LABOR INFORMAT-l-ON-PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE COME FROM AN ALL ERNATE-'DATA SOURCE. TILDE SIGN ( ), ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PART.S_ARE..-DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY, OR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED BY NATIONAL AUTO GLASS SPECIFICATIONS, INC. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES. SOME PARTS THAT ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS MAY BE OE 'SURPLUS PARTS OR OTHER OE PARTS OFFERED AT A SPECIAL PRICING DISCOUNT. ;FOR FURTHER CLARIFICATION PLEASE REVIEW THE SUPPLIERS LIST ATTACHED TOTHIS ESTIMATE, OR CONSULT THE APPRAISER OR ESTIMATOR. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 3 09/16/2005 AT 05:31 PM 786A6210859N7860101 31963 ESTIMATE OF RECORD 2004 HOND CIVIC VP 4-1 .7L-FI 4D SED BLUE INT:BEIGE ALTERNATE PARTS USAGE i AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 0 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 0 I i I 4 lµ r a i } - I .moi • ` ,�r t „ , - 9/15/2005 , .Y y+ ..�� ..r ,j,;hi,4.��,.~r.,'�'�,y�"cat'��'�� i'r y, �� ,�r�M�r`,�„,�x.� r�� + '4�`•j"�7t r ,r'{�'�*ie'.�; ° • .'7"G: '` t`i ��SK} �-• 7� � '"� cr'� x�.i�z� •s.�.3;'- - ";r I i I -77 -.Aw __._..�I..._._•..----• q i 1n�w Owl il a. I ' I � I t• '' - '•' i i ON— 11yt�,�T.;h,'j..•c"i�..� .-�Ly,:`;,,t.. I I RECEIVED E 15 2006 Penny Bailey CLERKBOARD OF CONTRA COSTA CO. MAR MAR I 2006 6 L4 i lea �— haee 6,cz� G -710 t ice! AMENDED CLAIM BOARD OFF SUPERVISORS OF CONTRA COSTA COUNTY C°/9 BOARD ACTION: APRIL 119 2006 Claim Against the County, or District Governedlby •). 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. D notice of the action taken ony our claim by the Board of Supervisors.(Paragraph iV below), given Pursuant to Government Code Section 913 and MAR 1 5 2006 915.4. Please note all "Warnings". COUNTY AMOUNT: $3,;000.00 MARTINEZCALIEL . F° DATE RECEIVED: MARCH 15, 2006 CLAIMANT: . BRUCE R.. CHRISTENSEN MARCH 15, 2006 BY DELIVERY TO CLERK ON: ATTORNEY: . UNKNOWN HAND DELIVERED BY MAIL POSTMARKED: ADDRESS: 5019 ALHAMBRA VALLEY ROAD MARTINEZ, CA 94553 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, e Dated: MARCH 159 2006 By: Deputy II. 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'retuin claim on groLznd that it was filed late and send warning of claimant's right to apply for leave to preser►t a late claim(Section 911.3). ( ) Other: Dated: 6(49 By: InDeputy County Counsel I ' 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. B- ARD ORDER: By unanimous vote of the Supervisors present: TV. Claim is rejected in full. ( ) Other: certify that this is a true and con-ect cypy of the Board's Order,entered in its minutes for this date. o Dated: r// I:UV�6 JOHN C[JLI EN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice.in connection with this matter. if you want to consult an attorney, you should-do so immediately. *For Additional;Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that 1 am now, and at all times herein mentioned, have been a citizen of the United States, over age 1.8; and that today if 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. o Dated: A,/ar�/�� JOHN CULLEN, CLERK By Deputy Clerk • � L..� rutt�t� !+lVKFtS BOARD OF SUFERVISORIS OF CONTRA COSTA COUINTY 1V JJC . YNEXCTIONS TQM NIT A. A claim relating to a cause of action for death or for injury to person or to personal properly or growing crops shall be presented not late: than six months after the accrual of the cause of action. A claim relating to any;other cause of action, shall be presented not later than one year after tht accrual of the cause of action. (Gov. Code§ 911.2.) B. Claims must be filed with the i Clerk of the Board of Supervisors at-its office in Room 106, County Administratiom Building, 651 Pine Street, Martinez,.CA 94553, C. if claim is against.a district governed by the Board of Supervisors, ranter than the County, the :tame of the District should be.filled.in. D. if the cWm is against more tli n one public entty, separate claims must be filed against eacb public entity, i E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of WS form.' �esree�e�r�s�e.•eeeee�e�ei009e9eeeeoeeeeoeeereeeeeboboe offset RE: Claim By. } Reserved for Clerk's filing �F IL 'CIA Wn Sz td RECEI ED 9a Against the County of Contra Costa of MAR 1 U 2006 9�°s�GA� �oo� District) CLERIC BOARD OF 9c 9 (Fill In tbA name) } CONTRA COS A COVISORS �9s j The undersigned :laimant hereby makes claim agai=the Cotusty of Contra Costa or the above-named district in the sum of&_'3i tom, i.Yp and in support of this claim represents as follows; i 1, When did the damage or injury occur? (Give exact date and hour) 1( 0<_ Lf t1?►�1 . 2. %we did the damage or iajury►occur? (Include city and county) 3. flow did the dataage or injury occur? (Give full details; use extra paper if required) i +1 04-wn i'Yla,n- j► � plivt�;nec�e. wcs b ii ,� ;to . 4, What particular act or omission on the part of counry or district officers, StMailtS, or emploXees. caused the injury or damage? rai�ure, �fStiCJn� eYelEcy 'tU a- ir-�55 l �ov�-c� o� � p�Y-�lvlr4c� l y\�-1 5 What are the names of cou:ty or distYiC!enit;ers, savant, or Grnployees causing the damage cr injury? I i I I b, What d=age or injuries do your claim resulted? (Give full extent of injuries Or damages claimed. Attach two estimates for auto dlem►age,) FWLv" -&Wk n%LAc ,�L.Fes Ll in -kuL-o off- 0CC:u ipc ect CA How was the amount claimed above comptnad? (Iniulude .the estimated amount of $ny prospective iajuzy a7 damage,) ' 1 8. Names and addresses of witnesses,doctors, and hospiWs: •� ��-+�'� c w�r� �►� G',1� ,G-r=��►Asn Silk /)'l tiu:,,,b,n ��,,�,, ��1 I✓l� . ,(, 9, List the experahttues you made;on accouat of this accident of injury: �f E r ANtoyisr ! r "- t-/�� i is$Nosees a9@*pooldes*asses aaa$me%40606.got e/4aaeaaealaaa�isaaaaar•a••a• ' ) Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf` I SEND NQTICES T0: (A orney) Name nod sd&ess ofAttarney &IAII� I .) ► ► (Claimarst's Siginatme) (Address) CATelephone No. }Telephone No. e�e�eear��ea•aa.e•oeeeeee•�a•ftea�aaaaaa•aset.e�.eago eavel I ' I PUBLIC RECORDS NOTICE., Please be advised Oiat this claim form,;or any claim filed with the County under the Tort Claims Alt, is subject to public disclosure under the Californii Public Records Act (Gov. Code, 55 6500 et seq.) Furthermore, any attachmetns.addendutYms, or supplements attached to the claim farm, 'including medical records, ire also subiect to public disolosurc. *as ar a et a a s see a as aeaIVa06aanow•aaae•60aaeesea a■Iles a*a aasa asap•e a of a 0 of as a s a•a r••1,0 I i NOTICE: Section 72 of the penal Cede provides) Every person wha, with intenr to defraud, prssents for allowance or for payment to any s*,•nte board er officer, or to any comity, city, or district board or officer, authoraed to allow or pay the soma If genuine, any false or froudulatt claim, bifl, account vouchir, or writing, is punichable either by imoso:nmertt in rise County jail Cor a period of not more than one year, by;a fine of not e�%cedinthousand g ore dollars ($1,000,00), or by both such imprisonment and fine, or by irrprisonmsnt in the axte prison, by a fine of not exceeding tai thousard dollzrs ($10,000), or by both such imprisonm[mt and fine, i i I V AMENDED CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTiON:APRIL 11, 2006 Claim Against the County, or District Governedby j the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section re (9) The The copy of this document mailed to you is your f California Government Codes. notice of the action taken on your claim by the MAR 172006 Board of Supervisors.(Paragraph IV below), given Pursuant to Government Code Section 913 and COUNTY COUNSEL 915.4. Please note all "Warnings". MARTINEZ CALIF. AMOUNT: AN AMOUNT IN EXCESS OF THE !JURISDICTION OF THE SUPERIOR COURT DATE RECEIVED: MARCH 17, 2006 CLAIMANT: MARK A. RANDLE BY DELIVERY TO CLERK ON: MARCH 17, 2006 ATTORNEY: KERRIE WEBB MARCH 16, 2006 LAW OFFICES OF KERSHAW, CUTTER & BY MAiL POSTMARKED: ADDRESS: RATINOFF, LLP d 980 9th STREET, SUITE 1900 SACRAMENTO,. CA 95814 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. MARCH 17, 2006 JOHN CULLEN, C Dated: By: Deputy Il. FROM: County Counsel TO: Clerk of the Board of Sup rvisors (, VFI,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'shouldireturn 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: 'r t 7-0 Ce By: f'VTCAR9� 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). 1V. B ARD ORDER: By unanimous vote of the Supervisors present: ( his Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:Tr r�� JOHN COLLEN, CLERK, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this n ce was personally served or deposited in the mail to file a court action on this claim. See Government ode 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 frilly prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. 0 Dated: �y��i� aZ.do,4 JOHN CULLEN, CLERK By Deputy Clerk i REC MAR 1 7 200 AMENDED CLAIM AGAINST PUBLIC ENTITY 6 [Gov. Code §905.2, 910, 910.21 CLERKBOgRD CONT Rq COSTPERVISORS N Cp I TO: Contra Costa County Board of':Supervisors Attention: Clerk of the Board 651 Pine Street j Martinez, CA 94553-1229 I i I Mark A. Randle heri eby makes a claim against the Contra Costa Regional Medical I Center, 2500 Alhambra Avenue, Martinez, California 94553, and makes the following statements in I support of the claim: 1. Mark A. Randle, 82 Trident Drive, Pittsburg, CA 94565. 2. Notices concerning the claim should be sent to Kerrie Webb, of the law offices of j Kershaw, Cutter& Ratinoff, LLP, 980 9`' Street, Suite 1900, Sacramento, CA 95814. I 3. On September 20, 2005, Claimant sustained permanent injuries when his healthcare i professionals at Contra Costa Regional Medical Center failed to properly secure him onto a gurney, and caused or allowed him to fall into an empty whirlpool bathtub. Thereafter the healthcare i professionals at Contra Costa Regional Medical Center failed to properly treat Claimant's injuries to his I pelvis, hips, left leg, and lower back, and other areas that are unknown at this time. I 4. At the above time and place, Claimant was a patient at Contra Costa Regional Medical I Center, and was being treated for sacral decubitus ulcers. Among other things, Claimant received whirlpool therapy for treatment of his sacral decubitus ulcers. At the above time and place, Claimant had completed a whirlpool therapy treatment, and was not properly secured onto a gurney when his I healthcare professionals began to move the gurney, causing or allowing him to fall. Claimant is 1 i I i i i informed and believes that Contra Costa Regional Medical Center, and its employees and agents, failed I to exercise the standard of care and skill ordinarily and reasonably required of physicians, surgeons, hospitals, nurses, therapists, etc., in!that, without limitation, said practitioners failed to properly secure him onto a gurney, and caused or allowed him to fall into an empty whirlpool bathtub. Claimant is I informed and believes that Contra Costa Regional Medical Center, and its employees and agents, failed thereafter to provide Claimant with jappropriate treatment for his injuries to his pelvis, left hip, left leg, i and lower back, and other areas thai are unknown at this time. I 5. As a result of the negligence of the Contra Costa Regional Medical Center, and its agents, employees and other persons whose identities Claimant is presently unaware, Claimant sustained permanent physical and emotional injuries including, but not limited to severe damage to his i pelvis, left hip, left leg, and lower back, as well as other damage and other personal injuries that are unknown at this time. I i 6. The names of the public employees causing the claimant's injuries are unknown at this time. i 7. The claim is made in an amount in excess of the jurisdiction of the Superior Court. i i i Dated: March 16, 2006 KERSHAW, CUTTER& RATINOFF, LLP i i KERRKWEBB Attorney for Claimant I 2 I ' I i I I Re: Randle Public Emily Claim I i PROOF OF SERVICE I am a citizen of the United States; over the age of 18 years, not a party to the within action, employed in the County of Sacramento, California, and my business address is 980 9`h Street, 19`h I Floor, Sacramento, California 95814. I am familiar with this firm's practice for collection and I processing of documents for mail with the United States Postal Service, hand-deliveries, and facsimiles. II On this date, service of the f i llowing documents: I AMENDED CLAIM AGAINST PUBLIC ENTITY I I I in this matter was effected by: I Mail Personal Service _X_ Federal Express Facsimile I on the parties to said cause as follows: i i Contra Costa County Board of Supervisors Attn: Clerk of the Board 651 Pine Street Martinez, CA 94553-1229 I i I it Executed under penalty of perjury on March 16, 2006, at Sacramento, California. I , I Sherry Mintle LL- gre =¢ Sam' s _ q a � ' a❑ ~ . _ � cc Uj Lt s EF a os Q 4N ❑ z❑ o a ._ m m f f a co -co 0.6 a W ❑ Q �3 'CD - m„ `n M �u d �,Qm. rr f'. 9N El S m .A o E oc t E ❑ W co W C mmo$ o ymn- fG �- 5 CD Co0c �o❑N C _ s m >� .� '.. .'�+jr c •:i•6rnri'','�J . 7 ym c� .. ,v ¢mom„figg �g..E a`r�:_ a 3 0'�';am 9mj rr 'eJr �rV'L:1 nCD zsa 0 . I ..I J l - I(4U7 Tie ❑ ❑ l W ru co \41- rq CO cb, � d 40 NN _j rd :t': cc rq Co! LLLn Lrl z e Z a y ��,ti Q W _ ! . 3 I- W = rr w iJ l .o o w a CD vv` W o inz ¢ i3 } ¢Z v ocQ 3 QIP cel . 3x364 133d..:1N131d133H I OT •suoponnsuo uooaeogdme lams puu load jol naeq aaS 1 f:v ( j AMENDED CLAIM. 0 BOARD OF SUPERVISORS QF CONTRA COSTA.COLTNTY BOARD ACTION: `4 ` 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. (�Inotice of the action taken on YOUr claim by the Board.of Supervisors.(Paragraph IV below), given MAR 1 0 2006 Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". COUNTY COUNSEL AMOUNT: O�� MARTINEZ CALIF. �. p�� DATE RECEIVED: s �1bJQ6 CLAIMANT: (,�rtL l Yl e � FOR ROBERT WESTIItLUND BY: 0tQ,!"LQ,S L blo n S BY DELIVERY TO CLERK ON: l0 ATTORNEY*A BY MAIL POSTMARKED: 31q job ADDRESS: R©• C3OX (0(10 co� -Som , CA 6)C2 7b3 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Clerk.`; ' Dated: l I By: Deputy II. 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, Lith Sections 9.10 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 file4 late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: I Dated: 3- 13^co(0 By: K_nc 6L-4� Deputy County Counsel III. FROM: Clerk of the Board TO: C I unty Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. B RD ORDER: By unanimous vote of the Supervisors resent: ( This Claim is rejected in full. ( ) Other: I I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. a Dated: �� o2G0 JOHN CUL;LEN, CLERK, ByAADeputy 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 ion 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 jWarning See Reverse Side of This Notice. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that 1 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: e�R ��/�� .� JOHN CULLEN, CLERK By Deputy Clerk Kemper RECEIVED JAUTO AND ROME I March 9, 2006 MAR 1 U 2006 CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. Clerk Contra Costa County Board of Supervisors County Administration Building, Room 106 651 Pine Street Martinez, CA 94553 Our Insured: Robert We.terlund Injured Party(ies): N/A Our File#: 786 A6 217713/CLL Date of Loss: 12/13/05 Your Driver: Jerry Barbie Your File#: 59729 Dear Clerk: I am enclosing the completed claim form as well as copies of the supporting documents for our claim of$1,048.61. Please send me a separate form if our insured needs to fill one out for his deductible. I If you have questions,please feel free to call me at (916) 294-2527. Thank you very much for your cooperation 1 I Sinc fly: I arles L ons j Claims Repre ative Kemper Independence Insurance Company clyons@kahg.com kahg.com CC: File i i i I (916) 294-2500 (800) 822-8426 (916) 294-2600 Fax P.O. Box 6660 I Folsom, CA 95763-6660 www.kemperautoandhome.com caLH I i MAR-07-2006 .13:56 CCC RISK MANAGMENT BOARD OF SUPERVIbutc.� Ur 925 335 1421 P.02iO3 INSTRUCTIONS TO CLMYIANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be .presented not later dl-m one year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, Courih,Administration Building, 651 Pine Street,Martinez,CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each. public entity. E. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the end of this form. a Nan Novas ass a no no am MEN Room man I as soon am son NEEDS a no a■a■Raw MORE a at a a as am a■eras ENE& RE: Claim By: Reserved for Clerk's filing stamp Against the County of Contra Costa or ) District) (Fill in the name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ and in support of this claim represents as follows: 1. When did the damage or injury oc lur? (Give exact date and hour) �7��-��-yl�, o�DO� �l�—��/� roc�•Y�� /� 2. Where did the damage or injury o �Icur? (Include city and county) J. How did the damage or injury occur? (Give full details;use extra paper if required) S�IuG� pu�lti �uy��'rr�� , /o/- 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? �/ /hl'7�/jelp 10 ivy �f ��// ✓�!''r 5 What are the names of county or 'district officers,servants, or employees causing the damage or injury? 71.112 rY I I MAR-07-2006 13:56 CCC RISK MANRGMENT 925 335 1421 P.03iO3 3 6. What damage or injuries do your iclaim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto age.)'. OO 7. How was the amount claimed above comp -Led? (Include the estimated amount of any prospective injury or damage.) 8. Names and addresses of witnesses,doctors,anp hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TRVM1 AMOUNT •aaaaaraaasrrraaraaaaasaaaaraaaaaaaaaaataaaaaaaaaaaa■aaaaaaaaraaaaaaaaaaraaaaaaaa■■r1 .Gov.Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attorney) 1 Name and address of Attorney ) } (Claimant's Signature) (Address) Telephone No. )Telephone No. ■■aaarrraaaaaaaNunn aNunn aaaaaaaaa■laaataaaaaaasaaaaaaaaaaaaaaaaraueaaaaaaaaaraaamini PUBLIC RECORDS NOTICE: Please be advised that this claim form,or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums,or supplements attached to the claim form,including medical records,are also subject to public disclosure. ■saaarrasaaaaaaaaaaaaaaaaaRas aaaaa ■■a aaaaaaaaaaraaaaaraaaaaaaaaaraaaaaaaman mass Sunni NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud,presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a. period of not more than one year, by.a fine of not exceeding one thousand dollars ($1,000.00), 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. TOTAL P.03 QLL FOCUS'. ' 03/09/06 PAYMENT HISTORY - PAYEE/PAYMENT FOR INFORMATION MPHF01 CLAIM# 786 A6 217713 N 786 NAME WESTERLUND*ROBERT*D D.O.L. 12/13/05 CLAIMANT # 1 CLAIMANT NAME WESTERLUND*ROBERT*D *----------------------- PAYEE/PAYMENT FOR INFORMATION ----------------------* PAYMENT TYPE COVERAGE CODE PAYMENT ALLOCATION ISSUE PAYMENT PAYMENT CHECK # DATE PAYEE/PAYMENT FOR AMOUNT STATUS 514 996825 12/20/05 ROBERT D WESTERLUND 543 . 19 ACTIVE Collision1with other veh: not hit and run LESS $500 DEDUCTIBLE FROM REPAIR ESTIMATE j NEXT FUNCTION F0000011A ALL ITEMS HAVE BEEN DISPLAYED i 12/16/2005 AT 09:42 AIS: 786A6217713 7860101 72585 KEMPER AUTO AND HOME GROUP A UNITRIN COMPANY P.O. BOX 6660 FOLSOM, CA 95763 (916)294-2500 ESTIMATE OF RECORD WRITTEN BY: ALBERT PUJOL 12/16/2005 09:42 AM ADJUSTER: AUDREY ADAMS (916)294-2500 INSURED: ROBERT WESTERLLJNID CLAIM #786A6217713 7860101 OWNER: ROBERT WESTERLUND POLICY #RQ 431541 ADDRESS: 103 GILRIX DATE OF LOSS: 12/13/2005 AT 09:00 AM MARTINEZ, CA 94553 TYPE OF LOSS: COLLISION DAY: (925)228-341;3 POINT OF IMPACT: 6. REAR INSPECT 103 GILRIX DAY: (925) 642-3295 LOCATION: MARTINEZ, CA. 94553-0000 NON DRIVE IN REPAIR DAYS TO REPAIR FACILITY: LICENSE # 2001 CHEV K1500 4X4 SILVERADO EXT 8-5.3L-FI 4D LONG TAN INT: VIN: 1GCEK19T61E137922 LIC: I6N97183 PROD DATE: ODOMETER: 0 TILT WHEEL INTERMITTENT WIPERS DUAL MIRRORS CLEAR COAT PAINT POWER STEERING POWER BRAKES ANTI-LOCK BRAKES (4) DRIVER AIR BAG PASSENGER AIR BAG 4 WHEEL DISC BRAKES. SPLIT BENCH SEATS REAR STEP BUMPER STYLED STEEL WHEELS ------------------------------------------------------------------------------- NO. OP. DECRIPTION QTY EXT. PRICE LABOR PAINT I ------------------------------------------------------------------------------- 1 REAR BUMPER 2 O/H BUMPER ASSY 1.8 3 R&I R&I BUMPER ASSY INCL. 4 REPL STEP PAD CENTER 1 48.72 INCL. 5 REPL RT BUMPER BRACKET -1 35.41 INCL. 6 REPL RT BUMPER BRACE 1 29.68 INCL. 7* R&I TRAILER HITCH & INSPECT * 1.0 8** REPL QUAL REPL PARTS TRAILER HITCH 1 20.00 0.1 COVER 9 PICK UP BOX 10* RPR RT SIDE PANEL 1.5* 3.1 11 ADD FOR CLEAR COAT 1.2 12 REPL RT DECAL ZF1 1 11.93 0.3 13 REAR LAMPS 14 R&I. RT COMBO LAMP ASSY 1/2 & 3/4 0.4 TON 15# RPR TIN^_ COLOR 0.5 16** REPL QUAL REPL PARTS MASK FOR 1 . 5.00 0.2 OVERSPRAY/ COVER CAR 17# REPL HAZARDOUS WASTE DISPOSAL 1 3.50 i 1 i 12/16/2005 AT 09:42 AM 786A6217713 7860101 72585 ESTIMATE OF RECORD 2001 CHEV K1500 4X4 SILVERADO EXT 8-5.3L-FI 4D LONG TAM INT: ------------------------------------------------ ---------------- NO. OP. DESCRIPTION QTY EXT. PRICE LABOR PAINT -----------------------------j------------------------------------------------- 18## RPR WET SAND / BIIFF .5 PNL 0.5 -------------- ------------ ------------------------------------------------ -- SUBTOTALS =_> 154 .24 6.3 4.3 ----- ------------------------- -- -------- ---------------------------------------- ESTIMATE NOTES: INSPECTED 01 CHEVY K1500 PICKUP IN PLEASANTHILL 12/15/05 SETTLED CLAIM PEP, ASS=GNMENT. ISSUED PAYMENT TO VEH OWNER LESS DEDUCTIBLE NET. AMT $543.19 & MAILED COPY OF ESTIMATE TO VEH OWNER. PARTS 154.24 BODY LABOR 6 .3 HRS @$ 70.00/HR 441.00 PAINT LABOR 4.3 HRS @$ 70.00/11R 301. 00 PAINT SUPPLIES 4.3 HRS @$ 30.00/HR 129.00 ---------------------------------------------------- SUBTOTAL $1025.24 SALES TAX $ 283 .24 @ 8.2500°% 23.37 --I-------------------------------------------------- TOTAL COST OF REPAIRS $ 1048.61 ADJUSTMENTS: DEDUCTIBLE 500.00 --I-------------------------------------------------- TOTIAL ADJUSTMENTS $ 500.00 NET COST OF REPAIRS $ 548.61 THIS IS NOT AN AUTHORIZATION TO REPAIR. ALL SUPPLEMENTS NEED PRIOR APPROVAL. PLEASE CONTACT ALBERT PUJOL AIT 925-260-6676 CELL REGARDING ANY NECESSARY CHANGES. THANK YOU, ALBERT PUJOL STAFF APPRAISER KEMPER AUTO AND HOME THE UNDERSIGNED REPAIR FACILDTY AGREES TO COMPLETE THIS JOB IN THE DAYS ALOTTED ON THE DAYS TO REPAIR LISTED ON THE FRONT OF THE ESTIMATE. X 2 12/16/2005 AT 09:42 AM 786A6217713 7860101 72585 ESTIMA' E OF RECORD 2001 CHEV K1500 4X4 SILVERADO EXT 8-5.3L-FI 4D LONG TAN INT: FOR YOUR PROTECTION CALIFORNIA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM: ANY PERSON WHO KNOWINGLY PRESENTS FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT_ OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. THE FOLLOWING IS A LIST OF ABBREVIATIONS OR SYMBOLS THAT MAY BE USED TO DESCRIBE WORK TO BE DONE OR PARTS TO BE REPAIRED OR REPLACED: MOTOR ABBREVIATIONS/SYMBOLS: D=DISCONTINUED PART A=AP?ROXT_NLATE PRICE LABOR TYPES: B=BODY LABOR D=DIAGNOSTIC E=ELECTRICAL F=FRAME G=GLASS M=MECHANICAL P=PAINT LABOR S=STRUCTURAL T=TAXED MISCELLANEOUS X=NCN TAXED MISCELLANEOUS PATHWAYS: ADJ=ADJACENT ALGN=ALIGN A/M=AFTERMARKET BLND=BLEND CAPA=CERTIFIED AUTOMOTIVE PARTS ASSOCIATION D&R=DISCONNECT AND RECONNECT EST=ESTIMATE EXT. PRICE=UNIT PRICE MULTIPLIED BY THE QUANTITY INCL=INCLUDED MISC=MISCELLANEOUS NAGS=NATIONAL AUTO GLASS SPECIFICATIONS NON-ADJ=NON ADJACENT O/H=OVERHAUL OP=OPERATION NO=LINE NUMBER QTY=QUANTITY QUAL RECY=QUALITY RECYCLED PART QUAL REPL=QUALITY REPLACEMENT PARTICOMP REPL PARTS=COMPETITIVE REPLACEMENT PARTS RECOND=RECONDITION REFN=REFINISH REPL=REPLACE R&I=REMOVE AND INSTALL R&R=REMOVE, AND REPLACE RPR=RElPAIR RT=RIGHT SECT=SECTION SUBL=SUBLET LT=LEFT W/O=WITHOUT W/ =WITH/ SYMBOLIS: #-MANUAL LINE ENTRY *=OTHER [IE. .MOTORS DATABASE INFORMATION WAS CHANGED] --=DA--ABASE LINE WITH AFTERMARKET N=NOTES ATTACHED TO LINE. MQVP=MANUFACTURER'S QUALIFICATION AND VALIDATION PROGRAM, OPT OEM=ORIGINAL EQUIPMENT MANUFACTURER PARTS EITHER OPTIONALLY SOURCED OR OTHERWISE PROVIDED WITH SOME 'UNIQUE PRICING OR DISCOUNT. THIS ESTIMATE HAS BEEN PREPARED BASED ON THE USE OF CRASH PARTS SUPPLIED BY A SOURCE OTHER THAN THE MANUFACTURER OF YOUR MOTOR VEHICLE. ANY WARRANTIES APPLICABLE TO THESE REPLACEMENT PARTS ARE PROVIDED BY THE MANUFACTURER OR DISTRIBUTOR OF THE PARTS, RATHER THAN BY THE ORIGINAL MANUFACTURER OF YOUR VEHICLE. i I 3 t 12/16/2005 AT C9:42 AM 786A6217713 7860101 72585 ESTIMATE OF RECORD 2001 CHEV K1500 4X4 SILVERADO EXT 8-5.3L-FI 4D LONG TAN INT: ESTIMATE BASED ON MOTOR CRASH ESTIMATING G1UIDE. UNLESS OTHERWISE NOTED ALL ITEMS ARE DERIVED FROM THE GUIDE DRlGH99 DATABASE DATE 11/2005, CCC DATA DATE 11/2005, AND THE PARTS SELECTED ARE OEM-PARTS MANUFACTURED BY THE VEHICLES ORIGINAL EQUIPMENT MANUFACTURER. OEM PARTS ARE AVAILABLE AT OE/VEHICLE DEALERSHIPS. ASTERISK (*) OR DOUBLE ASTERISK (") _INDICATES TEAT THE PARTS AND/OR LABOR INFORMATION PROVIDED BY MOTOR MAY HAVE BEEN MODIFIED OR MAY HAVE. COME FROM AN ALTERNATE DATA SOURCE. TILDE SIGN (-) ITEMS INDICATE MOTOR NOT-INCLUDED LABOR OPERATIONS. NON-ORIGINAL EQUIPMENT MANUFACTURER AFTERMARKET PARTS ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS WHICH STANDS FOR COMPETITIVE REPLACEMENT PARTS. USED PARTS ARE DESCRIBED AS LKQ, QUAL RECY PARTS, RCY,IOR USED. RECONDITIONED PARTS ARE DESCRIBED AS RECON. RECORED PARTS ARE DESCRIBED AS RECORE. NAGS PART NUMBERS AND PRICES ARE PROVIDED BY NATIONAL AUTO, SPECIFICATIONS, INC. POUND SIGN (#) ITEMS INDICATE MANUAL ENTRIES. SOME PARTS THAT ARE DESCRIBED AS AM, QUAL REPL PARTS OR COMP REPL PARTS MAY BE OE SURPLUS PARTS OR OTHER OE PARTS OFFERED AT A SPECIAL PRICING DISCOUNTI. FOR FURTHER CLARIFICATION PLEASE REVIEW THE SUPPLIERS LIST ATTACHED TO THIS ESTIMATE, OR CONSULT THE APPRAISER OR ESTIMATOR. SOME 2006 VEHICLES CONTAIN MINOR CHANGES FROM THE PREVIOUS YEAR. FOR THOSE VEHICLES, PRIIOR TO RECEIVING UPDATED DATA FROM THE VEHICLE MANUFACTURER, LABOR AND PARTS DATA FROM THE PREVIOUS YEAR MAY BE USED. THE PATHWAYS ESTIMATOR HAS A COMPLETE LIST OF APPLICABLE VEHICLES. PARTS NUMBERS AND PRICES SHOULD BE CONFIRMED WITH THE LOCAL DEALERSHIP. CCC PATHWAYS - A PRODUCT OF CCC INFORMATION SERVICES INC. 4 12/16/2005 AT 09:42 AM 786A6217713 7860101 72565 ESTIMATE OF RECORD 2001 CHEV K1500 4X4 SILVERADO EXT 8-5.3L-FI 4D LONG TAN INT: ALTERNATE PARTS USAGE AFTERMARKET PARTS AFTERMARKET SELECTION METHOD: AUTOMATICALLY LIST NO. OF TIMES USER WAS NOTIFIED THAT AN AFTERMARKET PART WAS AVAILABLE: 0 NO. OF AFTERMARKET PARTS THAT APPEAR IN THE FINAL ESTIMATE: 2 5 I I C -- `F.Ir :F• - ' • cY '.0 •k' k!. `i 4 c.. ... },� •i:-moi i+ _ fIR - :7, - 10 lb Nuf ZLI >•rr- .rc4 - - ~M'a �l - -'� �.I , a i tom:•^. .iT';:- 1tfr'-. _ SII ;;:,;__' YY •'j.i i - - F':;' l.:: .s.>� ,::iso��- _'14:•':,`,��x y' ,F- ` aGf - .1•n :.f::. �.' �f a: !: 'd ..may. t •'C '1�:: :�:' '•fr �''f.. ±`.tin:�' �•,. �. Y.•. y «... 'A•'•+:a-s .-1.'.i,. .:. ' - -.p.•.eE'�%'ijj>��yi:�':%wirt�'ffti' ._x•i�..t �- :�.- jS :�_�; :_ "45-4 _••stif Tt c ryrt - L t ti t L.1 -44 . t _ i� _ Y 7 j a � 1 _ Sod S�\\ `fid vs ' \ \ j to 11 \ 1 40 00, � p • � ti N O \ \ OCD m \ O N N cy) \ �Nv 0 c� \\ 0- x \ c� �\ a \ \ \ C.y 10% \\ W APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA �I BOARD ACTION Application to File Late Claim ) NOTICE TO APPLICANT APRIL 11, 2006 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 "WARNING"below. MERCURY CASUALTY COMPANY Claimant: FOR: CAROL KRETCHMER BY: TOBY SZPER MAR 2 1 2006 ' Attorney: UNKNOWN COUNTY COUNSEL, Address: P.O. - BOX 997195 " ' MARTINEZ CALIF. SACRAMENTO, CA 95899-7195 Amount: $15,145.73 By delivery to Clerk on: _MARCH 209 2006 Date Received: MARCH. 20, 2006 By mail,postmarked on:. DELIVERED BY COUNTY COUNSEL I. FROM: Clerk of the Board of Supervisors TO: . County Col nsel Attached is a copy of the above noted Application to File Late Claim. DATED: MARCH 21, 2000 OH;� Cuu]EN Clerk,By: DEPUTY II. FROM: County Counsel TO: Jerk of theBoard of Supervisors ( ) The Board should grant this Application to File Late Claim (Section 911.6), The Board should deny this Application to File Late Claim (Section 911.6). DATED: 3' SILVANO B. MARCHESI, County Counsel,By: h'l DEPUTY III. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted (Section 911.6). (V�, This Application to File Late Claim is denied (Section 91'.1.6)..- I certify that this a true and correct copy of the Board's Order entered in its minutes for this date. DATEAev.; oe":6 JOHN CUL•LEN, Clerk, By: DEPUTY WARNING (Gov. Code §911.8) 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 anfleation for leave to present a late claim)was denied. 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. IV. FROM: Clerk of the Board TO: (1) County Counsel (2) County Administrator Attached are copies of the above.Application.-.We notified•the applicant of the Board's action on this Application by mailing a copy of this document,-and a'memo thereof has been filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. DATED:P Ird /a ce"'19 JOHN CULLEN'', 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: t APPLICATION TO FILE LATE CLAIM P.O. Box 997195 MERCURY Sacramento, CA 95899-7195 INSURANCE GROUP (916) 636-1534 I March 13, 2006 RECEIVED Contra Costa County MAR 15 2006 Board of Supervisors Attn: John Sweeten 651 Pine St. Room 106 CLERK BOARD OF SUPERVISORS Martinez, Ca 94553-4068 CONTRA COSTA co. RE: OUR INSURED: Carol Kretchmer OUR FILE NUMBER: YNO02584-88 DATE OF LOSS: June 5, 2005 YOUR CLIENT: Contra Costa County Fire Department YOUR FILE NUMBER: RISK MANAGEMENT FILE 58439 Dear Mr. Sweeten: We believe you may have inadvertantly denied our claim without all the facts. We made you aware of our claim to recover for property damage caused by your fire department on September 7, 2005 well within the six month statute. We had numerous conversations with Ms. Bailey in risk management regarding the claim during the ensuing months. On December 12, 2005, over six months after the loss, we received notice that we were required to submit our claim on your specific form. We resubmitted our claim as requested and were then told the time period to make a claim had expired. We have consulted with counsel and it appears from their analysis that we had filed a valid claim within the required time frame and provided more than enough information to identify the claim and preserve the statute requirements. I have enclosed our attorney's analysis of the matter. Thank you for your attention to this matter. Very truly yours, MERCURY CASUALTY COMPANY TOB SZriner aims Ex Delta Claims i I .Validity of Notice of Claim: §910 . 6 (a) permits a party to amend an insufficient Notice of Claim prior to the six month expiration provided in §911 . 2 . §910 . 6 (b) also provides that failure by the party to amend the Notice of Claim as instructed by the government entity is not in itself a defense by the entity to the claim, if a court determines that the claim originally presented "complied substantially with §§ 910 [elements to be included in the Notice] and 910 . 2 [signed by the claimant] . " Therefore, if the Notice of Claim filed on December 5, 2005 substantially complied with . these requirements, it should be deemed sufficient, and whether the Amended Notice was filed late is immaterial . 1) The first deficit noted by the County was a failure by Mercury to identify the date the accident occurred in its Notice of iClaim. . However, it is likely that the Notice came with correspondence from Mercury which would have identified the date of the accident at the top of the letter, clearly marked. Therefore, for the purposes of constructive notice; it is likely that Mercury did substantially comply with this provision. If, however, the date was not actually provided, it is more than likely that the County will be able to stand by its initial assessment of insufficient notice, as it would be unreasonably difficult to locate a particular accident without its date. 2) However, the fact that the claim was not provided on the form offered by the County would not weigh heavily against Mercuriy, so long as Mercury supplied all necessary information, such as dates, times, places, and the amount of damage alleged, sufficient to put the County on notice of the situation it should investigate . As the County specifies only that the date is lacking, it is likely that Mercury supplied all other necessary information, and a court would find- that even thouI h it was not filled out on the county' s standard "Claim Form, " Mercury substantially complied by providing the §910 requirements to put the County on notice of the incident and potential lawsuit . Subrogatee' s Time Line: However, we may. not even need to reach the point. of arguing substantial notice and equity. Case law specifically holds that for purposes oz. Gov. Code §910, et . seq. , a subrogatee' s cause of action accrues upon the` date the payment is made to the subrogor, not the date of the accident . Allstate Ins. Co. v. County of Alameda (1973) 33 Cal ..App. 3d 418 , 420-421 . Allstate specifically references Ins . Code §11580 . 2 (g) , which states that the insurer paying a claim under tine uninsured motorist coverage shall be entitled to subrogation of the rights of the insured, within three years from the date the payment to the insured was made. (This case also confirms that the claim for subrogation against "any person" would also include against a governmental agency. ) Despite the standard argument that the subrogee has no greater rights than the subrogor, and therefore should be tied to the date of accident as the basis of the statute of limitations, Allstate specifically finds that §"11580 . 2 (g) gives the insurer the right to bring a claim within the statutory period measured from the time its cause of action accrued, i . e . , the date of payment . The case recognizes and clearly affirms the creation of this exception to the well established doctrine of a subrogee not having any greater right than the subrogor. (Allstate at p. ) Since the facts in this Mercury case are squarely in line with the Allstate case, we are on firm ground for maintaining that the January 9, 2006 filing. was timely, as the October 7, 2005 payment by Mercury would provide Mercury until Apri1--.7., .2006 to file its claim with the Conta Costa County. We therefore recommend resubmitting the January ,19, 2006 claim drafted on the correct form to 'the County, with a cover letter explaining this legal position. BOARD: {SUPEL2VISORS OF CONTRA CC' A COUNTY /L� INSTRUCTIONS TO CLQ IN AST i, A. A claun relating io a cause.of action:for death br`for.44jury to person or to personal property or growing crops shall be presented not later than six-months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. 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. ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■r■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■t RE: Claim By: Reserved for Clerk's filing stamp C-RCoR,r Crp,_5u4LTY CoJ%!1PAN\-1 ) ) .Against the County of Contra Costa or ) JAN. COPTap C05 i-jo C0J1g-T i 1=, Rc l3uu_i,District) - Y�;vlsoRs (Fill in the name) ) cLEaKBorAirR p°CST, CO. The undersigned claimant hereby makes claim against the County of Contia Costa or the above-narned district in the .sum of$_1 5,11-1 S?' and in support of this claim represents as follows: I. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) �}1FC- ( NT--RSEC-r)-t! OF ',tA5Go R10 rg1'10 C,nMIjVb pl]GI(3C0 f7. U.n�7�cofL�onfo%G-» c.urr'�'Lly Cos%.9 3. How did the damage or injury' occur? (Give full details;use extra paper.if required) t✓iAc- TRv G Ir 9 cUuR. SN,Sv(LE-DS VC I-11cLC C_C31 L1 0 TV 6La*� 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? DRrVe6L CSF FIF,C-TR�c�K �1sFERC--� ANTCnSCci 1cN A-r /aN U►,sAFE S 9EC� P HF_-r1 D-T?Jen- V r-�H ICLr 5 W 6 IL& GLvS E C-NDu&-t-+ ;V «r1 s►T1-rVT-C- A I+A ZAR.9. 5 What are the names of county or district officers, servants, or employees causing the damage or injury? 3-o S F 1-4 ?. P G 1-,,, C,�Si D�/O13�o �ii2C �J2oiECj/at1 fJiS%nlcj i AMENDED CLAIA-I BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: JANUARY 24/06 Claim Against the County, or District GoN;erned 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), giver Pursuant to Government Code Section 913 and 915.4. Please note all "Warnings". AMOUNT: $15,145.73 C:LAIMANT: MERCURY CASUALTY COMPANY FOR: CAROL KRETCHMER ATTORNEY: UNKNOWN DATE RECEIVED: JANUARY 09/06 ADDRESS: P.O. BOX 997195 BY DELIVERY TO CLERK ON:JANUARY 09/06 SACRAMENTO, CA 95899-7195 RECEIVED FROM BY MAIL POSTMARKED: COUNTY COUNSEL. FROM: Clerk of the Board of Supervisor's TO: County.Counsel Attached is a copy of the above-noted claim. JOHNS F , Clerk Dated: JANUARY 09, 2006 By: Deputy ; II. FROM: County Counsel TO: Clerk of the Board of Mpervisors. ( ) 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). (vy'Clairn is not timely filed. The Clerk should return clairn on grc.und that it was filed late and send warning of claimant's right to apply for leave to present a late claim(Section 911.3). .. j Dated: 1- 9—C , By: Deputy County Coun: 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( , Claim was returned as untimely with notice to claimant (Section 911.3). I.V. BOARD ORDER: By unanimous vote of the Supervisors present: O This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated.- 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 deposit in the.mail to file a cows 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 Helder penalty of pee jury 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 ful: lir e}�aid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated / �DJ�)I-N SWEETEN, CLERK.ray Deputy Clea iI II 10 ID 0 raf1N in 4` t7f coo cc CD BQ QD C=� LL WC=D UAci Q C6 zip toC3 as OCCW rl OCJ cl") OOC W� L6 cl= ICC CY) o I.- CO 9 LU 2c I z cc c" cr 1c, C. uj N Ch LA r 0. N cv fts Ln pv� 10 < ANEW 1,0 0 1 VAM.W.-k Z.