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HomeMy WebLinkAboutMINUTES - 05092006 - C.22 I i15 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 097 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 CaliforniaGovernment Codes. ) you is your notice of the action taken on your claim by the Board of D �g�Ci� Supervisors. (Paragraph IV below), given Pursuant to Government Code Section 913 and 915.4. Please note all AMOUNT: UNKNOWNAPR 0 7 2006 "Warnings". CLAIMANT: NANCY GALAN COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: UNKNOWN 1 DATE RECEIVED: APRIL 07, 2006 1250 KENDALL COURT 07, 2006 ADDRESS: WALNUT CREEK, CA 94595 BY DELIVERY TO CLERK ON: i 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, ler Dated: APRIL 07, 2006 By: Deputy 11. FROM: County CounselI TO: Clerk of the Board of Zpervisors . (�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). 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 _(o I By: !"Yl eputy 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. OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated.. B *?.$4OHN,CULLEN, CLERK, By Deputy Clerk WARN (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 hi 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, giant, addressed to the claimant as shown above. Dated' G `a�>G JOHN CULLEN, CLERK By Deputy Clerk I � 1 J Nancy Galan ��p� 1250 Kendall Court q/ Walnut Creek, CA 94595 ApR 0 7 �4�� 2046 eavr aFwiA� �S=q ORS March 30, 2006 Hand Delivery Contra Costa County Board of Supervisors 651 Pine Street, 151 Floor Martinez, CA 94553 Conira Costa Regional Medical Center 50 Douglas Drive Martinez, CA 94553 Re: Nancy Galan v. Contra Costa County Honorable Members of The Board: This is a Government Tort Claim brought on behalf of Nancy Galan,whose address is 1250 Kendall Court, Walnut Creek, CA 94595. This claim is based upon the following facts: On or about October 13, 2005 Nancy Galan was twice taken via ambulance to the Emergency Room of Contra Costa Regional Medical Center where she was provided medical and,psychiatric treatment and services and thereafter admitted to said facility. At said times there was a failure to properly diagnose and treat her, a failure to contact her emergency contact to learn of her medical history and failed to warn her of the severe risks of taking Risperdol which was provided to her by Contra Costa County medical personnel. Nancy Galan will allege and prove that you fell below the standard of care by failing to prevent and/or timely and properly diagnose NMS and treat her in an appropriate manner, thereby causing Ms. Galan to suffer ongoing and permanent injuries. Claimant is informed and believes that said negligent acts occurred as a direct result of employees and/or agents of the Contra Costa Regional Medical Center of Contra Costa County. r e . r 1 � Contra Costa County Board of Supervisors Contra Costa Regional Medical Center March 30, 2006 Page 2 Based upon the foregoing, Ms. Galan submits her claim for negligence and medical malpractice and demands one milliion dollars or such sum as deemed appropriate by a trier of fact in Contra Costa County Superior Court of unlimited jurisdiction. Very truly yours, Nancy Galan CLAIM ,�.1� 1 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY nn-- `r'',�/ BOARD ACTION: MAY 09, 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 i Supervisors. (Paragraph IV below), PR 0 5 Zv06 given Pursuant to Government Code AMOUNT: UNKNOWN COUNTY COUNSEL Section 913 and 915.4. Please note all MARTINEZ CALIF. "Warnings". CLAIMANT: ANITA MARIE BOOZE ATTORNEY: THOMAS WOELFEL DATE RECEIVED: APRIL 05, 2006 ADDRESS: 500 YGNACIO VALLEY ROAD, StBY:DEIJIVERY TO CLERK ON: APRIL 05, 2006 SUITE 300 WALNUT CREEK, CA 94596 BY MAIL POSTMARKED: APRIL 04, 2006 FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. APRIL O5 2006 JOHN CULLEN, Cr _ Dated: , By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors c OThis claim complies substantiallywth Sections 910 and 910.2 (V'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: By: 60 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). WIV. OARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: l� I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date_ Dated:AW AVt W.I"D;JOHN ,C ULLEN, CLERK, By Deputy Clerk WARM (Gov, code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personalty 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 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/%5e/0, JOHN CULLEN, CLERK By Deputy Clerk , i r i OFFICE OF THE COUNTY COUNSEL SILVANO B.MARCHESI COUNTY OF CONTRA COSTA COUNTY COUNSEL Administration Building 651 Pine Street, 91" Floor ° SHARON L. ANDERSON CHIEF ASSISTANT Martinez, California 94553-1229 925 335-1800 �" GREGORY C. HARVEY ( ) 0; -- i'3;a#11\1���: <. �,Z VALERIE J. RANCHE (925) 646-1078 (fax) a n'� `- 4� ASSISTANTS �OSrA CO--- NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Thomas Woelfel Attorney at Law 500 Ygnacio Valley Road, Suite 300 Walnut Creek, CA 94596 RE: CLAIM OF: ANITA M. BOOZE Please Take Notice as Follows: The claim you presented against the Colunty 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: [ ] I. The claim fails to state the name and post office address of the claimant. [ ] 2. The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [X] 3. The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [X] 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. Thomas Woelfel, Esq. Re: Claim of Anita Booze Page Two [ ] 7. You are required to submit your claim on the proper form, which is enclosed. Please resubmit I your claim on the enclosed orm, 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. [ ] S. Other: SILVANO B. MARCHESI COUNTY COUNSEL By: GV/P" W 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, Iver the age of eighteen years, and not a party to the within action. My biju�ness address is Office of the County Counsel, 651 Pine Street, 9th Floor, Martinez, CA 94553-1229. On 2l,D/o I served a true copy of this Notice of Insufficiency and/or Non-Acceptance of Claim by pl cing the document in a sealed envelope with postage thereon fully prepaid, in the United States mail at Martinez, California addressed to ThomaWoelfel, SOO Ygnacio galley Road,nSurte 30Q Walnut Creek, CA 94596., 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. 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 1�,2d�1� at Martinez, California. Kathleen O'Connell cc: Clerk of the Board of Supervisors (original) Risk Management Page 2 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 Clerk of the Board of Supervisors at its office in Room 106, County Administration Buildingj 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By: 1� Reserved for Clerk's filing stamp ) Against the County of Contra Costa or. ) A PR v •) 7006 ;; RVISORS District) 2. , -.-R (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)opcur? (Give exact date and hour) do mall-oh 231 20D.b S � ,ppeA on Am uneven piveme2T; J u 2. Where did the damage or injury occur? (Include city and county) 12�Ghmonol, CA �� a, she/fier CCen" Cost Ca011 . 3. How did the damage or injury+occur? (Give full details; use extra paper if required) I fnppeo( on to e✓v pavement-, 85 the hee,( of my shoe eon cetal In ,l;hvZ6,n " Un eti pa-veoUnr and cau4tA a. >vkXp)"k.. Mg Vdd 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? 5 What are the names of county or district officers, servants, or employees causing the damage or injury? VV4�J *.3. "( �ll Z�)��1� L+��C� lL�7GC �Z' c �1�1G/2 C'GLGGJ �G SfYCGf/Z G/2 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 8. Names and addresses of witnesses,doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT r■wasaa■assasws a Room Mass■rrrrrr■ssa sn ssrrassasssarsass ussaa■sassaasnss an■w■ r se*NONNI Qlov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SEND NOTICES TO: (Attornoy ) Name and address of Attorney ) 1 _ (Clai ant's Signat NSo0 ��N� UilyGl.. ;; ` ` (Address) Telephone No. 1/, )i elephone No. r,rrrrrrr...as 0 a no an warm now .........■ss aaassssrswwssss nassssssnssas■sa a e a a 0 a a NOaal PUB IIC 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. r■nss■sasae■■e ass■■asae■s■asa■a■■arra aaa nsasasnaaaa assn asrewewi■wanes an a a a&■ ie e a Mann 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. 0 o ¢d G o t LU UU k O 4 cy �� LUat Q Um cr uj t 44- .; � l :,�it tl 1 CLAIM BOARD 0. SUPERVISORS OF CONTRA.COSTA COUNTY I BOARD ACTION: MAY 09,' 2006 ll , Claim Against the County, or District Governed by ) the-Board of Supervisors, Routing Endorsements, )-1 NOTICE TO CLAIMANT and Board Action. All Sectionreferences are to ) The copy of this document mailed to Califoriiia Government Codes. you is.your notice of the action taken on yor claim by the Board of APR 0 5 A(06t Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNTUNKNOWN COUNTYCOLINSE1 Section 913 and 91.5.4. Please note all MARTINEZ CALIF. "Warnings". CLAIMANT: ANITA MARIE BOOZE ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 05, 2006 ADDRESS! 847 'c BROOKSIDE DRIVE 13Y]DELIVERY TO CLERK ON: APRIL"05, 2006 RICHMOND, CA 94801 BY MAIL.POSTMARKED: APRIL 04, 2006 I FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, r Dated: APRIL 059 2006 By: Deputy 11, FROM: Coiuity Counsel _ TO: Clerk of the Board of Supervisors This claim complies substantll�iawith Sections 910 and 910.2. (' ) P (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 Ofher: J Dated: By: � �( ' J1'1 , Deputy CountyCounsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) O Claim was returned as untimely with notice to claimant (Section 91 1.3). 1V. BOARD ORDER: By unh iimous vote of the Supervisors present. (✓ This Claim is rejected ui full. ( ). Other. I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. I Dated:/A� ®' o,I' 6 JOHN CULLEN, CLERK, By Deputy Clerk WARM (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 ail altortey of your choice ill connection with this matter. If you want to consult an attorney,you should do so immediately. *Foe•Additional Wanting See Reverse Side of,11tis Notice. AFFIDAVIT OF MAILING I declare under penalty of Jerjuty that I .1111 flow, and at all times herein mentioned, have been ;t citizen of the United States, over age 18; and that today I deposited in the United States rostatSet-vice in Martinez, California, postage fully prepaid a certified copy of this Board Orrdder and Notice to�Claimant, addressed to the claimant as shown above. Dared; %may asp �O(01 JOHN CIJI_.LLN„ CLERK By ��—Deputy Clerk LAW OFFICE OF THOMAS R. WOELFEL 500 YGNACIO VALLEY ROAD, SUITE 300 Licensed in: WALNUT CREEK, CA 94596 Oakley Office -California TEL: (925) 977-9600 4664 Sandmound Blvd -Hawaii FAX: (925) 977-9687 Oakley, CA 94561 (925) 684-2667 May 20, 2006 Board of Supervisors Contra Costa County RECEIVED 651 Pine Street, Room 106 Martinez, CA 94553-1293 MAY 2006 Re : Shelter Trip and— F 11 Claim :CLERK 60ARDO SSUPERVISORS Return of Documents for Rejection of Claim CONTRACOSTACO. Dear County Board of Supervisors : Per my April 14 , 2006, letter to County Counsel, a copy of which is enclosed, I have advised you that I am not representing Ms . Booze for the claim which I believe pertains to a trip and fall incident involving a County shelter where she lives . Accordingly, I am returning herewith the documents you sent to me on May 10, 2006, in which the county has rejected that claim, and I ask that ,you directs all correspondence .rec[ardincf that claim directly to Ms . Booze . Please do not hesitate to contact me should you have any questions regarding the foregoing. Very truly yours, LAW OFFICE OF�THOMAS ' R. WOELFEL Thomas R. Woelfel Enclosures . cc: Monika L Cooper, Deputy County Counsel, OFFICE OF THE COUNTY COUNSEL w/ copies of enclosures. LAW OFFICE OF S t THOMAS R. WOELFEL 500 YGNACIO VALLEY ROAD, SUITE 300 Licensed in: WALNUT CREEK, CA 94596 Oakley Office -California TEL: (925) 977-9600 4664 Sandmound Blvd -Hawaii FAX: (925) 977-9687 Oakley, CA 94561 (925) 684-2667 April 14, 2006 Monika L. Cooper, Deputy County Counsel OFFICE OF THE COUNTY COUNSEL 651 Pine Street, 9th Floor Martinez, CA 94553-12219 Re: Shelter Trip and Fall Claim Return of Documents for Rejection of Claim Dear Ms. Cooper: I am in receipt of the "Notice of Insufficiency and/or Non- Acceptance of Claim", which I believe pertains to a trip and fall incident involving Ms . Anita M. Booze at a County shelter where she lives, which you forwarded to me. Please be advised that I am, not representing Ms . Booze for that claim. Accordingly, I am returning herewith the above-referenced document . to you, and I ask that you direct all correspondence regarding that claim directly to Ms . Booze . Please do not hesitate to contact me should you have any questions regarding the foregoing. Very truly yours, LAW OFFICE OF THOMAS R.R. ELFEL Thomas R. Woelfeli Enclosure. y � yy r. a N ti .I o n ul U. Cj . Q m•x 0 LP LA tp - (,St o cn U) 0 1 _ UJ S4 >, OM "i > O 41 M - t ;Y S4 U N td 44 U N N O Rf -ri G 23 S4 CU -14 O O Ln b }' Cil U 1-0 '51 p'? y.7 �.y d rn o n P4 >4 Ga 4 H W(r� u � z it �x O u7 3 IF � LO Ch O W U U)O N a ' y y r- � N 1211 � `--A N � Ln ON t{1 N v 4 f PA14 � U s� b� Y " Y ' R .aGo a waw o p, C4) Off', . H N O1 a.to ax°o `� r CLAIIv1• BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 09, 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 V Supervisors. (Paragraph IV below), APR 0 6 2006 given Pursuant to Government Code AMOUNT: UNKNOWN Section 913 and 915.4. Please note all IQ UNTY COUNSEL "Warnings". CLAIMANT: RICH ALBRIGHT MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED:; APRIL 06, 2006 ADDRESS: 71 JANIN PLACE BY DELIVERY TO CLERK ON: APRIL 06, 2006 PLEASANT HILL, CA 94523 RECEIVED THROUGH FAX BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, r Dated: APRIL 06, 2006 By: Deputy It. FROM: County Counsel TO: Clerk of the Board of SLIfervisors (v"This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: -r � By: MC Deputy County Counsel III. FROM: Clerk of the Board I TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911.3). IV. POARD ORDER: By unanimi us 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. Datedl7Gby 0 9 04iW4 JOHN CULLEN, CLERK, By Deputy Clerk WARNI (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personally served or deposited ur the mail to file a courtaction 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 MAILINGI I declare under penalty of perju4 y 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- JI-IN CULLEN, CLERK By Deputy Clerk 04/06/2006 08: 58 9256857295 CONCORD COLLISION PAGE 02/04 sHri ub-2N�J5 09:26 CCC RISK MPNNGMENT 925 335 1421 P.E2 BOARD OF ,SUPERVISORS OF CONTRA, COSTA C,6LTATY INSTRUCTIONS TO CLAIMANT A. A claim reiatine, 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 no: later thann one year after the accrual of the cause of action (Gov. Code § 911,2.) B. Ciaims must be filed With the Clerlc of the Board of Supervisors at its office in Room 106, County Administration Building, 65 1 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 again more than, one public entity, separate claims must be filed against eacli. public entity. E. Fraud. See penalty for fraudulent claims,ims, Penal Code Sec. 72 at the end of this form. ►►•r•Ne•a•rfar•••aRe e• l��•••R•Rpertf.sf�ee•[s•rM�•i<t'�••Rme�•[r■•11•r•4■rrMc•ri•1 RE: Clain By: Reserved for Clerk's filing stamp RECEIVED Against the County of Contra Costa or ) =APRO06 District) CLERIC BOARD OF SUPERVISORS (Fill lir the name) CONTRA COSTA CO. The undersigned claimant be=bv des clma m against the County of Contra Costa oz the above-named district in the sum of$ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) %M�PJa.447 14qtee r/ /!'—d 2oG-K 6� .arPnox�...►m; �r� '�:3prv, 2. 'Where did the damage or injury occur? (Include city and county) SE•4 V- c.R tck- RD, —.+CAA` .<�4 4.-v " ✓A�. Y a P-a sG M R h^7 M.467,-ep-/0R-N4A $Itam 60N'r X-Q tot�,o Co• �S) 3. How did the damage or injury oocur7'(Give full details;use extra paper if required) 4. What particular act or omission on the part of county or district officers, servants, or employees caused the 'jury or damage? no o . 5 What are the names of county or district officers;servants, or employees causing the damage or injury? ,,,,/q 04i'06,'2006 0o: 58 9256857295 CONCORD COLLISION PAGE 03/04 o. Hn UriLri 925 335 1421 P.03 6. why damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attache two estimates for auto damage.) . 're agra..+ r� Cs7.^�A'rr �•!s v.e., R,..ss by ..e rw-S T 8 '0 rM CIL ee..P^. b I r1r. a,s...Aad- 'rW I.e•'a e,e.— ""f-IM- QMs .,.rerr vwor'iFde. .�rT sFWr_I re. .rrr r-r wevccc 7. blow was the amount clzizned above computed? (Include tlae estimated amount of any prospective injury or damage,) 8. Names and addresses of witnesses,doctors, and hospitals: (92s) ?a8=,ngSz - ta4ssE.xe/e /a +JCHf�a C, 9. hist the cxpenditures you made on account of this accident or injury: D�/ TTIvIEAM OUIvT {{1R{RRt.I{RR{{R[[{R■l{{Its xRRl lx R{{/.[[[[[{•RR{[RBBB\..{[[[\\R1R[[{R[Rx[{RRa M{rIRR WWI } .(kv. Code Sec. 910.2 provides "Tbe claim shall be signed by the claimant or by some person on his SEND NOTICES TO; (Attomev)_ Name and address of Attorney ) ) {C�aiman�t's Si tvxe} } (Address) 11 Telephone No. )Telephone No��a2/ 9.s' a R.{tRa[RtRRt[[Rxi■{{R}1{i. ffR{RRRRR{RxR■•R[R{tax's RR RR 0ti1RR{{RR{RRRxR RR wo[.{e.0i{\■R1 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 Califoraia Public Records Act. (Gov. Code, 59 6500 of seq.) Furthermore, any attachments,addendums, or stupplements attached to the claim forte, including medical records, are also subject to public disclosure. R v■{R R R R r s{R R R{{R R R{ R{R R R■{.R R R R{.R R{{R[R{h Env 0►0R{R R R{u R{{R R-a l R R v R{R R R{{R R e R R{R R x i NOTICE: Section 172 of rhe Penal Code provides: Evers,person who,with intent to defraud; presents for aliowanco or for payment to any state board or of.Eic ez. ar to any county, city, or district board or ofi'icer , authorvmd to allow or pay the same if genuine, any false or fraudulent claim, bill, account va'ache7,, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a finc of not exceeding one thousand dollar's ($l,DD0.00), or by both such imprisonment and fine, or by irrlprisorment iz; the state prison; by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. TOTAL P.03 0 9256857295 CONCORD COLLISION 7PAGE 04/04 04/06/2006 0��.:y58 iN. I � Deals an Wheels o / 1775 Concord Ave Concord, CA 94520 Whe Bus' (9251 82.7-0816 Fax: i925) 827-0792 , Quote #127 www-dea lso nwheets925.co m I Wednesday, March 22.2006 Rich Albright � Primed 21 4:12:50 PM nn Concord CA. 94520 � Wednesday, March J2.2006 MAKE &MODEL MILEAGE LICENSE NO. PHONEj REP CS PO# TERNS 1497,Ford,Mustang Gl' 19700 5DSA.564 975 928-0195 I,lelf wlayn rash VIA7 _ TORt7QE E: R;ly TZE TRAN'30,S510N- i CbLOR PROD DATF I LALP4?XVVF14tilb4 I I I �AIALOG UESCRIf�TIO.N QTY I PARTS j LABOR DISC FE'F j YOTAL1 Code i Out' hiller sppd:>llies six 17 180I 5 a 1 580.00 5580 00 C1h+ hide!speciatlties slr 37 18x i0.$ 1 560,00 5580.00 Vap Mount&Computer Spin Balance Passenger Tire 2 15 50 $31.00 Welcome, We appreciate your business. PAID BY Parts $1,160.00 Taxable 51.160.00 Rich Albright Labor 531.00 Non-Taxable $31.00 Freight $0.00 Tax n95.70 Other $0.00 FET $0.00 Estimate f $1 ,286,70 i All prr S 9nd lito, w Uranl^eC for Amor-h.5 rr ICXI mil,s,WI11/haver r01n9:flrl It vehicle i£dlSMarlle,far n< ealon Afltl yon rhme not 11!),,vn n wwre 19I[or urilirin.y6l'.4hlrle 4111 1._ -A..(.art,. V0,nin Inn a wnrking5 7N,o 2 vp.w d_.fi41. 4nwneer.Whi,*Je may MI op"'m pmporly dun Io d-1e%1 nar1.. I&mm not n:.Pcnnit Io Sir pert.,II m hrem poor,(L.. Ii 1 I I Prices do not reflect applicable sales tax. F age 1 0; 1 925GO57295 Q�-%'06/2006 08:58 9256857295 CONCORD COLLISION PAGE 01/04 �J c �"q A.. J V' CLAIM n J BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 09` 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 DS upervisors. (Paragraph IV below), iven Pursuant to Government Code AMOUNT: $24,000.00 APR 10 2006ection 913 and 915.4. Please note all "Warnings". CLAIMANT: MARY A. STAUDT COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: APRIT 10_ 200h ADDRESS: 566 LA VISTA ROAD BY DELIVERY TO•CLERK ON: APRIL 10, 2006 WALNUT CREEK, CA 94598 , HAND DELIVERED BY MAIL POSTMARKED: FROM. Clerk of the Board of Supervisors TO: County Counsel Attached is a•copy of the above-noted claim. JOHN CULLEN, er Dated: APRIL 10, 2006 By: Deputy I1. FROM: County Counsel TO: Clerk of the Board of Su ervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: N i3P 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 BOARD ORDER: By unanimous vote of the Supervisors present: (t 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: a JOHN (CULLEN, CLERK, By Deputy Clerk WARN (Gov. code section 913) Subject to certain exceptions,you have only six(6)months from the date this notice was personalty served or deposited in the mail to Men court action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: /0, 09046 JOHN CULLEN, CLERK By eputy Clerk O, 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 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 gol erred by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By: Reserved for Clerk's filing stamp ,-�— RECEIVED APR1 u 2006 Against the County of Contra Costa or ) CLERK BOARD OF SUPERVISORS District) CONTRA COSTA CO. (Fill in the name) I ) J ) The undersigned claimant hereby m es claim against the County of Contra Costa or the above-named district in the sum of$' 000 °� and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) OC-bbe_r 10, )-005J 10 30 A-I 6 /I ; y 5 2. Where did the damage or injury occur? (Include city and count �,(fard: 3+ree k 'MVM- hi`ez ¢off, WiiJ�� 7cic�a �- oCvrred on �- GIA -1 1 3. How did the.damage or injury occur? (Give full details; use extra paper if required) �d on st�u( k- Co,1-fiul'✓l�2 �rji^j ` urle Ven CoIncre- , I-w c� -F-(f i" -� cin o!- �- A ( j- - 5(ah5 � i���� �re�I. .��.. t���nc�. 4. What particular act or omissibh on the part of cot4ty or district ocers, servants, employees caused the injury or damage? C �oin ��S ,� �-�` 5� � Idp lks � Fled- -c _ e da F-Q1 tocLrl , 1"w Ind h, M.a.I-� -k, Seer Sf-6'ee :S 5 What are the names of county or district officers, servants, or employees causing the damage or injury? Oo k o w n F . What damage or injuries do yoTautod sulted? (Give full extent of injuries or damages claimed. Attach two estimates fo , ge.) �c sL.r a 7 6 A &)Y -v 5 l 1 f`/ -�o mw a_rM J ��� Q' tl Chc;.\y_S iryt 3c 4-14-, loss C ,Wa_ncQ, aeI8 -P50P it Pri ink 7. How was the amount claimecU above computed? (Include the estimated amount of any prospective injury or damage.) ! r"�6 �p pe_5t or'vl med,Lf,Q 6. +ef cc-re�- j �}„r2 6. -fer 8. Names and addresses of witnesses,doctors, and hospitals: 9. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT ..............r..r..r.rr.man.............r.r rr rrrrrrr manrrrrrrrrrrrr rr■■rr r. so Emmons 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) ) . Name and address of Attorney ) } (Claimants Signature) fr j 5( � t-&- Vj's (Address) Telephone No. )Telephone No. 's3by .........................rrr rr r.rrrr.rrr rr rrrr rrr-... ....................... . .......� 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. r rrrrrrra■r■rrrrrr■■rrrrrr■■rr rrrrr rrrrrrrrrrrrrrrr a rr■■rrr■rirrurrr rrrrr■ �...rrrr� 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, o i 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. -.a i! CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY r, BOARD ACTION: MAY 09, 2006 V� 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 �'J D Supervisors. (Paragraph IV below), APR 1 2006 given Pursuant to Government Code AMOUNT: UNKNOWN Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings". CLAIMANT: EL;ORES JACKSON MARTINEZ CALIF. ATTORNEYUNKNOWN DATE RECEIVED: APRIL 10, 2006 ADDRESS: 73 LOUANN PLACE BY DELIVERY TO CLERK ON: APRIL 10, 2006 BAY POINT, CA 94565 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, ern Dated: APRIL 10, 200b By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors I Otis 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. T1 ie 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: ��r 3- By: MCjqA;�� 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). IV./BOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: / d /&JOHN CULLEN, CLERK, By Deputy Clerk WARNIN (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 nail to file a coact 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 hnniediately. *For Additional Warnurg See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of pen juiy that I am now, and at all times herein mentioned, have been a citizen of the United States, over age I8; and that today 1 deposited in the United States Postal Service ill Nlartinez, California, postage fully prepaid a certified copy of this 130a1-d Order and Notice to Claimant, addressed to the claimant as shown above. Dated: /d JOHN CULLEN, CLERK By Deputy Clerk TORT CLAIM CALIFORNIA CMI,CODE SECTION 914 ET. SEQ. Claimant: Ed Jackson Elores Jackson 73 Louann Place RECEIVED Bav Point, CA 94565 APR 1 0 2006 Notices to be sent to: CLERK BOARD OF SUPERVISORS Ed Jackson CONTRA COSTA CO. Elores Jackson 73 Louann Place Bay Point, CA 94565 Basis for Claim: On October 11, 2005, Claimants were residing at 10 Highway Avenue,Bay Point, CA. On October 11, 2005, officers of the Contra Costa Sheriffs Department entered the Claimant's home without permission, located at 10 Highway Avenue,Bay Point, CA. Sheriff claimed deputies visit was in response,to a call from Protective Services regarding James Clay. Claimants were the caregivers of James Clay, a disabled man with limited mobility Protective Services contacted claimants regarding James Clay's blood pressure. Claimants were returning to their residence to transport James Clay to the hospital. Present at the scene were 4-5 iofficers, including one female officer; the claimants, Ed Jackson and Elores Jackson; James Clay; and other residents of the household, Edwin Jackson,Raymond Johnson,Priscilla Lewis, and Fanny Lewis. Claimant Ed Jackson was given permission by one of the officers to go into the kitchen for a drink of water. As the claimant was walking to the kitchen he was then jumped on by one the officer and forcefully restrained by the officer. The officer grabbed him by the neck, twisted his arm and threw him down and held him down with all of his weight on Ed Jackson's back. v The female officer pushed and threw claimant Elores Jackson down to the concrete ground. When auestioned byi Elores Jackson about being pushed, female officer threatened to do more than push her. Claimant Ed Jackson was then handcuffed and placed in the back of the patrol car. cf The wrongful conduct with regard to Claimant consisted among others of: • Violation of constitutional rights under 4th Amendment, I"Amendment, 14th Amendment, entered home without legal justification, committed battery upon them without any justification, used excessive force,violated rights to privacy threatened physical harm. Conduct was motivated due in part to their race. Damages: Claimants have suffered out of pocket medical expenses, loss of income, pain and mental suffering and emotional distress as a result of the conduct stated above. Claimant Ed Jackson continues to suffer to his neck, arm, and shoulders from the actions taken to restrain him. Claimant Elores Jackson suffered injuries to her right knee, right side,back, and neck from being thrown down onto the concrete ground. She must now use a cane. Dated: By Elores Jac on Claimant I fY CLAIM n BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: MAY 09, 2006- Claim 006Claim 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. I ) you is your notice of the action taken on your claim by the Board of (S Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: UNKNOWN APR 10 2006 Section 913 and 915.4. Please note all COUNTY COUNSEL "Warnings",. CLAIMANT: ED JACKSON MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 10, 2006 ADDRESS: 73 LOUANN PLACE BY DELIVERY TO CLERK ON: APRIL 10, 2006 BAY POINT, CA 94565 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of SupeMsors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, rl Dated: APRIL 10, 2006 By: Deputy II. FROM: Comity Counsel I TO: Clerk of the Board of Supervisors ( lis claim complies substantially with Sections 910 and 910.2. ( ) This Claire 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). O Other: Dated: 44-13"0�a By: /��Z�jt.� Deputy County Counsel I11. 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. OARD ORDER: By unanimous vote of the Supervisors present: _ (1 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. Date& of, JOH CULLEN, CLERK, By Deputy Clerk WARNI (Gov. code section 913) Subject to certain exceptions,you have only six(6)months froth 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 Orderand Notice to Claimant, addressed to the claimant as own above. bated:A/" /0. �,6 JOHN CULLEN, CLERK By Deputy Clerk TORT CLAIM CALIFORNIA CIVIL CODE SECTION 910 ET. SEQ. Claimant: Ed Jackson Elores Jackson �7CkOSTIA 73 Louann Place Bav Point, CA 94565 Notices to be sent to: CLERK C Ed Jackson Elores Jackson 73 Louann Place Bay Point, CA 94565 Basis for Claim: On October 11, 2005, Claimants were residing at 10 Highway Avenue, Bay Point, CA. On October 11, 2005, officers of the Contra Costa Sheriff's Department entered the Claimant's home without permission, located at 10 Highway Avenue,Bay Point, CA. Sheriff claimed deputies visit was in response to a call from Protective Services regarding James Clay. Claimants were the caregivers of James Clay, a disabled man with limited mobility Protective Services contacted claimants regarding James Clay's blood pressure. Claimants were returning to their residence to transport James Clay to the hospital. Present at the scene were 4-5 officers, including one female officer; the claimants, Ed Jackson and Elores Jackson; James Clay; and other residents of the household, Edwin Jackson,Raymond Johnson, Priscilla Lewis, and Fanny Lewis. Claimant Ed Jackson was given permission by one of the officers to go into the kitchen fora drink of water. As the claimant was walking to the kitchen he was then jumped on by one the officer and forcefully restrained by the officer. The officer grabbed him by the neck, twisted his arm and threw him down and held him down with all of his weight on Ed Jackson's back. V The female officer pushed and threw claimant Elores Jackson down to the concrete ground. When questioned by Elores Jackson about being pushed, female officer threatened to do more than push her. Claimant Ed Jackson was then handcuffed and placed in the back of the patrol car. The wrongful conduct with regard to Claimant consisted among others of • Violation of constitutional rights under 4"'Amendment, I"Amendment, 14"' Amendment, entered home without legal justification, committed battery upon them without any justification, used excessive force,violated rights to privacy threatened physical harm. Conduct was motivated due in part to their race. Damages: Claimants have suffered out of pocket medical expenses, loss of income, pain and mental suffering and emotional distress as a result of the conduct stated above. Claimant Ed Jackson continues to suffer to his neck, arm, and shoulders from the actions taken to restrain him. Claimant Elores Jackson suffered injuries to her right knee, right side, back, and neck from being thrown down onto the concrete ground. She must now use a cane. Dated: !� lD y Ed ack- Claimant CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY r BOARD ACTION: MAY 09, 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 CLAIM AGAINST CONTRA COSTA COUNTY (Paragraph IV below), AND ANTIOCH POLICE DEPARTMENT D t to Government Code AMOUNT TO BE DETERMINED A IT ction 9 nd 915,4. Please note all AMOUNT: A LATER DATE APR , Q��,g CLAIMANT: ANDRE L. LONG COUNTY COUNSEL MARTINEZ CALIF. ATTORNEY: UNKNOWN DATE RECEIVED: APRIL 10, 2006 ADDRESS. 2408 MIMOSA COURT BY DELIVERY TO CLERK ON:APRIL 10, 2006 ANTIOCH, CA 94509 HAND DELIVERED BY MAIL POSTMARKED: FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. APRIL 10, 2006 JOHN CULLEN, C r Dated: By: Deputy II. FROM: County Counsel I TO: Clerk of the Board of Supervisors ( "This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). 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: j4-i eA-c(, By: Deputy County Counsel I1I. 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. OARD ORDER: By unanimous vote of the Supervisors present: (✓� This Claim is rejected in In 11. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated./hie JAdZ JOHN CULLEN, CLERK, ByDeputy Clerk WARNI (Gov. code section 9113) 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 coma action on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claiinant, addressed to the claimant as shown above. Dated:/7�/D��d JOHN CULLEN, CLERK By Deputy Clerk BOARD OF SUPERVISOR OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A Claim relatirn 1 to a cause of action for death or for injury to person or to personal property or growing cn ips shall be presented not later than six months after the accrual of the cause of action, A clai m relating to any other cause of action shall be presented not later than on year after the accru al of the cause of action. (Gov. Code §911.2,)- B. Claims must be files I 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 agair st a district go vemed by the Board of Supervisors, rather than the County, the name of#a 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 per alty for fraudulent claims, Penal Code Sec. 72 at the end of this form. *�wfw,-: �x:r:s�.m,xaxre:.:xxrww*+wwwwwwwwwwwwwwwwww+w+w+nF+„t,twry. Reserved for Clerk's filing Stamp Re: Claim By: ) Andre L. Long Against Contra Costa i,ounty and ) AP Antioch Police Departr lent, ) R 1 02006 �LERh 90ARD CENTRA CLOS q Co. OL7SpRS The undersigned clairr ant hereby mlakes claim against the County of Contra Costa and the Antioch Police Departr lent, 1. When did the d amage or,injulry occur? March 10, 2006. 2. Where did the;lamage or injury occur? On route from Antioch Police Department, Antioch, Califoi nia to Martinez County Jail 3. How did the da rage or Injury occur?.The Community Service Assistant who was transporting Cl;dmant slammed on her brakes while transporting Claimant; Claimant was not wearing a s eat belt, although he asked to be strapped in prior to their departure. As a result of the Community Service Assistant slamming on her brakes, Claimant was thrown into the metal dividing door that separates the inmates from the officials, as a result his nose Nas broke, his back injured and he sustained injuries to the right side of his head. 4. What particular act or omission on the part of the county or district officers, servants, or employees cau aed the injury, or damage? (1)The Commr inity Service Assistant/Driver failed to fasten Claimant in a seatbelt prior to leaving the f ntioch Police Department. (2)The Commi inity Service Assistant failed to immediately obtain medical care for Claimant_ The Community Service Assistant took Plaintiff to the Martinez County Jail, Claimant infom ied her that He was unable to get out of the vehicle and that he was lightheaded, di:zy and needed medical care. The Community Service Assistant left Claimant in the vehicle and returned with approximately four Officers and a nurse. The Officers told Cl aimant to come out of the vehicle, Claimant told them he could not because he wa s injured, they in return told Claimant either he come out or they were coming in to gr;t him. The Officer's ignored the fact that the Claimant was obviously injured, implying that"he just has a bloody nose and was very physical to Claimant while escorting him ii aside the Martinez County jail. While at the Martinez jail, a nurse came in and said that Claimant needed to be taken to the hospital. Claimant was placed back in the vehicle, "ac ain" not secured by a seatbelt and taken to CCC Regional Medical Center. (3) After being taken to the(hospital, Claimant had to wait 5 1/2 hours for medical care. (4)While waitir g for medical treatment, Claimant was handcuffed and left on a gumey in the middle of a hallway. The blood from his nose had dried up so severely that Claimant was unable to breath out of his nose. (5) Prior to heir g transported to Martinez County Jail and after claimant received medical care, the same Community Service Assistant refused to put the seat belt on Claimant. Claimant aske( if he could have the seat belt on, especially since the reason he was initially injured,vas due to her failure to properly secure him in the seat, but for the third time she, outric ht refused. When Claimant arrived at the Martinez County jail, the second time, T ie nurse at the jail gave Claimant an ice pack without covering it and rudely told Clai rant either he take it as it was or throw it away. The ice packs are clearly marked that they are not to be placed directly on the skin, they need to be wrapped in sor ie sort of protective covering prior to applying directly to the skin. S. What are the n ames of cou I ty or district officers, servants, or employees causing the damage or inju y. Claimants to provide this information at a later date, he is in the process of obtr ining same and retaining legal counsel; however, the County has a record of all en ployees who Claimant encountered on this date. 6_ What damage ,)r injuries did your claim resulted? Broken nose, back spasms, and severe headac ies. Claimant has been off work since this incident occurred. The monetary amot int is undetermined at this time; Claimant is still under the doctor's care. 7. How was the a nount claimed above computed?Amount to be determined at a later date. 8. Names and ad,tresses of witnesses, doctors, and hospitals: (1) Antoinette long, Claimant's iSpouse. (2) Dr. Jarr es Edward, Claimant's Treating Physician a 9. List the expend tures you made on account of this accident or injury. DATE TIME AMOUNT To be provided at a later date. irxirerur:rrrxrxrrxxxaxrxexexrrrarrsrterrrr+rerreime:wxwrerxrrxrtrrmrere:sere:errrarx+Re++x�arxr+xxrer+e:rarrrmrxe Gov. Code Sec, 910.2 provides"The claim shall be signed by the claimant or by some person on his behalf." SENO NOTES TO: (Attoi ney) ) Name and address of Atl xney ) Claimant Is the process of retaining ) (Clai mb nt ignature) Legal Counsel. ) 2408 Mimosa Ct. (Address) ) Antioch, CA 94509 Telephone No. ) Telephone No. (925) 777-9849 µarrrrrarraar+rrrrrrraaNaaa mrtrrrrrrrrrrrrssrersrrrrrrrsrrerrsaerAxrwrxrkxkrWrArw,NAkikAararr PUBLIC RECORDS NOTICE: Please be advised that tt is claim form, or any claim filed with the County under the Tort Claims Act, is subject to public diSCIOSL re under the California Public Records Act. (Gov. Code,§§ 6500, et seq.) Furthermore,.any attachr lents,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. swsssswara,e,er.A.i#aAkhMf raaaaraaaaraarrrrerrrrre rr+rrsreseaeseee+.zwawee.�MA.Y#MA+�kiNrrrsrri�rr.Wrrrrrr NOTICE: Section 72 of the Pena!(:ode provides: Every person who, with i stent to def I ud, presents for allowance or for payment to any state board or officer, or to any county, ;sty, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent cl aim, bill, account voucher, or writing, is punishable either be imprisonment in the County jail for a period a not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both s ich imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousa nd dollars($10,000.00),or by both such imprisonment and fine.