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MINUTES - 03081994 - 1.15
CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County. or District governed by) BOAR_ D ACTION the Board of Supervisors. Routing Endorsements. ) NOTICE TO CLAIMANT M CV 8 1994 and Board Action. All Section references are to The copy of this document mailed to you s your notice of California'Government Codes. ) the action taken on your claim by the Board of Supervisors_ (Paragraph IV below), given pursuant R-o : erinmer�N CodeVj Amount: $25,00.00 + Section 913 and 915.4. Please note rni.ngi---.� CLAIMANT: CAVTRFTT, Edward - C FEB 8 ATTORNEY: Laura Ajlouny Date received �- _ --COUNTY COUNSELJacoby & Meyers Law Offices BY DELIVERY TO CLERK ON February �i1ARTINEL CALIF. ADDRESS: 100 Bush Street 4700 San Francisco, CA 94104 BY MAIL POSTMARKED: February 3, 1994 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pp BB NN DATED: BIL DeputyLOR, Clerk .Il. FROM: County Counsel TO: Clerk of the Board of Supervisors VThis claim complies substantially with Sections 910 and 910.2. . ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: -e-&4LL g 9 y BY: e! beputy County Counsel �i . J_ U (/ 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). ]V. BOARD 0 ER: 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 ante in its minutes for this date. Dated: PHIL BATCHELOR, Clerk. Byf 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 &. 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 ceder 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 1 deposited in the Unitedtates stat 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 A i qiq BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator a+I 1 I EDWARD CANTRELL I. Settlement Letter (w/Attorney Designation) II. Claim Form III. Fire Dept. Report IV. Medical Providers A. Regional Ambulance B. Brookside Hospital C. North Oakland Medical Center V. Medical Specials A. Regional Ambulance B. Brookside Hospital C. North. Oakland Medical Center VI. Prescriptions JACOBY& MEYEKS LAW OFFICES PERSONAL INJURY UNIT 100 Bush Street,Suite 700,San Francisco,CA 94104 415/399-8951: FAX:415/399-1939 February 2, 1994 Clerk of the Board of Supervisors Contra Costa County County Administration Building 651 Pine Street, 1106 Martinez, CA 94553 Re: Our Client Edward Cantrell Date of Loss: 10-16-93 Location 26th Street (between Emeric and Pine Avenue) San Pablo, California Dear Sir or Madam: Our office represents Edward Cantrell, who sustained injuries in an accident caused by. the negligence of the County of Contra Costa. Enclosed please find our demand package. Every effort has been made to provide you with all the information necessary to evaluate his claim. Liability On October 16, 1993, at approximately 1:00 a.m. , Edward Cantrell was taking a walk in his neighborhood with two friends. As he was walking on 26th Street (between Emeric and Pine Avenue) which was darkly lit, his left foot became caught in an open manhole. The depth of the manhole went up to his knee, and was he unable to dislodge himself. As a result, the San Pablo Fire Department and ambulance assisted in removing Mr. Cantrell's left -leg from the open and uncovered hole. Mr. Cantrell was rushed to the hospital by ambulance because he was experiencing extreme leg pain. Damages Brookside Hospital Immediately after dislodging Mr. Cantrell's leg from the exposed hole, he was rushed to Brookside Hospital. He was examined and was found to have tenderness over the left malleolus, injury of the left ankle. X-rays were taken which, fortunately did not reveal any fractures, but some soft tissue swelling was noted. He was diagnosed with left ankle strain. His ankle was wrapped with an . ace bandage, and was given crutches and Vicodin for pain. He was also advised to rest and elevate his left foot, and follow up with the Richmond Clinic in one week. We um MCMC d peper. On November 24, 1993, Mr. Cantrell presented himself again to Brookside Hospital. He was suffering from neck and back pain since this incident on 10-16-93. He was given a soft cervical collar and Flexeril for pain. North Oakland Medical clinic On November 4, 1994, Mr. Cantrell presented himself to North Oakland Medical Clinic. He was suffering from neck and back pain, left knee and ankle stiffness and pain. The pain was aggravated by weight bearing, walking, and daily living. His neck and back pain 'was a constant and mild pain that became moderate after prolonged periods of lying and sitting. He had taken Tylenol and Flexeril that had been prescribed by Brookside Hospital, but he still had symptoms. He also had radiating pain from his left buttock to his left thigh with swelling aggravated by prolonged standing or walking. Some relief was reached by rest, hot packs, and medications: He had difficulty sleeping and often awoke with neck and back pain and stiffness. Examinations revealed edema and tenderness in the anterior lateral forefoot and stress on the lateral collateral ligament. Palpation revealed tenderness over the dorsal second, third and fourth metatarsal. There was also tenderness and palpation of the musculature in the connected tissue in the right lower .back to the posterior pelvis and iliolumbar. His left knee has moderate tenderness and contusion- over the left pretibial tubercle that was consistent with contusion. He was diagnosed with cervical spine musculoligamentous sprain and strain. lumbosacral strain. superimposed on degenerative arthritis. left knee wrenching injury with contusion. lateral collateral ankle strain with direct ;Closed trauma to the anterior forefoot, doubt fracture. A treatment program of physiotherapy to the cervical spine (static traction and infra-red heat and stretching range of motion exercises) , physiotherapy to the low back (stretching range of motion exercises) was prescribed. He was given an ankle brace, hydoculator pack, home care booklets. Motrin and Parafon Forte was also prescribed for pain. On November 10, 1993, Mr. Cantrell presented himself to North Oakland Medical Clinic. He continued to use a left ankle, knee, and low back brace, and cervical collar for support. He also continued to use crutches in order to keep weight off his left knee and ankle. He stated that to be off the crutches for more than 20 minutes tended to aggravate his neck pain and stiffness. He still awoke in the middle and night with difficulty sleeping. Examinations were performed and he was found to have less contusion and effusion at the left ankle. The left knee continued to be tender at the lateral joint space. He was advised to rest, continue taking his- medications and physiotherapy. On November 17, 1993, Mr. Cantrell was re-examined for his progress and treatment. He continued to suffer from left ankle and forefoot pain and stiffness. He also continued to use crutches, a cervical collar, and a knee brace. His back showed improvement after weeks of physiotherapy, taking medications, and a home care program. On December 10, 1993, Mr. Cantrell was re-evaluated for his final treatment. His left knee was stable. His low back and cervical spine revealed some restricted motion. The final diagnosis for Mr. Cantrell was cervical and lumbar spine musculoliagamentous strain, mild aggravation of the low back. left knee strain, and left lateral collateral ankle strain and contusion. Mr. Cantrell had reached a maximum level of treatment and care to his pre-injury status. He was advised to continue the use of his pain medications, perform general body strengthening and conditioning such as walking daily. Prescriptions Mr. Cantrell also incurred expenses for medications totaling $ 41.29. Medical Specials Name of Provider Amount of Bill Regional Ambulance $ 567.10 Brookside Hospital 631.98 North Oakland Medical Clinic 3,183.00 Payless Pharmacy 20.90 Sav-On Pharmacy 20.39 Total Medical specials $ 48423.37 Conclusion Edward Cantrell has: suffered the consequences of an accident for which he was not at fault. Mr. Cantrell is entitled to compensation not only for the foreseeable results of the injury, but for the aggravation of existing conditions that are adversely affected. Considering the nature and extent of our client's injuries, we are prepared to recommend that he accept $ 25,000.00 to settle his claim against the County of Contra Costa. Very truly yours, JACOBY4AjVy LAW OFFICES Laura Attorney at Law LNA/whh IJACOBY PERSONAL INJURY UNIT 100 Bush SUM,Suite 700,San Francisco,CA 94104 41!V399.895t:FAX:4151399-1939 Pursuant to Section 2695.2 (c) of the California Code of Regulations, Title, 10, chapter 5; 1 authorize the Law offices of Jacoby & Meyers to handle my claim for the loss which occurred on to This authorization shall be valid for only one year from the below date unless renewed or revoked by the undersigned. Any and all prior authorization are hereby revoked by the undersigned as of the* date of this authorization. or ign-ature Printed Name Date 11 We use rsqdod popm. Chaim to: BOARD OJWPERYISORS OF CONTRA- COSTA COUS INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops'and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. 'Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County; the name of the District- should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By } Reserved for Clerk's filing stamp Edcuad' Cao, -ell RECEIVED } Against the County of Contra Costa ) FB 7 or } District) CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ aS,000 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) . N o2b'14-4Vet,,9, Che-6jem-1 z a-not Jam.`see es �Si! A66to G . ---__________4._.__ 3. How did the damage or injury occur? (Give full details; use extra paper if required) Afr, L'�►n�re<( �s *J4 t ki/t y � Wif4s 4too �r�:t,.clf Asoa-,cs' W (k:Z��f' r- -,*tie too.-/e% l.�f S°fnee`t� 4ee ire ;4%? IeVV c-f wt aft( y�e�ll n G rl p!l P r 1 na of ko 7p /�GI"•rir.l2 Ci.Gs G.e r� *0%0 S-,^ / 466 4:1— jctG(.e 7d','s' a�dce.�.. /ri - lir? 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? - vey lr g en-f A4-ai A fig n-6 CC— = - (over) What are the names of c3unt 'or district officers servits or employees causing 5. Y , ' the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. der UiCd Sfii'a,✓1 Qcact 6 41&%be" S+--a;N 7. How was the amount claimed above computed?~(Include the estimated amount of any prospective injury or damage.) N4 8. Name and addresses of witnesses, doctors and hospitals. f( 4/s phi �SSCS WiMa", al ove- Bice_ �ro�s-de �OSi /34 ! � . 6s ✓ W 7.ov v Son P16/0, s'an R-41o, e4 Sar., W.6"a* CSIo) z3.r-7eae> ------------7----------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT � EX cess � X10, oao Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or me Perwm on his behalf." Name and Address of Attorney �o— N• (Cl—airbhtls gnature 041 i� ,sash -. , �� 7� lOD 13wsl� Sfi�e `# 700 Address C.4 9410� Telephone No. � �s� � s� Telephone No. NOTICE Section 72 of the Penal- Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by-a fine_of not exceeding ten thousand dollars ($10,000,. or by - both such imprisonment and fine. _ �rK� �Go�oto✓i� ��.Q��G�d, C Silo) ged Blest COur,ty Fire District/07045 1 NC I DEN"i 93--012514--00c:, PAGE NO. 1 .INCIDENT REPORT :SECTION A -- COMPLETE FOR PLL INCIDENTS . . . Al thru A4. . . F D I D 017045 INCIDENT NUMBER 93012514000 MULTI AGENCY NO DATE 10/16/93 DISgpTCH 0110. 00 ARRIVAL 0114. 00 END 0131. 00 ADD DAYS 00 FIRST IN COMPANY 70 DISTRICT 70 SITUATIONS F=OUND 3;= AUTOMATIC OR MUTUAL AID 8 METHOD OF ALARM 7 WEATHER 1 AIR TEMPERATURE 000 PROPERTY MANAGEMENT . . . A5 thru All. . . INCIDENT ADL"KESS/LOCATION 1526 26TH STRE=ET IFO ROOM/APARTMENT ZIP CODE 94306 CENSUS 0000. 00 RESPONDED: CAREER 0003 VOL 0000 ENGINE 001 TRUCE; 00 RESCUE/MED 00 OTHER 00 . . . Al2 thru A13. . . GENERAL PROPERTY USE 96 SPECIFIC PROPERTY USE OCCUPANCY TYPE :STRUCTURE TYPE STRUCTURE STATUS OCCUPIED AT TIME OF INCIDENT SECTION E - COMPLETE FOR EMS NUr'!i{E=EZ 0:' PA':IENTS 001 HIGHEST LEVEL OF CARE CAPABLE (FIRE/OTHER) 5/6 HIGHEST LEVEL OF CARE PROVIDED (FIRE/OTHER) 5/6 SITUATIONS FOUND 69 TRANSPORTED] BY:: FIRE DEFT 000 PVT AMB (ICY 1 CORONE=R 000 OTTER 000 ECTION' t -- COMPLETE LTE If' OTHER THAN AN FIRE OR HAZMAT ACTIONS TAKEN 31 MEMBER MAKING REPOR"r REVIEWER 25014 F"ANK 25014 FANIF, . SIGNATURE SIGNATURE INCIDENT SUMMARY: Medical emerpentyj patient with his left foot stuck in a hole in the street. INCIDE=NT/F=IRE SUPPLEMENTS ALARM TIME 0110. 00 ALARM TYPE 7/telephone tie into FD 70NI_ 1 STATION' 700 SH I E=T r, ;lA�' No. PR0►'E=RTY VALUE 0000000 )O C011, TENT VALUE 000000000 CONTINUED. . . West County Fire District/07045 INCIDENT `J3-i12514--i Q0 - PAGE NO: 2 INDEX OF 901 CODES A SITUATIONS FOUND 3 - RESCUE, EMERGENCY MEDICAL CALL -. 32 -- EMERGENCY NEL'I CAL CALL AUTOMATIC OR MUTUAL A I D 8 •- NO AUTOMATIC/MUTUAL A I D METHOD OF ALARM 7 - TELEPHONE TIE-LINE TO FIRE DEPARTMENT WEATHER 1 CLEAR PROPERTY MANAGEMENT 3 - CITY, TOWN, VILLAGE OR OTHER LOCAL GOVERNMENT GENERAL PROPERTY USE - SPECIAL 96 MOTOR VEHICLE TRANSPORTATION SPECI=IC PROPERTY USE BUILDING CODE OCCUPANCY TYPE STRUCTURE TYPE STRUCTURE STATUS OCCUPIED AT TIME OF INCIDENT E HIGHEST LEVEL CAPABLE OF BEING PROVIDED - • IRE 5 - BASIC EEfGtNcr MEnlci_ r Ec ,, :IA;•.y1 HIGHEST LEVEL CAPABLE OF BEING PROVIDED - OTHER R 6 - ADVANCE LIFE SUP O'i HIGHEST LEVEL OF CARE PROVIDED - E=IRE - BASIC EMERGENCY MEDICAL TECHN:CCI 1:N HIGHEST LEVEL OF CARE PROVInED - OTHER u - ADVANCE= LIFE: SUPPORT SITUATIONS FOUND 6 - MISC INJURY RELATED, CONTI HUED 69 -" NOT CLASSIFIED G TYPE:: OF ACTIONS TAKEN 31 RESCUE, SCL _, 7_4JtiE FROM H= _ - 7-ZI-11 West County Fire District/07045 INCIDENT 93- 012514-00ti? PAGE NO. 3 - NARRATIVE -- C0NFIDENI'lAi_ Patients condition upon arrival : On arrival E-70 'Found the patient: in the middle of the street with his left foot stuck in a aper, hole for a water main shut-tiff valve. Patient advised he was walkinrq down the, street and accidentaly stepped into the hole . which wasmissinCj a cover. Occupant at 1526 26th _street advised that the cover had been missinq for alonq time. Specifics on EMS provided : On arrival E--70, assisted by .Aid€. Paramedic 116, removed the patients foot from the hole. Lyon removal of the patient' s foot AMR Paramedics administered first aid. Patient' Es condition upon release: Patient complaininq of pain in his left foot and ankle. Disposition of patient : Patient transported to Brookside Hospital by AMM. List responding companies below. indicates' which c_mp aniE5s w��rkeA. E-70. CEIVING H9SPITAL CONTRA C_° A COUNTT'PRE-POSPITAUCARr%.; RM - ' IELD _ BASE t 1 CC� ' 1 T E 11L_1 1 1�.AGENCY A rn r 1 _RADIO'OR--n— AUTH.� -RESPONSE* i r CALL REG . CALL DIS EN RO E ISI ON SCENE CONTACT EN ROUTE(H) ARRIVE IH) .ME T�' 1Qh A NR,E ___ F' AGE - _ I - .�.-..... w .ter -CATION/FOUND 1'fc'Ft i).�C� `' -gE�"j HOSPITAL �� 4'S - ETA /('t (G) (A) i i1EF COMPLAINT 6 A fL LEVEL OF DISTRESS: NAD r' GLEB MOD SEV A ev-t v rK s-' Aft u Lr I ��,L.� Q r.x-, r ----r------� TRAUMA CRir.-:. .Y. _ (i36S_ eljQJ , IN, n3:P,7-L �,J- `TRAUMA DEST Y- __....__- �_.__ _..... -r•.=a`r"=G ';y, ii+= -TIME T.C.BYPASS Y N F= i CRAMS ! -LERGIES-O.. ._..... ..___--_ _ _— bEC0,M`--- C_P,, )LA--VT • Ito CORCIAOMC3tO-0 � <✓Y1 a,l l >S"r'��'"_51 MVA i HaG� GCS .' tom_ :TALS B/Ptd P _ R _._ CAP/REFILt� ' EMT- _t^'C� Ror_5r S--�:L-c EO VCS IMO 6 7 UALITY < EMT 1 MECH, 1 2 o s s 7 ; ��I T t AiG'`h1 81051.time Ia•6 ' KG RHYTHM 7- — _..-- s FD _i.2 ZC)e_\ '(Y\.C> J e t „I ANAL I I-� VOICE- t= .� FACT •9 10 tt 12 13 14 15 16 17 OC:ALERT X RESP TO CHIC' LOSS OF CON Y PLUM i�L,i,-t C'AM �_ 18 19 20 21 22 23 24 Ktl'D if DIAPHORETIC AR COOL HOT _PQr' nn \- C-,+t' t`j i m•Q pENOEZVOUSWIIO. Y N 1 ;OL"O1:rR�N0 FLUSHED PALE CYANOTIC 4 t-i's V= ' {EAD �AR INJURY _�, T�c';,►tel t ` �"�_�s EN ROUTE ;1RWA ETfNOISY FOREIGN BODY 'r1 �= i�.t r ARRIVED AT -_ RENDEZVOUS SITE_ : 'UPI 4-tiN€ '"S RT_ `�L oTHE,R=- "" -.... T -. RELEASED TO HEC 2._ : LEA FLUID_. — NOSEI~CM�b FLUID 45 �C:�Q VEC ONTENDE TENDER TRACH.MLS_ JVD _ �� HELMET v " � t � SEAT BELT Y N CHE N E TENDER UNEQ " "' �-Z�-�,�./ - _UNG • Q UNEO (� RLES RNCHI WHZES G- \Lt-\ cwt.\ CSP, T t sTARREa LD r 'N ��e� 'C" —''� S7�EER G--�.. ABDOME MO TENDER (+�,.:/ RGD DIST ' r • { - WHL DAMAGE Y N PELVI NTENDER TENDER INCONT BAC YC' D TENDER INJURY i X 1.-f MPH EXTREMITIES:PULSE-ALL�EDEMA INJURY�_ M/ " D3=- �� ��;���� "� EXTRICATIO E GENERAL ASSESSMENT: t.QrL-�-' �t�____ t`+ x h1 :I" �1" I-:z� EBL Q ::rmit,30a 'T31p )MPt WEIGHT 57n I<C-, MiCP EXAM BY: t1 /n -'1 Ak M q Na.,5. �-r- EKG STRIP Y t RELEASED TO BLS: M I A TIME"- :� .- �+ �t 1 nr3 -�I III_, FRM Y CN v l'('• P�M,y 5 --ro f--ti'C1vk Q SF .coke��„+�p r_ e tJ k tJC� : MANAGEMENT: Time Done [nit Response B/P P R rr 9t mii6 o► • ,^..` ' t - REASON FOR PROLONGED SCENE TIME F'KrO IC EMI;, \ Q{= .C'•CS-- ERC.n1 !AQI F`, PRIOR MOVEMENT OR TREATMENT N CODE TO SCENE �'2 SCENE ASSIST.71� ?.C'�t_..• ••-ASSISTANCE•ENROUTE ��"Y"" _ TRANS.M AMBL CbDE j INCIDENT LOCATION/CITY(map Goor./pg.) IV INFUSED �t�.l—T—CC'S PVT.MD - - BASE HOSPITAL/MICN PT PERSON- A '_ �h I `_RAD/DRIVER ItJ00J M INTERN .:SIGN .1 CERT.# 1 l_) SIGN_16.}1- CERT.# [IG SIGN OM GAS,F FRnM MEDICAL RESPONSIBILITIES: I:.refuse medical- care Wand "trans # eyed to-me_.b- Regional 'EASON FOR PROLONGED SCENE TIME x's"Q is z'i n+J or- rico— r-k'xn !-koI - - 'RIOR MOVEMENT OR TREATMENT[ ,�� - CODE TO SCENE ;CENE'ASS!ST. l EtN-•- - ASSISTANCE ENROUTE "' TRANS.TO AMB. Q 1-1r`! CODE 1 JCIDENT LOCATION/CITY(map coor./pg.) ; ' INFUSED CC'S CC'S PVT.MD BASE HOSPITAL/MICN RAD/DRIVER !`'�� INTERN _ GN_ ___. CERT.# aL~ Q SIGN 1 ""' CERT.# ��- SIGN -.r.. RELEASE FROM MEDICAL RESPONSIBILITIES: I refuse. medical care and trans offered to me by Regional Ambulance in so doing relieve th a Costa Codi ty, and the Advanced a Supporta Hos Bpital and physician i i of any further responsibility nature (P,Wi IMF 111ptent a pUdya) Witness— Date ❑ re t0 sign If Ratiec"nab a to Sign State Reason: +� REASON FOR 71FAMILY REQ CLOSEST UNDESIGNATED REROUTE 6 ;CEIVING HOSPITAL/M.D. HOSPITAL SELECTION MD REO. SPECIAL SERVICES TRAUMA CENTER OTHER �Ll5(y Na�� aIf5 fiz l `j( © i f�C�i C ZIP PHONE DOB i .TIENT ADDRESS ICFY) INSURANCE#'S i INDUSTRIAL i Y EMPLOYER RESPONSIBLE PARTY PHONE r )MMENTS: MILEAGE p I BEGIN — 13 , 'q-ADDRESS END I � '� NO,OF PTS. TRIP NUMBER TOTAL ! i e •`�. • .i PAT ACCT# : 61560096 MED REC#: 77-48-19 ADM DATE : 10-16-93 SVC CD: EMR ADM TIME : 01 :38 PT TYPE: E READMIT #: 954669 SRC CD: FC: R 01 :46 10/16/93 ACTIVE OUTPATIENT DEPARTMENT ER VIP: N NAME: CANTRELL, EDWARD L SR SEX M RACE W MS S DOB 12-19-50 AGE 42 ADDR : 13403 S. P. AVE SP13 PRIOR HOSPITAL : CITY : SAN PABLO ST : CA PRIOR STAY - ZIP : 94806- PH: 510-000-0001 SMK N RELIGION OTHER SS# 552-74-6625 ID# 10 6030 NO PHYSICIAN OCONNOR, MICHAEL NONE SISTER SISTER SMITH, DIANA SMITH, DIANA P.O.BOX 308 P.O.BDX 308 PINOLE CA PINOLE CA 94564- 510-000-0000 94564- 510-000-0000 SELF NONE GUAR SS#: 552-74-6625 CANTRELL , EDWARD L SR TERM EMPLOYED: 13403 S. P. AVE SP13 UR AGENCY : SAN PABLO CA AUTH#: NONE 94806- 510-000-0001 CONSERVATOR: N MEDI-CAL OUTPATIENT P 0 BOX 15600 SACRAMENTO CA V �T 95851- ,.,�'�3c CANTRELL , EDWARD L SR 07609552746625 MCALOP MCALOP LEFT ANKLE PAIN 10-16-93 WALKING ON STREET, STEPPED IN MANHOLE .10-16=93 0101 10-16-93 NO -MCAL CARD WITH PATIENT -LMG - Am CANTRELL, Edward L. Sr, 77-48-19 M. O'Connor, M. D. 10-16-93 This patient presents to the emergency room after having stepped 'on_ a_manhole cover and sustained inversion injury to the left ankle. Apparently the manhole cover was protruding from the.pavement. As a 'result, he- twisted his left ankle. The patient did not fall down and did not fall into the man- hole. He -did not injure any other -part of his body. The patient complains of- pain at the lateral aspect of his left ankle-. The patient, in the distant past, has had various accidents and as a result- has chronic neck and back pain for which he takes Flexeril. THE PATIENT IS ALLERGIC TO CODEINE. The patient also tends to get gastric upset when he takes Motrin. REVIEW OF SYSTEMS: Otherwise unremarkable. No chest pain; no abdominal -- pain. No change in his- chronic neck and back pain. No weakness or paresthesias. The patient has been drinking tonight. EXAMINATION: This white male is in no acute distress . HEENT: Normocephalic; nontraumatic. No tenderness in his neck. The neck has normal alignment. of the vertebrae. No stepoff. Full painfull range of active neck motion. LEFT ANKLE EXAMINATION: Tenderness over the lateral malleolus. No swelling, erythema or ecchymoses . The patient' s left ankle joint is stable. He has some pain on .inversion and eversion - of the ankle. . Flexion and extension are pain-free. Examination of the left foot is unremarkable. Skin is intact throughout. No neurovascular problems. The remainder of the left lower extremity is unremarkable, X-RAY OF THE LEFT ANKLE does not appear to show any fractures, dislocations or other pathology. . DIAGNOSIS: Left ankle strain. The patient was given Ace wrap and crutches . In view of the fact the patient was drinking., his friend - took him home. The patient was advised not to drink when taking Vicodin (which he requested) . By -the� time he is able to fill the prescription, the alcohol would be gone from his body. Side effects of Vicodin were discussed. He is (continued) -EMERGENCY ROOM REPORT ` ' - ti CANTRELL, Edward- L. Sr. 77-48-19 10-16-93 - . ' Page two . not to -.drive or drink when taking Vicodin. He is to rest and elevate the left ' 'foot. To follow up at the Richmond Clinic this week. He may return for any problems . APPROVED FOR AUTOSIGNATURE MICHAEL 0 CONNOR, M. D. MO:mt-3 #6372 dd: 10-16-93 dt: 11-16-93 . " - EMERGENCY 1-16-93 . -EMERGENCY ROOM REPORT BROOKSIDE-HOSPITAL:. = -"EMEPLCENCY MEDICAL RECORD - riage Documentation _ San-Ppblo, CA94806 • ATE: I l6-( � -_.,,,y ': •='•=- -.�. :,,y,.., O Unschedulec3`Return Within 72 Hours t Mame_(Last, First, M.l.)mow - ice' 61- l SbO0,9t) � — fes} { 6 _ 7 Sex & D B" s Carrier Priority I/E7 - C-A)tTREI.L —EDIrA�C $�{ x R -M I - II III FT .17 C C?)� )q c);t VETHOD D 1016.93 x ARRIVAL O PM O other AD OF ❑Ambulatory -XEMT ❑W/C PM2 71 19/19 S O TRIAGE TIME EXA,��cM77 RM TIME POLICE NOTIFIED? SOCIAL SERVICES 4P L 11 G t/f OYES OYES ` Chief Complain VA , ' 00—Os— PMH 00—OS— PM _ K/ MEDICTION N�?p�i f LNMP G P _AB_LAST TD ALLERGIES NKA❑ C" l j _ BP P �_�._{ UB/oB DAT C/' T _l`� O HE R � # �� — WT-- DRSG: ❑ M.D. TIME TATED INTERPRETER LANG' ❑ FOLLOW-UP HISTORIAN FAMILY/FRIENDS O YES 9 Si nature: R.N. IN WAITING RM ONO H + P SH: FH: - PMH: r PRO RP. ❑ SEE PROGRESS NOTE: Co Physician's Name Time Called Time Responded Time Arrived LAB TIME X- AY TIME MD 0 DERS INSURANCE AUWA, TIMje ROUTE SITE SIGNATURE ORD INITIAL ORD INITIAL ❑ ER Panel ❑ Cx R ❑ BC Abd X-R �! ❑ Lytes 11 O PT/PTT - ❑ ABG D U/A O O U/A PREG - - Old Recor ❑ BICX O EKG' ❑ 0- Condition:f Mproved ❑ Stable ❑Critical ❑ Expired DISP:,❑ADMIT SERV RM TIME 1. „�/� . PMD ACCEPTING �-- - .❑TRANS TO: MD 3. _'rmatigPoRT R4• n RDS-. 0 ALS ED/DC TIME 0 HOME MD/SI wow BROOKSIDE HOSPITAL San Pablo, CA 94.806 _ - ED NURSING'FLOW SHEETS DATE: _ NAM E: 02 L/ml}. U Cannula U Mask b 15 b A 0 1 Cf D Cardiac Rhythm O 1 . 2 3 4 5 6 7 8 9i cANT'a fU, EDWARD s. Silk r R Pupil Guage (mm) ,���CORMOR • • ® ® R 12i29r1950 0 LMG � s P IA RI S CRYING/QUALITY HYDRATION/MUCOUS COLOR ACTIVITY•LEVS1. START AMOUNT RN ❑Suong/Normal MEMBRANE ❑Pink ❑Playful TIME AMT PARENTAL FLUIDS/BLOOD SITE ABSORBED SIG. O Whimpering ❑Moist ❑Pale O Irritable . O Moaning/ ❑Dry O Cyanotic O Dull ACT— Highpitched ❑Poor Skin Turgor CARDIAC RESP. NEURO TRAUMA ❑HR Reg. ❑Clear Bilat ❑Oriented ❑Nothing Visible O HR Irreg. ❑Labored Name/Place/Time ❑Laceration ❑Chest Pains ❑Rhonchi O Alert Only ❑Palpitations ❑Confused ❑Edema ❑Retractions ❑Dizzy O Wheezes ❑See GCS ❑Burns ❑Cough ❑MAEW ❑Puncture ❑JVD O Sputum EENT ❑GSW i GI ❑Redness ❑Nausea/Vomit GYN O Swelling ❑Deformity ❑Diarrhea/Constip. ❑Vag DC O Drainage O Swelling ❑Bowel Sounds ❑Color ❑OD ❑Bruising GLASCOW COMA SCALE Yes/No ❑Vaginal Bleed O OS ❑ROM Decrease g ❑ EYE Spontaneous 4 MOTOR Obeys Command 6. ❑Abdomen_ El Cramping ❑ Blurred Vision OPENING To Voice 3 RESPONSE Localizes Pain 5 ❑FHT ❑Foreign Body To Pain 2 Withdraw(pain) 4 SKIN INPUT OUTPUT None 1 Flexion(pain) 3. GU ❑Warm VERBAL Oriented 5 Extension(pain) 2 ❑Frequency O Dry IV URINE RESPONSE Confused 4 None O Dysuria ❑Cool 1 ❑ Retention ❑Diaphoretic PO EMESIS Inappropriate Words 3 TOTAL ❑Urethral DC ❑Pale Incomprehensible Wds 2 ❑Incontinence ❑Rash OTHER OTHER None I PUPILS:Size R NR I TIME BP P RESP T PULSE GCS NURSING PROGRESS NOTES r , r . I DISCHARGE DISPOSITION METHOD OF DISCHARGE: TIME: C!_� d--AMBULATORY ❑W/C O CARRIED CRUTCHES ❑ CRUTCH WALKS WELL O AMBULANCE ADMIT PT. BELONGINGS: ❑ PATIENT 0-FA ILY ❑ SAFE LIST ITEMS: O MEDS TO PHARMACY – TRANSFER: O FACILITY O BLS ❑ ALS ❑AIR TR AN FER REPORTI.TO: R.N. COMPLETED: TRANSFER FORMS O X-RAYS GIVEN * r �e�nw. w HARTING ❑ CHART COPIES_ GIVEN RN SIGNATURE . _ BROOKSIDE HOSPLTAL _ -EMERGENCY DEPARTMENT NURSING - FLOW SHEET vols-m(9192) DATE NAME � TIME MEDICATIO ROUTE SITE S N TIME EDICATIONS E SITE RN SIG TIME 9P P RESP T PULSE L E GCS NURSING PROGRESS NOTES L2u , ` - - G y BROOKSIDE HOSPITAL - 2000 VALE ROAD SAN PABLO, CALIFORNIA-94806 TELEPHONE (510) 235-7006 x 2892 WEST CONTRA COSTA RADIOLOGIC MEDICAL GROUP, INC. R. W. JANG, M.D. M. M. LAPP, M.D. E. M. TA4, M.D. W. G. WIERZBOWSKI, M.D. REPORT OF ROENTGEN EXAMINATION ' OF CANTRELL, EDWARD L: SR. 42 774819 Name Age Patient Number REFERRED BY: MICHAEL O'CONNOR, M.D. X-RAY NO 15-78-32 DATE: .10/ 16/93 ROOiVI-NO: LEFT ANKLE t AP , oblique and lateral views. Mild soft tissue swelling is noted laterally , but there are no fractures , bone or joint abnormalities , or definite joint effusion . R.W. JANG D. RWJtrvw - October ,17, 1993 - Previous X-rayl 08!93 CHART eT pri sa s _ _ BROOKSIDE HOSPITAL 10103. CONQITIONS OF SERVICE 11_q8_19 SAN PABLO, CALIFORNIA b 1 S 6 0 0 'n 7 o 1. CONSENT TO MEDICAL AND SURGICAL PROCEDURES "' The undersigned consents to'the procedures which may be performed during this hospitalization C A N T E�.L . {)Y x R 13 [" $"it f{ f{ or on an outpatient basis,including emergency treatment or services,and which may include `O e G 4 M N O R but are not limited to laboratory procedures,x-ray examination,mildical or surgical treatment 101693 M r R or procedures,anesthesia,or hospital servjtes rendered the patient under the general and special 12/19/1950 4 2 L M G I instructions of the patient's physician of surgeon. 2. NURSING CARE This hospital provides only general duty nursing cars unless,upon orders of the patient's physician,the patient is provided more intensive nursing care.If the patient's condition is such as to need the service of a special duty nurse,it is agreed that such must be arranged by the patient or hisiher legal representative.The hospital shall in no way be responsible for failure to provide the same and is hereby released from any and all liability arising from the fact that said patient is not provided with such additional care. 3. LEGAL RELATIONSHIP BETWEEN HOSPITAL AND PHYSICIAN All physicians and surgeons furnishing services to the patient,including the radiologist,pathologist,anesthesiologist and the tike,are independent contractors with the patient and are not employeas or agents of the hospital.The patient is under the care and supervision of hisJher attending physician and it is the responsibility of the hospital and its nursing staff to carry out the instructions of such physician.It is the responsibility of the patient's physician of surgeon to obtain the patient's informed consent,when required,to medical or surgical treatment,special diagnostic or therapeutic procedures,or hospital services rendered the patient under the general and special instructions of the physician 4. RELEASE OF INFORMATION Upon inquiry,the hospital may make available to the public certain basic information about the patient,including name, address, age, sex, general description of the reason for treatment(whather an injury,burn,poisoning,or other condition},general nature of the injury,burn,poisoning or other condition,and general condition.If the patient or the patient's legal representative does not want such information to be released,he/she must make a written request for such information to be withheld. The patient or the patient's legal representative may obtain a separate form for this purpose upon request. The hospital wig obtain the patient's consent and his/her written authorization to release information, other than basic information, concerning the patient, except in those circumstances when the hospital is permitted or required by law to release information. The undersigned agrees that,to the extent necessary to determine liability for payment and to obtain reimbursement,the hospital may disclose portions of the patient's record, J including his/her medical records,to any person or corporation which is or may be liable,for all or any portion of the hospital's charges,including but not limited to insurance companies,health care service plans,or workers'compensation carriers.Special permission is needed to release this information where the patient is being treated for alcohol or drug abuse. 5. PERSONAL VALUABLES It is understood and agreed that the hospital maintains a safe for the safekeeping of money and valuables, and the hospital shag not be Gable for the loss or damage to' any money,jewelry,eyeglasses,dentures,hearing-aides,documents, furs,fur coats and fur garments or other articles of unusual value and small size,unless placed therein, and shall not be Gable for loss or damage to any other personal property,unless deposited with the hospital for safekeeping.The GabMity of the hospital for loss of any personal property which is deposited with the hospital for safekeeping is limited by statute to five hundred dollars($500.00)unless a written receipt for a greater amount has been obtained from the hospital by the patient. I do not have itemslvaluables to lock in the safe 6. FINANCIAL AGREEMENT Pu�nUPremlGerbrJlenrarntx muds The undersigned agrees,whether he/she signs as agent or as patient, that in consideration of the services to be rendered to the patient,helshe hereby individually obligates himsetflherself to pay the account of the hospital in accordance with the regular rates and terms of the hospital.Should the account be referred to an attorney or collection agency for collection, the undersigned shaft pay actual attorney's fees and collection expenses. All delinquent accounts shall bear interest at the legal rate. 7. ASSIGNMENT OF INSURANCE BENEFITS The undersigned authorizes,whether he/she signs as agent or as patient,direct payment to the hospital of any insurance benefits otherwise payable to or on behalf of the undersigned for this hospitalization or for these outpatient services,including emergency services if rendered,at a rate not to exceed the hospital's regular charges.It is agreed that payment to the hospital, pursuant to this authorization, by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. It is understood by the undersigned that helshe is financially responsible for charges not covered by this assignment. B. HEALTH CARE SERVICE PLAN OBLIGATION This hospital maintains a fist of the health care service plans with which it has contracted.A list of such plans is available upon request from the financial office.The hospital has no contract, express or implied,with any plan that does not appear on the list.The undersigned agrees that helshe is individually obligated to pay the full cost of all services rendered to himther by the hospital if helshe belongs to a plan which does not appear on the above mentioned fist. The undersigned certifies that helshe has read the foregoing,received a copy thereof,and is the patient,the patient's legal representative,or is duly authorized by the patient as the patient's general agent to execute the above and accept its terms. 01 Data J ata—Meted! axdi servatm If other than patient, indicate relationship: Time Witness Financial Responsibility Agreement by Person Other than the Patient,at the Patients legal Representative: I agrx to accept fmantial respon?Aty for servicea rendered to the patient and to accept the terms of the Fina tial Agreement.AuigmNnt of kwante eenerits,W Haft Care Semite Plan Oration PrmrWo s alcove. Date Financially Responsible Parry Tim _ _ A COPY OF THIS-DOCUMENT IS TO-BE DELIVtRE0 TO THE —- - - PATIENT AND ANY-OTHER PERSON WHO SIGNS THIS DOCUMENT. PLEASE NOTE: Th"xamination and treatment that you have'recr<ived in the Emergency Department has been given on an emergency basis only, and is not intended to be a substitute for complete medical care. It is important that you be checked again as instructed. If you notice any worsening of your symptoms,promptly call your referral doctor or return to the hospital. If. an x-ray or EKG has been peri d, it has been read on a preliminary basis only, and will be reviewed by a radiologist or internist within 24 hours. Yo ill e n Tied if additional findin are noted. YOUR DIAGNOSIS IS: TRAUMA ADULT PEDES GYN-GU ure . HeaJlnjwy Viral URI Pneumonia/Bronchitis Fever Control Otitis Media Miscarriage,Spont. PID rainlStrain Concussion' Gastroenteritis Asthma Viral URI OGlis/Extema Miscarriage,Threaten Ovarian Cyst '690 NecklBack Pain tracer/Gastritis COPD Flare' Gastroenten'Gs Pneurnonia/Bronchitis Irregular Vag.Bleed Curettage Contusion Corneal Abrasion' Esophagitis' Tension Headache Pharyngitis.Viral' Asthma' Vaginitis' Menstrual Pain' Fracture Abscess' Chest Wall Pain' Hypertension,New Pharyngitis,Strep' Poisoning,Pedes' Cystitis,Fem. Kidney Slone' Cast and Splint Care Cellulitis' Seizure,Recurrent' Dehydration' Pha",Strep Pend'g' Febrile Seizure' Pyelonephritis' GCIChlamydia' Suture Removal- Animal Bite' Abdominal Unknown Overdose' Hives' Croup' Scabies No Complications Alcohol WID Syndrome Biliary Colic Chicken Pox Conjunctivitis' PRINTED INSTRUCTIONS PROVIDED: ❑ indicated above ❑ other: ❑ PARENTS/GUARDIAN INFOR7 OF CAR SEAT LAW. ADDITIONAL INSTRUCTION" / r _3 -7i► -77/L4 ❑ Call 235-7006 x 2100 on for the results of your test: r �YS�llrl�c-� YOUR EMERGENCY DEPARTMENT PHYSICIAN HAS BEEN: E. Nipomnick I. Ahwah J. Rampulla M. Gibson R.Turner B. Gustin R. Mandiberg L.H. Hodgeson T. Smith I have received and un erstand then instructions outlined above. X A-01 Patient or Representative Staff Date D/C Time b. ., • ,_ `„ _;: �, .t _HOSP,ITAL WORK/SCHOQLNOTI �I �A I �t��•_.��r�...�;_ �:•�:_.:. F.0 T ONrFORIVS• - .1.. .d.-+J'�r' •N.'`. T Y.l, .:� .:W14':\'.' :M,: .+Le --• 'K. ...-4i: Sa"o".=.� .:,ti"`.'*'':'� ' n'"•„c_�rr*' :f,'n '•''�..',yr'�. t. '+' ..•...y.:. : .:+ti:�': .j,. ^r_ a ,5�,, _ ,:. K.�:+` { ..�X•altz;:.t•...:`.:.- � .j'!�'_F".-:":'::.'��';: :tir,:.R:�:;;'z- T=: =-.>•' �'�-rwas'seen'rn the;Errlergency:Department,on . ... •S:-• �"tet•: •7`.,.,.i' .',Y,:. - -E:'%!::- .. .. - _ . He/She.should be:abie toreturn to work/school°on -'• with the.following restrictions: --X M.D. -------------- EMERGENCY DEPARTMENT PRESCRIPTION Drug Name Mg. Diso. 1 Sig. 0 Do not drive while Physician �� �- P• ed taking medication. Signatu ame M.D. 0 Do not substitute. O Spanish Instructions. E.Nipomnick I.Ahwah J.Rampulla M.Gibson . ur fiber L.H.Hodgeson T.Smith - - d - bONN00 ,0- __ p BROOKSIDEHOSPITAL b u dS I 4bVMt73 ''1'13 ti IN V3 .; p - 2000 Vale Road - p r� C 4 San Pablo.CA 94806 — T " O h.-LL .. t raj U U 9 .7 q EMERGENCY DEPARTMENT ` l - - DISCHARGE INSTRUCTIONS 4 - - Eb9TOT . - ` BROOKSIDE HOSPITAL ,� _ _ �r 2000 VALE ROAD � ��" i syr `§►J �:= y -' a SAN PABLO, CA 94806 r (�� :- IXC ft C#:'`-7 V121 n t510 235-7000 M - • PE. Y- 4 EtM :...:::�, .-. 23:22 li/24/93 ACTIVE OUTPATIENT A V �" ' ` IP. ` Y ' dK �.. -Y..,,•,ria_`;Sr .a�,• ,y: PATIENT INFORMATION.r A. AGE T. r `' ir 19-5Q: : : Z:IR�� �.2$80b�•- — jMIC.�Y :�#3El:I��T�[� �,A.a;�: .,.,_,•,:.,_":-•{.�':. '�'::"' _ _ PHYSICIAN '• roti-^4r.:•: +,r���+,r,, t- -tiC'-`+i..=". .:.x_ ,.r•:E,..srr.::ri-;:i;t'�ar .' - �.�ti_�"`a:'.ri. ��-�.z.,w%'. '�jf�.. ' r �a•�r�'� -^�.:.,.��:' _ PATIENT EMPLOYER NEAREST RE�LyAy�TIVE EMERGENCY CONTACT NO 'j�••iry� Ji•'- h'-yrx;,h� �Ss7`•_.Y T':��,,�w.-`�:rY• }rata.._... . _ •:�,R•c� :�,�, - .a. �•_.. ��z. }S.I SITER' �,:..�r. _ - �•�rr. '� iS;C��I:T��st,. i•A:NA�,=~=i. r:� .*�S�.L�:H:;•-.DIAN..A= �-:�:.''`::';��- . . ='.;..-r Wtom� �<-.•�. '{�• .:.=:•__...�, _ ••.!c;r +�•'.':rYY:=:� a:`}�:r•.r1 �-.erC`�.�. -.��`:���li' :n:.�:i 'e_'•_�+d'�,+: ���lS}:a• ;� _ ,`::_.%'.`��-'^.'�=_:_:�. GUARANTOR GUARANTOR EMPLOYER OTHER i __. " ..� 'QUA$ SS,# 5552-74=. 625-- }CANTR LLtTaj ' S -�y [] O.YFLli; =.;....;:�:�:.:;..�; y q `lC CY pie h��+y \i'..:. R�•:..l,i �!i+�•,•S, s- i�t+. .' r R' •'�'+'e< .,•-•- - .•�1C7iG�j4��+`R�' + Y�+ ° .7:'`:rri::,�ii'.,t:.'..:_: NS-E T.0 • ' N: a.�:•:;.ix,..... .� �•. - -�i_rel..��'�A''•..... 'i�;;-_.: PRIMARY INSURANCE SECONDARY INSURANCE TERTIARY INSURANCE =S .S3 ��. ,.:.,,Y�, X GROUP-POLICY-CLAIM GROUP-POLICY-CLAIM GROUP-POLICY-CLAIM�� - 1r'tily,:��.,. t:.•.�_e.� ' •fir ti ... �._. .1 �f.L'"}y-:.,•:}}i. CA 11[IVA I ADMIT DIAGNOSIS - ' t -NECI� N• � HEp_ .g _ _�" - ,i:•?:reynx L.iS'r _ aSy �.•L••' + - :- YJrx•'a•. :}rov w Z".'�.1�r,'d3`;�`4"i CY c � s� �.i Ki�•�-.- �J�.!+�.tl. _���+••�:•�"��r'X?�: .� 4 a ti :ti '%1, �,-'r1: �:s�rJ:'s..:Y? ELAT�N1tHEF3E� "'rY;rs. ;F. : ciRciF :.��1y�s+;:�.����=;�;,=.+.�' ��'_,r;:'';:ONE•: ACCIDENT DATE TIME ONSET :rA11 193 HISTORY/COMMENTS - _WILL,RENDE6,.Fi ATMEf`ll"-.::�.?::.�r_. :: �: �... .. .v.e.� j,.ti, i:�IJ LiC�- b-' � ,.4CEQF.E1�F3'�IAME AND,NO`-C-�:�°-•_ �:z:}'taF�'�Tl �..:�7� .•� „• 'a=�✓`�:d•.5a•• �••• - •�'r�s�\7�$MS�•�r'4'-�.y:. ��:-:��.T••••Y.;-r: 1 - - - CLERK INITIAL + 7,p SROOKSlDE HOSPITAL EME' NGY NlEDlCAL RECORD rA Triige Documentation - San'Pablo,-CA 94806 DATE: ❑ Unscheduled Return Within 72 Hours 112,4q3 Name (Last, First;M.1.) — v• 4c L.F._ W - .•. Sex Agre, ' DOS Ins Carrier Priority 1/ET b 1 S 9 2 9 9 4 _ 4 Li M `(�. 12`19- I II ••1l METHOD OF PMD ARRIVAL y Ambulatory ❑ EMT ❑W/C `,4 CANTRELL, EaWARO CT PM ❑ Other 3999 L S R E K Ft- TRIAGE TIME EXAM RM TIME POLICE NOTIFIED? SOCIAL SERVICES —E R �p S Z'J ❑ YES ❑Yes 112493 X 2 a Chief Complai t VA 12f1<9f19S0 42 [4G NGUI _1 4t5gg p ��!rJ �N1�t,►� �,ErI 'OD PMH i i GCU(.. ( tC. MEDICTIONS ❑ NLNMP e _ `... P AB LAST TD ALLERGIES NKA ❑ BP P S B/OBJ DATA L o-- ___ T Gln_ S Cha r�l� rr\ l��S rnQ�0 figg So R 9m 12' �Wvr,d wo, x G w,Gs tx;-d „ q ��$ TX: ICE a I DRSG: s r tna br-,FILC A61i. Sejrj Ut rc+ "'Jr.,,q- M.D.TIME ❑ DICTATED INTERPRETER LANG FAMILY/FRIENDS 0 YES 'C J ❑ FOLLOW-UP`HISTORIAN IN WAITING RM ❑ NO Signature: R.N. H + SH: G ` FH: A& rya,p��,,. PMH: !a t PROC:/INTERP. O SEE PROGRESS NOTE: Consulting Physician's Name rime Called Time Responded ' Time Arrived LAB TIME X-RAY TIME MD ORQERS INSURANCE AUTH ❑ TIME ROUTE SITE SIGNATURE ORD INITIAL ORD INITIAL ❑ ER Panel ❑Cx R ❑ BC ❑ Abd X-R ❑ Lytes ____ ❑ C-Spine ❑ PT/PTT ❑ - ❑ ABG ❑ ❑ U/A ❑ .__ ❑ U/A PREG .r ❑ Old Record r ❑ BICX ❑ EKG p ❑ Condition: ❑ Improved" NStable ❑ Critical ❑ Expired DISP: ❑ADMIT SERV RM TIME DX t. 2. -PMD - --ACCEPTING.. - _ MD O TRANS TO:- - - 3.. = " /f BROOKSIDE HOSPITAL'San PaN:�_rA 9480Fi ED'NURSING FLOW SHEET 77 DATE: NAME: e- C L/min O Cannula O Mask C 91.4 � Cardiac Rhythm 1 2 3 4 5 6 7 8 9 'CA�. R-rL-L:tt. E.n ftPupil Guaga (mm) 191. �Ex Ito$ PEDIATRICS 0 42 OtO CRYING/QUALITY HYDRATION/MUCOUS COLOR ACTIVITY LEVEL START AMOUNT RN O Strong/Normal MEMBRANE O Pink O Playful TIME AMT PARENTAL FLUIDS/BLOOD SITE ABSORBED SIG. O Whimpering O Moist O Pale O Irritable O Moaning/ O Dry O Cyanotic ❑Dulf Highpitched O Poor Skin Turgor CARDIAC RESP. NEURO. TRAUMA O HR Reg. O Clear Bilat O Oriented O Nothing Visible O HR Ineg. O Labored Name/Place/Tae ❑Laceration O Chest Pains O Rhonchi O Alert Only O Palpitations O Confused O Edema O Retractions O Dizzy O Wheezes O See GCS O Burns O Cough O MAEW O Puncture O JVD O Sputum EENT O GSW ,.J GI ❑Redness O Nausea/Vomit GYN O Swelling O Deformity O Diarrhea/Constip. O Vag DC O Drainage O Swelling O Bowel Sounds O Color O OD O Bruising Yes/No O Vaginal Bleed O OS O ROM Decrease GLASCOW COMA SCALE ❑ EYE Spontaneous 4 MOTOR Obeys Command 6 O Abdomen- O Cramping .O Blurred Vision OPENING To Voice 3 RESPONSE Localizes Pain 5 O FHT O foreign Body To Pain 2 Withdraw(pain) 41 SKIN INPUT OUTPUT None I Flexion(pain) 3 GU O Warm VERBAL Oriented 5 Extension(pain) 2 O Frequency O Dry IV URINE RESPONSE Confused 4 Nona i O Dysuria O Cod PO EMESIS Inappropriate Words 3 O Retention O Diaphoretic TOTAL O Urethral DC O Pale Incomprehensible Wds 2 O Incontinence O Rash OTHER OTHER None I PUPILS:Size R NR TIME BP P RESP T PULSE GCS NURSING PROGRESS NOTES a 3�I5` Fl- e •J` v t/-G./clr.�-G_.._ �•-c.c.•'i2, !3'�c,.--� .D/�G- r�s?`�ec,,. I DISCHARGE DISPOSITION _ _ METHOD OF DISCHARGE: TIME: J _ ••q AMBULATORY O W/C O CARRIED _ O CRUTCHES O CRUTCH WALKS WELL ❑ AMBULANCE ADMIT PT. BELONGINGS: ❑ PATIENT" ❑ FAMILY ❑ SAFE LIST ITEMS: - ❑ MEDS TO PHARMACY ' TRANSFER: O FACILITY O-BLS O ALS O AIR _ TRA �FE�5R-BZ'49TT0: R,p)COMPLETED: O��NSFER FORMS O X-RAYS GIVEN , - :��� . - - ...fir.�.� _!��'• — _ Mme - —_ ... —. 03 . — _ _ ��.. •sl.'; 4 — .'�✓ . BROOKSIDE HOSPITAL 1, 1.529 . CQi.IDITIONS OF SERVICE _ SAN PABLO,CALIFORNIA `' •C-A N T R E L.L s -E D WARD L SIR E K R 1. CONSENT TO MEDICAL AND SURGICAL PROCEDURES 9999 —E R MOS The undersigned consents to the procedures which may be performed during this hospitalization 112493 M X ' or on an outpatient basis,inclutfing emergency treatment or services,and which may include 12/19/1950 42 L M G -i but are not limited to laboratory procedures,x-ray examination,medical or surgical treatment or procedures,anesthesia,or hospital;ervices rendered the patient under the general and special instructions of the patient's physician or surgeon 2. NURSING CARE This hospital provides only general duty nursing care unless,upon orders.of the patient's physician,the patient is provided more intensive nursing Cara.If the patient's condition is such as to need the service of a special duty nurse,it is agreed that such must be arranged by the patient or hislher legal representative.The hospital shall in no way be responsible for failure to provide the same and is hereby released from any and all liability arising from the fact that said patient is not provided with such additional care. 3. LEGAL RELATIONSHIP BETWEEN HOSPITAL AND PHYSICIAN All physicians and surgeons furnishing services to the patient,including the radiologist,pathologist,anesthesiologist and the like,are independent contractors with the patient and are not employees or agents of the hospital.The patient is under the care and supervision of hislher attending physician and it is the responsibility of the hospital and its nursing staff to carry out the instructions of such physician.It is the responsibility of the patient's physician or surgeon to obtain the patient's informed consent, when required,to mad'ical or surgical treatment,special diagnostic or therapeutic procedures,or hospital services rendered the patient under the general and special instructions of the physician. 4. RELEASE OF INFORMATION Upon inquiry, the hospital may make available to the public certain basic information about the patient,including name, address, age,sex,.general description of the reason for treatment(whether an injury,burn,poisoning,or other condition),general nature of the injury,burn,poisoning or other condition,and general condition.If the patient or the patient's legal representative does not want such information to be released, helshe must make a written request for such information to be withheld. The patient or the patient's legal representative may obtain a separate form for this purpose upon request. The hospital will obtain the patient's consent and his/her written authorization to release information, other than basic information, concerning the patient, except in those circumstances when the hospital is permitted or required by law to release information The undersigned agrees that,to the extent necessary'to determine liability for payment and to obtain reimbursement,the hospital may disclose portions of the patient's record, including hislher medical records,to any person or corporation which is or may be liable,for all or any portion of the hospital's charges,including but not limited to insurance companies,health care service plans,or workers'compensation carriers.Special permission is needed to release this information where the patient is being treated for alcohol or drug abuse. . 5. PERSONAL VALUABLES It is understood and agreed that the hospital maintains a safe for the safekeeping of money and valuables, and the hospital shall not be liable for the loss or damage to any money,jewelry,eyeglasses,dentures,hearing-aides,documents,furs,fur coats and fur garments or other articles of unusual value and small size,unless placed therein, and shah not be liable for loss or damage to any other personal property,unless deposited with the hospital for safekeeping.The liability of the hospital for loss of any personal property which is deposited with the hospital for safekeeping is limited by statute to five hundred dollars($500.00)unless a written receipt for a greater amount has been obtained from the hospital by the patient. I do not have itemslvaluables to lock in the safe 6. FINANCIAL AGREEMENT P4UWWVW4KWV6WJC"WV6W WWI The undersigned agrees,whether helshe signs as agent or as patient,that in consideration of the services to be rendered to the patient,he/she hereby individually obligates himself/herself to pay the account of the hospital in accordance with the regular rates and terms of the hospital.Should the account be referred to an attorney or collection agency for collection, the undersigned shall pay actual attorney's fees and collection expenses. All delinquent accounts shall bear interest at the legal rate. 7. ASSIGNMENT OF INSURANCE BENEFITS The undersigned authorizes,whether helshe signs as agent or as patient, direct payment to the hospital of any insurance benefits otherwise payable to or on behalf of the undersigned for this hospitalization or for these outpatient services,including emergency services if rendered,at a rate not to exceed the hospital's regular charges.It is agreed that payment to the hospital, pursuant to this authorization,by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. It is understood by the undersigned that helshe is financially responsible for charges not covered by this assignment. 8. HEALTH CARE SERVICE PLAN OBLIGATION This hospital maintains a list of the health care service plans with which it has contracted.A list of such plans is available upon request from the financial office.The hospital has no contract, express or implied, with any plan that does not appear on the list. The undersigned agrees that helshe is'individually obligated to pay the full cost of all services rendered to him/her by the hospital if he/she belongs to a plan which does not appear on the above mentioned list. The undersigned certifies that he/she has read the foregoing,received a copy theleof,and is the patient,the patient's legal representative,or is duly authorized by the patient as the patient's general agent to execute the above and accept its terms. _ q3t_ osa PateentlPstentt6wrdaNCa�,xveW d r I other than patient, indicate relationship: T' Witness Financial Responsibility Agreement by Person other than the Patient.or the Patient's Legal Representative: 1 agree to accept fasendat respansibilty for sarsieos rxdned to the patient and to accept the turns of the _- - Finandal Agreement.Assigrenent of Insurance Benefits,and Health Care Service Plan Obligation Provisions above. Date Financially Responsible Party Tim. - _ A COPY OF THIS DOCUMENT IS TO BE DELIVERED TO THE .PATIENT.AND ANY OTHER PERSON WHO:SIGNS THIS DOCUMENT. Witness ♦ - - ' �- •-f• '` T^�a - .. , ems. '�.-%, _ PLEASE NOTE: e-examination-and treatment that you have..ceceived in the Emergency Department has been given on an emergency basis- fitly,:and is not intended_to be a-substitute for complete medical care. It is important that you be checked again as•instructe ..Ifyou notice-any worsening of your symptoms,promptly call your referral doctor or return to the hospital. If an x-ray or EKG.has been performed, it has been read on-a preliminary basis only, and will be reviewed by a radiologist or �= internist within 24.hours. You will be notified if additional findings are noted. YOUR DtAGNOSJS IS:.14e.4— 4e.4 ' TRAUMA t rt. ADULT 'ti PEDES GYN-GU t acerat�NPundure Head Iniury Viral URI- PrieumonialBronchitis Fever Control_. ' Otitis Media Miscarriage,Spont. PID SprainlStrain Concussion' Gastroenteritis `7 Asthma Viral URI' '' •OGtis/Extema Miscarriage,Threaten Ovarian Cyst BumlAbrasion NecktBadk Pain UW/Gastritis COPD Flare' Gastroenteritis PnerurioniaBronchitis irregular Vag.Bleed Curettage Contusion Comeal Abrasion' Esophagitis' Tension Headache Pharyngitis,Viral' Asthma' Vaginitis' Menstrual Pain' Fracture Abscess' Chest Walt Pain' Hypertension,New Pharyngitis,Strep' Poisoning,Pedes' Cystitis,Fem. Kidney Stone' Cast and Sprint Care Celturrs' Seizure,Recurrent` - Dehydration' Pharyrg,Strep Pend'g' Febrile Seizure' Pyelonephritis' GC1Chlamydia' Suture Removal- Animal Bite' Abdominal Unknown - Overdose' Hives' • Croup' Scabies No Complications Alcohol W/D Syndrome Biliary Colic Chicken Pox Coniunctivitis' PRINTED INSTRUCTIONS PROVIDED: ❑ indicated above ❑ other ❑ PARENTS/GUARDIAN INFORMED OF CAR SEAT LAW. A DITIONAL INSTRUCTIONS:, ❑ Call 235-7006 x 2100 on for the results of our test: YOUR EMERGENCY DEPARTMENT PHYSICIAN HAS E : E. Nipomnick .I.Ahwah J. Rampulia M. Gibson •. umer B. Gustin R. Mand erg L.H. Hodgeson T. Smith ,.-: I have received ,and 4unsQd the in ructio outlined above. •, X' X ' Patient or Representative ,�,+:"i"-9'�r:�i'-t-:�ir{, .':y—.1as. _.- • 'a - ��'' S1S'}S'�a�,Ge 1�1r s.ly�kr: x` 7:+'•'7Sat"atyt�Y.'sf TIF +. eh''.xs'rt`:syi�c�•:'•��i,'r-.,O kt-�r,.�''�.,S'{a'trt.e1• '..,.•�..'',t.a:'r.D'3.. •-/.0T:i;myt:e _ — ` ;: ------------ ?^ A •OtSC001':%OAT ' .r; : •..i_ -` '. W..r rC..+.. .+, 1+�L:::l'.r.•'yt� tir;,a.-t.M:vr!ar• T.*lyK.. .�'. v- n.,,�:4 _ -was a :I ;t 'e_Emergency#Departmerit:on<:. '°` �':.r•;yLy=F£9rlW'e�lN"'»�S.--hy'e,.ms:ss'�,o.>'yl e=a�—bl : .(. •Yr.+7^-:-.' � ',ab 7s1.7L• 1 Pu \ . a5 .a••: ; -Rr•ic:.t•:•i co...,_n•rs: KISC 001' :' � itheturnjo;worn =tetollwing rest i _ FMatti" xv t=M•.;• :;�:1', W 1 �"*"-.. '`"`fin J'' y 3.j. iS9:...-:•`-;•�-:;,••- . +'`..,�,r:;�.: Wit?,, k. 'r�' { ..-F.'�.,'__.rY:;,-•;;:v--S?b•iri l�r:,,.�/*�-.iT�;.:'•,.'i;_n"t-�.:'._:•w•;L•.;�r 'v' r,��ydt� ^'.T �' -iY. y .1iY nJYxw:f:�1S�:1SJj+•:.�F::::.�-�1.''''�y,!�..,•.3'"-:Uj:i:,'^.-,�.�Kq - �i«r:4.; 'u�••ai/ 8'-i+-Ci+l•�, � +'�Ni ••,�?�- R '�`` �:� •�•,-n .1.5::'�: "k,:;?r.;.:''N:'^e�,. '4," ... . �••' .`Tyr.2�•.--' r;G,f..'...J...�^'. ..is -.SRf:. •?+ .' .''.,l:e�. •a:+i:•' . r !N7. °...�'•.•:s;:••.,.:^...,:-�;•�:-.... j EMERGENCY DEPARTMENT PRESCRIPTION Drug Name Mg. DiSR. I Sig. i i - i - ❑ Do not drive while Physician Printed taking medication, Signature Name M . r ❑ Do not substitute. ❑ Spanish Instructions. E.Nipomnick 1.Ahwah J.Rampulla M: merO�@T 6R jMV4berg L.H.Hodgeson T.S 'th X SOW V3— 61366 W 3 Id Z OuYn03 ` '1`l3alNvD : t — o BROOKSIDE HOSPITAL *. p - 2000ValeRoad — ' b'�..8 —�� _ +b62bS T g San Pablo,CA 94808 - ' - EMERGENCY EPARTMENT= b DISCHARGE 1 - �TRUCTION8*. _ _ _ CANTRELL, Edward 4 November 1993 PERSONAL INJURY DOI: 16 October-. 1993 DOB: 19 December 1950 This is a new North Oakland Medical Clinic visit for this 42-year- old male who reports with multiple injuries referrable to a' fall into a man hole on 16 October, approximately 11:00 P.M. on a city street in San Pable California. At that time of night, Mr. Cantrell was walking with friends without any thing in his hands on this city street when he stepped into a open manhole on the pavement that was uncovered and that he did not see. He fell with his left foot down into the hole with his left lower extremity below the knee level and becoming stuck somehow in - the small hole. He could not extract himself and his friends attempted to help him and were unable to extract Mr. Cantrell from this manhole and summoned the fire department by dialing 911. The fire department and the emergency medical technicians and the ambulances responsed.and extracted Mr. Cantrell from the manhole where he was taken by ambulance to Brookside Emergency Room 'immediately. Mr. Cantrell had the immediate onset of left foot and ankle and knee pain and back pain. Mr. Cantrell reckons that as he' was being pulled out or as he fell in the hole in a twisting fashion that he somehow managed to wrench his neck as well. He was evaluated at Brookside Emergency Room with x-rays which revealed no fractures as he was released to be followed up with his private health care provider. Since the accident, Mr. Cantrell has continued to have neck and back pain and stiffness and pain in the left knee and ankle aggravated by weight bearing and walking or any attempts and doing his activities of daily living. The neck- and back pain is detailed as a constant mild pain becoming moderate after prolonged sitting or lying and on severe on attempts at bending, stooping and lifting and crawling. Mr. Cantrell is on disability' through SSI for a chronic back condition since 1990, apparently due to progressive osteo degenerative arthritis. He is married with 2 children, ages 16 and 7 and lives in his San Pablo apartment and in the last 3 week interval has attempted no work but is able to attend slowly to his activities of daily living including bathing, dressing, eating small meals and making the bed and doing light house duties such as answering the phone, unable to do any -bending, stooping and lifting or moping or carrying groceries or any repairs or heavy work. CANTRELL, Edward Page 2 4 November 1993 He has taken Tylenol and Flexoril prescribed by the Emergency Room and continues to have persistent symptoms without significant relief. He denies any bowel or bladder dysfunction difficulty nor any paresthesial" or numbness but reports a radiating pain into the left buttock down into the left thigh, approximately knee level and details the knee pain and stiffness and swelling aggravated by ' prolonged standing or- attempts at walking; and relieved by rest, ' hot packs and medications. He sleeps. poorly,and awakens with neck and back stiffness and pain particularly in the low back which he describes as moderate, intermittent becoming frequent on days when he is not totally sedentary. PAST MEDICAL HISTORY HOSPITALIZATIONS: Known old degenerative osteoarthritis in the neck and back. SURGERY/TRAUMA: Herniorrhaphy is 1986 and prior automobile accident to his neck in 1989 at which time he was admitted with head trauma and cervical spine strain which aggravated to low back condition. ALLERGIES: HE HAS ALLERGY TO CODEINE. SOCIAL HABITS: He smokes a pack per day and drinks socially. FAMILY HISTORY: Hypertension in the parents and grandparents. PHYSICAL EXAM Mr. Cantrell is a poorly developed marginally nourished caucasian male who appears older that his stated age of 42 . He comes in on crutches and complains of neck and back pain and obvious stiffness and complains of left knee and left arm pain and stiffness and has a swollen tender left ankle and knee. He is oriented x's 3 and delivers a reliable and consistent although somewhat deliberate and slow history and moves his entire upper torso stiffly obviously with some arthritis, stiffness and discomfort. He states that he has a mild headache at this time and slept poorly last night. HT: 519" . WT: 218. BP: 122/86 T: 98.2 P: 80 R: 20. He is right handed. ' Head - normocephalic without evidence or trauma. _ Ear, nose and throat are clear. No battle sign. CANTRELL, Edward Page 4 = 4 November 1993 diaphragmatic excursion but the lungs are relatively clear. CVS: Regular rate and rhythm wit a Grade I systolic murmur - no cardiomegaly, hepatomegaly, pedal edema, cyanosis, clubbing nor JV distension. There is a soft blowing left carotid Grade I bruit.' Low Back - The pelvis is level. There is a mild amount of right dextroscoliosis at approximately 5 degrees. There is tenderness to palpation of the musculature in the connected tissue in the right lower back extending into the posterior pelvis and iliolumbar. The upper buttock muscles are more or less atrophied. There is no sacroiliac notch tenderness. External and internal rotation . on both hips is normal to about 80 degrees. without significant pain. There is moderate tenderness .to palpation and -light percussion of the left greater trochanteric area. Motion is restricted: Finger tips 18 inches from the floor. Hyperextension is 0. Right and left tilt and rotation is approximately 30% of normal with pain on extremes of motion with very poor biomechanics. Deep tendon reflexes are 1+ and equilateral in the knee and ankle jerk. There is some generalized. atrophy and deconditioning. Motor power appears adequate for this individual. Toe and heel walk and resistance against knee and hip extension appears adequate and equilateral. Neuromotor and neurosensory functions and Wortenburg pinwheel and light touch is intact bilaterally. Straight leg raise is totally invalid due to' biomechanical reasons and generalized back and hip pain. Laseque's is negative. Sitting straight leg raise with assistance to approximately 80 degrees with simple low back tightness and pain. There is slight tenderness to compression of the left calf with no evidence of DVT. The left knee has moderate tenderness and contusion over the left pretibial tubercle consistent with contusion - with healing contusion. There is tenderness in the lateral joint space with some mild crepitation but the patella is intact. There is not evidence of effusion in the joint or the anterior compartment. The popliteal space is. unremarkable. I can feel good popliteal pulses. cannot feel DT pulses. ' There is absent of normal hair distribution from the mid calf proximally. Left Ankle - There is edema and tenderness in the anterior lateral forefoot and against stress on the lateral collateral ligament. Palpation reveals tenderness over the dorsal second, third and fourth metatarsal. There is no evidence of gout. CANTRELL, Edward Page 5 4 November 1993 LABORATORY: Urine analysis is within normal limits. DIAGNOSIS Multiple trauma due to injury of 16 October 1993: 1. Cervical spine musculoligamentous sprain and strain. 2. Lumbosacral strain superimposed on degenerative arthritis 3. Left knee wrenching injury with contusion. 4. Lateral collateral ankle strain with direct closed trauma to the anterior forefoot, doubt fracture. Verbal report from Brookside Emergency Room x-rays of the left ankle - no fractures or dislocations. TREATMENT Motrin 600 mg TID Parafon Forte 2 TID Ankle brace Physiotherapy to the cervical spine - 15 pound static traction and infra-red heat and stretching range of motion exercises Home care cervical spine booklets and instructions are given Soft cervical collar Physiotherapy to the low back - stretching range of motion exercises Hydroculator pack Ortho traction table Home care booklets and instructions are given. DISPOSITION: To continue time, rest and medications and physiotherapy - prescribed 1 hour 3 times per week. Will order x- rays of the lumbar and cervical spine and left knee. Further reevaluations will follow. NORTH OAKLAND MEDICAL CLINIC Family and Industrial Medicine Bruce E. Thompson, M.D. FAADEP - Board Certified Occupational Medicine BET/dyt File:hcw NORTH .OAKLAND MEDICAL CLINIC RADIOLOGY REPORT NAME: CANTRELL, Edward DATE: - 10 November 1993 EXAM: CS, LS, Left Knee AGE: 42 1. CERVICAL SPINE SERIES: No abnormal soft tissue swelling or soft tissue calcification is identified.- Vertebral body height, alignment, and overall mineralization is appropriate for the patient's age. Intervertebral disc spaces are maintained throughout. The C1-2 relationship appears normal. Neuroforamina are patent bilaterally. IMPRESSION: No fractures or subluxations are identified. 2 . LUMBAR SPINE SERIES: Vertebral body height, alignment, and overall . mineralization is appropriate for the patient's age. Intervertebral disc spaces are maintained -throughout. Some early degenerative changes are noted particularly anteriorly and superiorly at L4. Otherwise no fractures or subluxations are identified. Visualized SI joints appear normal. IMPRESSION: Some beginning degenerative changes but no fractures or subluxations. 3. LEFT KNEE SERIES: Visualized bony cortical margins are intact. Mineralization is appropriate. ' No fractures are seen: The initial bony spurring of the superior aspect of the left patella. is noted. The joint space is otherwise well preserved. IMPRESSION: No fractures are identified. - Dr. Michael Marsili, Radiologist CANTRELL, Edward 10 November 1993 PERSONAL INJURY DOI: . 10-16-93. Mr. Cantrell returns and details a stabilization in the previous level, severity and frequency of pain and stiffness in his neck and back. He is using the left ankle brace, knee brace, low back brace and cervical collar for support and continues to walk on crutches do the inability to put weight on his left knee and ankle. He states that using the crutches for over 20 minute period at a time temporarily aggravates his neck pain and stiffness and he has to stand up in the most comfortable positions, standing and leaning on his crutches or - slowly walking around a small circle for mobility. He states that otherwise his neck and back gets immediately stiff and painful; and he reports continued inability to sleep comfortably and awakens with morning gel phenomena lasting 1-2 hours despite - hot packs and medication, although relieved temporarily with medications and physiotherapy. PHYSICAL EXAM Essentially unchanged from that detailed previously with less contusion and effusion about the left ankle after we take the brace off. The left knee is still is tender only in the lateral joint space and the prepatellar and patellar space is normal and anterior Drawer sign and McMurry's and stress against the lateral and medial lateral collateral ligaments is essentially normal and intact. I feel that he can discontinue the use of the knee support as it does tend to partially occlude his otherwise poor circulation -clearly due to some advances pre-existing peripheral vascular disease. There is adequate distal and neurocirculatory function although there is a absence of hair and no palpable foot pulses. X-rays today - North Oakland Medical Clinic - Michael M. Marsilli, M.D. , Radiologist - 10 November 1993 : Lumbar spine - There is beginning degenerative changes without fractures or subluxations. Cervical Spine - No fractures or subluxations. Left knee - No fractures or subluxations are identified. CANTRELL, Edward Page 2 10 November- 1993 DIAGNOSIS To continue time, rest and medications and physiotherapy. NORTH OAKLAND MEDICAL CLINIC Family and Industrial Medicine C%V Bruce E. ompson, M.D. DEP Board Certified Occupational Medicine BET/dyt File:hcw. 6r1 CANTRELL, Edward 17 November 1993 PERSONAL INJURY Mr. Cantrell complains of continued pain and stiffness and difficulty about the left ankle and forefoot when ambulated, even with crutches. He continues to use his crutches, left ankle brace and has reapplied the left knee brace again 'with some slight embarrassment with slight distal 1/2 + edema in the pretibial area on the left. He reports improvement with his neck and back following physiotherapy and continues to use his medications which he refilled last time and is staying around the house and remains unemployed, able only to tend slowly to his activities of daily living. PHYSICAL EXAM Essentially unchanged. Again he is advised to discontinue the knee brace and continue the ankle brace and the low back brace and a soft cervical collar which he wears all day. DISCLOSURE: The initial history was obtained by Physician's assistant, Laurie Robinson, PAC; further history was ascertained by myself and appropriate additions were inserted; additional physical exam, review of other medical records, correlation of laboratory and x-ray data and preparation of this report was performed by the undersigned.. NORTH- OAKLAND MEDICAL CLINIC Family and Industrial Medicine Bruce E. Thompson, M.D. FAADEP Board Certified Occupational Medicine BET/dyt File:hcw CANTRELL, Edward 29 November 1993 PERSONAL INJURY DOI: 10-16-93.• Y Mr. Cantrell slowly .is improving with physiotherapy and time and he adequately demonstrates a very slow and somewhat ginger attempts at neck and back stretching and states that he does this for 30 to 40 minutes 3 times per day. The left ankle, neck and low back is improved and the left knee is essentially healed. He is continuing his home care program. PHYSICAL BEAM The left ankle has much more stability without effusion with good distal and neurocirculatory function and extreme stress against the lateral collateral reveals only minimal pain and tenderness and he can now fully tiptoe and heel walk forwards and backwards. The knee has essentially resolved. Low Back - Restricted motion: Finger tips 12 inches from the floor with no reversal of the lumbar lordotic curvature. He still has tenderness to palpation but to a much lessor degree of the posterior process and on the posterior ilio crest. There is improvement in the tenderness over the greater trochanter and I suspect that this is a low grade trochanteric bursitis; although Mr. Cantrell declines a direct steroid injection today. Cervical Spine - Is much better at night, sleeping . much more comfortably with less stiffness; and now that his' activity is more vigorous although still very slow and somewhat semi sedentary, he can slowly attend to his activities of daily living, make a bed and do light housework and carry a few groceries and prepare light meals but no repetitive bending, stooping and lifting or crawling. DIAGNOSIS 1. Essentially resolved left ankle and left knee injury. 2 . Slowly resolving cervical spine and lumbar spine musculoligamentous strain and sprain superimposed on pre-existing osteophytic degenerative changes. CANTRELL, Edward Page 2 29 November 1993 DISPOSITION: To continue a short period, perhaps 2 weeks on a 2 time per week basis and increasing activity and home care. I would anticipate a scion release perhaps within two weeks. NORTH OAKLAND MEDICAL CLINIC Family and Industrial Medicine Bruce E. hompson, M.D. FAADEP Board Certified Occupational Medicine BET/dyt File:hcw North Oakland Medical Clinic A ' 6105 San Pablo venue Bruce E.Ti son,M.D;,F.A.A.D.T.P. Oakland,California 94608 Diplomate,American Board of Family Practice (510)658-7660• FAX(510)658-5138 Board Certified Occupational Medicine Fellow,American Academy of Disability Evaluating Physicians Family&Occupational Medicine Qualified Medical Examiner A Professional Corporation CANTRELL, Edward 10 December 1993 NARRATIVE SUMMARY DOI: 16 October 1993 DOB: 19 December 1950 Edward Cantrell is a 42-year-old male first evaluated at North Oakland Medical Clinic on 4 November for multiple injuries referable to falling into. a open manhole cover injuring his left knee and left foot and.,straining his back and neck. The initial evaluation revealed a - diagnosis of cervical spine musculoligamentous strain .. and sprain and a low back strain superimposed on early degenerative changes with left knee wrenching injury and a left lateral collateral ankle stretch .strain. He continued to treat himself at home without improvement for approximately 3 weeks :prior to the initial visit and came in on crutches with a stiff neck and low back with resolving contusion over the left- forefoot and strain of the left knee. ' Treatment was instituted including cervical spine and lumbar spine knee and ankle supportive bracing, .anti-inflammatory medications (such as Motrin) and muscle relaxers, (Parafon Forte) , as well as time, rest and physiotherapy. Mr. . Cantrell' is an unemployed previously disabled middle aged individual who has a very marked deconditioning and poor soft and weak musculature throughout and has lived a very sedentary life. He has less than adequate nutritional status and unfortunately continues to smoke more than one.pack of. cigarettes daily; all risk factors known to delay normal tissue healing. Mr. Cantrell 's clinical course is characterized by one of gradual and slow improvement in his injuries and discontinuation of his crutches and cervical collar, but continues to complain of mild nearly constant low level of low back ache and pain aggravated by attempts at any work, bending, stooping and lifting, crawling, climbing, and has maintained a very sedentary existence at home with his wife and two children. The last evaluation of 29 November anticipated a soon release, and indeed after 3 further sessions of-physiotherapy and continued home care, Mr. Cantrell has now nearly achieved a preinjury status although he still has bad back and very deconditioned body but no significant further pain -or stiffness or disability related to the - -knee and ankle and neck injury. CANTRELL, Edward Page 2 10 December 1993 X-ray were obtained - 10 November Michael M. , Marsilli, M.D. , Radiologist which revealed degenerative changes in the lumbar spine without fractures or dislocations in the neck or the left knee. The initial x-rays of the left foot were obtained at Brookside Emergency Room and reported are within normal limits; and indeed, repeated clinical evaluations revealed no evidence of any dislocation, trauma or persistent stretch injury of the lateral collateral ligament. PHYSICAL EXAM Left Ankle - There is good stability against maneuvers in the left ankle indicating adequate collateral ligament security and a normal tibial tailor articulation and he can do extremes of toe and heel walks and raises. There is adequate strength and neuromotor and neurosensory function although he is somewhat weak and has a moderate degree of advanced peripheral vascular disease. The left knee is stable and essentially on physical examination is comparable to that of the right normal knee. Low Back - 'Still reveals some restricted motion - unable to reach further than 10 inches from the -floor with slow movement and poor reversal of curvature with some generalized tenderness and poor .bio mechanics and very tight hamstrings but essentially normal orthopedic biomechanics. There is no distal paresthesia, numbness, tingling or sciatica nor any evidence of discogenic trauma. Straight leg raise is restricted bilaterally but without leg pain; Laseque's is negative and sitting straight leg raise is to 80 degrees and normal bilaterally. Deep tendon reflexes and neuromotor and neurosensory functions in the lower extremities is perseved. Cervical Spine - About 80% motion in all planes, probably represented normal for this individual. Deep tendon reflexes and motor and sensory function in the upper extremities is equilateral and normal although he is somewhat weak for a man of his age. DIAGNOSIS Essential trauma from the instant injury of 16 October: 1. Cervical spine and lumbar spine musculoligamentous strain. 2 . Mild aggravation of low back degenerative osteoarthritis. 3 . Left knee strain. 4. Left lateral collateral ankle strain and contusion. DISPOSITION: As Mr. Cantrell is essentially achieved maximum medical outpatient improvement, further physiotherapy and follow- . CANTRELL, Edward Page 3 10 December 1993 up is discontinued. The prognosis probably remains stable for this individual who had some prior level of obvious low back disability, and has remained on SSI disability but essentially has achieved his previous status following approximately 1 month of time, rest and medications and physiotherapy and supportive brace. TREATMENT I recommend that Mr. Cantrell continue the use of anti-inflammatory agents such as Motrin twice per day on a regular basis. He has no further need for the crutches but may use the lumbar support for security and back fatigue relief. He has no further need for the cervical collar nor the knee or the ankle brace. I reassured Mr. Cantrell and advised him that I feel no further neuro diagnostic tests nor out patient treatment is indicated; but advised him to continue a course of general body strengthening and condition such as walking daily for several miles and to discontinue smoking. Nicorette gum was prescribed and anti-smoking literature was given. I did not give Mr. Cantrell a definite return appointment, and anticipate that he will remain relatively stable without further manifestations of symptoms from this recent injury, although I expect his low back will remain at a low level of symptoms and disability and probably slowly progress. I remain happy to see him in the event that further symptoms or concerns warrant. NORTH OAKLAND MEDICAL CLINIC Family and Industrial Medicine. !Bruce E. ompson, M.D. FAADEP Board Certified Occupational Medicine BET/dyt File:hcw North Oakland Medical Clinic - JOELL CARE REHABILITATION C-) 6105 San Pablo Avenue Bruce E.Thompson,M.D.,P.A.A.D.E.P. Oakland,California 94608 Diplomate,American Board of Family Practice (510)658-7660•FAX(510)658-5138 Board Certified Occupational Medicine Fellow,American Academy of Disability Evaluating Physicians A Professional Corporation FamiOccupational Medicine Qualified Medical Examiner atient: �-+n�ycQRAU4(� volved Areas: " iagnosis• 54PU aP C1,,M. L isiil' Dates: � �� o-g-'�'3 ;oafs of Therapy: �ain Relief i Strengthening Mobility/ROM Biomechanic Education Gait/Posture Functional Training 2mm o� 4` 2 0` m ° u -e 0 O m Q` i' m m DATE �' �+ om m Vj° St. c m g m >m j= c� �co /,,I �o �ro OY ti J C9oo y y �m Q TIME Q NOV - 4 199.3 ✓ ✓ ✓ V ✓ ✓ ✓ : (� 10V - 8 19M DV 10 1903 YV 1 2 1q,.M OV 1 5 19m 111! 1 7 JOV NOV 22 10 HOV 26 19 LOP 1903 DEC - 3 19T- 'EC - 6 1993 DEC - 8 i )EC 1 0 Is'- Nam Data VI-3 Color Character Glucose Bilirubin_.-- WBC `1 Ketone�- RBC ..-. i Sp.Gr. A � ; Casts(LPF) m(-,JL Blood Ep.Cells Q- pH Bacteria Protein Crystals Urobilinogen Other Tests Nitrite �"- Leukocytes "— Other Tests_ Technologist?-- NORTH OAKLAND MEDICAL CLINIC URINALYSIS REPORT OA�ell �JOV 8 199p o 4 I v 10 W.1 13 4 O/S , 4 1 f' UL y �Y 4 I rlov i 5 13' 17 (g rt /•t►VtG VA��1P11'GG4 s}�1! +11+1.9 rnfPZ, Sign,,x:c,-t U Vtq nuk cmar Rn++ h4a lkE4f' �NtiG NOV 19 1 - _ - Nov 2 2 1993 9 � + -6 rs I-A! 2 6 199 -P KinAl 2 7 iGq.l 7t* j t 2 9 19 f({{ ��. "�- `j� Ccn�+•yx,� � Sr�cdri .�4��;17 ;�,�t�i►'{. � � �ltnw2����'C 1 l�,c� tr.ci_•r-,',,,� ' VS'+rtr� 1)14 pi 1L'ut1 hzRf r SFtLrt1+✓ CYLrLi;c� t /►�vi+C l�Ja /,yr�er rP ��, .,J �L�tlnt�Lt, (aic2 jr+dl r)srr /c1�ar'. Lit )EC 1 1993 �� ` YS t ` OEC -'8 1990C e4 DEC I 0 V-191 - BROOKSIDE-� ��� SPITAL- . F I N AL: .••1lG V.x 6 94"� a 2400-Vale:Road - Sari Pa !o;'CA 94806 1 •a a p qp 1. •tf IRI. 'tD rr'Q_R D,:L 'S P, CQN TRtL•L. .�, 13403 S. P. AV : SPi3.. :'M :Di:=CAE:-oUTPtt.TIEtVT:`;=:.: -'•` SAN'- PA3Li .; - : CA: :94866 076095.52746625 ���.°;,, 1� -,I• a .+ .. � .• - - - « � . . .- " .. :-: :-• "� . 0/ 16 1 ED:'FA.CIL.I'TY II- •_ .40159021- --1'0'8 'o"6" 0/ 16 1 . LIN,EfV :..PA.CK -: :: 40158502 ErIERG'ENCY ROOM--:`:':-_'r-:'. . ':i:�:i:� :�::::: 7_ ::. . . . ; 0/ 16 1 LIMITED .E/R EXAM 48727066 65 .00 65.60 E R' RM—PR OF FEE b5 .00 5. 00 0/ 16 1 ,A:C t„T:A'MrIIV'e7fpH E N. 2=5”! = . - - - - - ' G� :4 715982 0 ':2 -9: _» : :• :: 0/ 16 1 AIVK}l;E.'3 MEWS - --4� 5.305085:.=115' QO 115..O.t7 0/ 16 1CAI ; - .4fi3C5754 I20` QU 120:.60:.''.+.- = ` 0/ 16 1 c3P :VISITi'� 4630000 1'' R AD ID-LO G;'Y - : `=:::;,;,.�• 23 5 ` :Z.. 5::-0* -' :'0 0: 0/ 15 1 ' 8ANDA•G'E' -.CE 3 :IN` 4k700035 1 . . . M1+„ .. 0/ 15 i GISPDSALE44704995. CENTRAL-.SUPRL•lES.. �;S G O.+aLC160U)R=5Av0 .-=.' .'ADDITibNAL PATIENT BILLING MAY BE N=C'cSSARY FOR ANY CHARGES :SOR?r4°OrD�t�E. NOT POSTED WHEN THIS-SILL WAS PRcPAnED, OR IF INSURANCE CARRIERS DO NOT PAY ANY PART OF Tr+.E AMOUNTS SHOWN. FORM 8530.136 ° _ s � ° _ . ° �. ° e st • s , (1=83) PLEASE'- :A.NON PRt7FiTORGANt2ATiON ..PHONE(510) 235-7006 IMPORTANT:INSUr= ' - COVERAGE IS O;;' ... BR C - " IDE ' SPITAL - - _ . . ' . F I n A� 10/30/9 3 f 2000:Vale Road • San:Pa lo; CA 94806 - - — _ �•'"1\'1W\� 111 .1711 7 . t � �� .. .. «}. 4 i - - �q1.. _ -rte.'• •, ..,',. •. /. .. -7 - F .. EDwARC L ,SR. C'A1yRc ,. 13.40 3'.".S;'..':P .SP 23 _ . .. ,.. AVE :', :1'SEpI.�C',21:>::O�sTPA.T'I:cNT _r. 806 IC,,L'CP.'' _ 0.7609552746525 TOTAL CURRENT. CHARGES 445.98 445.93- ~ BALANCE •-FORWAR0 CHARGES TO'-DATE;�-PA YiIENTS::-4-015:" Dc0uC_T-1 _E= AM -- O:tiN T'S. :r.---'_7_ C C:O,U:N.T� '9 A'L 11 N C E - - - ' _ '4:4:5•::9.$-' '- ... =7' •'PLEASE REFER TO PATIENT NUMBER ON ALL INOUIRE3 AND _ — ADDITIONAL PATIENT-BILLING MAY BE NECESSARY FOR ANY CHARGES Ci?.i:Ek-NOENCE. - NOT POSTED WHEN THIS BILL WAS PREPARED. OR IF INSURANCE "'CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN. ��3�i33 tl • � ` i ' ` i tl �' 0 ' 7• tl tl .•. PLEASE : ANON PROFIT ORGANIZATION!• PHONE(510) 235-7006 •- IMPORTANT'INSUR''' ,..� COVERAGE 19 n!:: JA.' �- 'lc/�oia.:� - - _ B•ROOKSIDE, F' SPITAL - - n M. j I L L 2000 Vale Road • San Pa lo, CA 94806 1 _ q E 0. A: ] L 5R' 'CAI-JR :r 6-i-5.00-90.- 77 c end • Ali s •• • - 1C/ 16/ :3 . 1 ?6 10/ 16/ 33 1 til 12 /19/50 552746c25 %;COivNOR � 151CriA_L E:D�iAR0 L' SR' CA:aTRELL 131,03 'S.' ?. ►vE SP13 ME 61 -C AL• 0UTPAT-?,ENT. ' SAN PAEL6 CA 9 4 8 C t MC AL CP 07609552746625 EIMERG•ENCY Ri01MI111 .00 121 :0C ER Ry=PR Or" FEE 05 .00 65.'u0 'PHAR'4ACI 2 .98 2.98 .•R AD 11)LO Gy 235 .00 23:0-00 CENTRAL..-SUPPL_:S 22 .0'0 22.0C i TOTAL' 'CURR ENT CHAP GES 4'45'.98 445.98 BALANCE -FORWARD :CHARGES T:0-DATE ' PAYMENTS': AQJS. ` DE7UCTT8LE AMOuWTS AC COUNT'•.EALANCE 4'45 .96 10 '"Z" Z PLEASE REFER TO PATIENT PIUMI3ER ADDITIONAL PATIENT BILLING MAY°__N=CESSARY FOR ANY CHAR.=S ONALLI:,ONCENC . -- NOT POSTED WHEN THIS BILL YiAS PREPARED. OR IF INSURANCE CORKED.CNCE:ICE. CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN. _ .. 4 v y FORM 0 0 '•0 ' 0 0 7• • �' 7• s 0 •1 3530-130 (1-53) PLEASE - -//-- /moi i , - IIAPORTANT:INSURA' 550.14;0. PLEk-n �20 ZCLG n"aQ�2�t4e A NON PROFIT ORGANIZATION PHONE(510) 235-7006= - •cOV_RAG=_iS c�_ .FINAL . �I1 BROOK I - 5 I L L .2000 Vale Road :San Pablo, CA:948Q6: 1 11!24. . . • �.: •.. .•_-. ......... - _::: :�::•.=:':�:_: =:: . ..=�.�:�_.::�.-:=.-� . . / 93 23 :. 19. 1:1l.2-4/ 93 Z_3 : .2 - '1.2'%"19/50 55`2.7.4* b2.5 : n00:G5.ON:�: L•AU►ZcL A. CD.:ARO (: SR CAiYTrELL 1340! SP , AVE'-,' TM11 ter. . ":` :. .: t�0I -C AL:"�J:t}T.F:il•=T E N T.-::- I. SAN PABLO CA 9480ii 07 60955274 6625 1/24 1' E0 FACiL'ITY ty22 108 0 - 1/ 24 , :1 LINEN.: P4 _ 10:5':0.0 ; 1�5o 13 .0 U Gt} =13:: E Ertcc'nicY:`Robm' - 1Z1 .Q:a 1/24 1. LIMITEO:*:E/:R:'$'EXa~lY,:.- - '~4.8727466. 65 00 - 65::00 ER RM=P. OF 05 _ - .00 -65:'00 TO TA �'Ct1RR cFIT�' HtiR'GES - 1$6 .0 - - 0- 8b:c�0 BALANCE, � FORWA2.0 .CHARG,.S ' TO-DATE .PA-.YME'NTS -A:DJS :: OEDUCT'i3 ACCOUNT CO G - .. N T :3AB 'A - _ . _ ..Y. - •• .. • ti:Y - - - - - - _ Iff , _ •• a :a• PLEASE R===asoaaA;;E:1rNu,+__A•.. , . -. ..:...,• ,:.-•'. .-.: ' � , '.. - ON ALL INOUIR'cS A-40 ADDITIONAL PATIENT BILLINGtiAY 3E NECESSARY FOR ANY CHARGES Ct .,? 7 1 CORRESPOioENCa.. - NOT POSTED Y.Y.=N THIS S(lt WAS PREPARED: OR IF INSURANCE 1 CARRIERS DO NOT PAY-ANY PART OF THE AMOUNTS SHOWN. FORm 8530.136 * • �' • • - - s • • . . (1-$3) PLEASE IMPORTANT:iNSURA: A `-^ '""r T»►rlilfdAirw.: + r>I�i ffil'I/a� : :;: NON PROFIT ORGANIZATION PHONE(510). 235-7006 - r,GVERAGE IS G.;= 0KSI 111m, Amid] .,F N L ; '] /3.019;3.: :or .J. 1 BR-0 :DE:: SPITAL - 3 I L L U 2000 Vale Road Sari:�a lo;. CA.94x06 -er=r S.O.M.M AR Y. 3 I L N EDWA2D L SR CANTRELL :% % o' ::.•61'59.2994 77.48-19 ' : :.' x.:." E 11/ 24 / y3 23 .1.9. . .11:/2ti/;53 23'.:22.'•-.'-1.2/19/50 :5:52.7-.4.6-b2'5,:• NLID GSONr'.:!-AUREL A. EDWARD:-C: 13401 SP .'AVE;-.:: 11 ME JI -CAL O.U.T.P.A:TI'ENT::- : SAN PAQC,: .: . : Ca -.'94 8'06 : ' ' . MC.aLOP : .0760955274b625 .�1 M X N• 0 . . 7. 1 N rw w MEN. •. Er.ERGENCY- R0OM. :: 121 .00 : . 12.1:0.0 E R RM-P:R•,OF::F.E E:: - _ 65 .0.0: ::.65..:QO TOTAL . CURR':-E.NT=-:CN:i•R:GES: = = 106 .00: :186:r"O - BA LANCE-FOAWAR-0 CLfARGE'S .:::..::::_:;::::.•..:. JO-DATE ' DEDUCTIB:LE` AM-0UNTS -- ACCOUNT .BA'LANCa lob .0 U.: - 7. <{ i� '�• F!--c 5=^`'=a-=PGTIEti'r:U^"3ER. _ ADDITIONAL PATIENT BILLING IMAY?__NECESSARY FOR ANY CHARGES CN ALL 114CUiR°S AND NOT POSTED WHEN THIS BILL WAS 'PREPARED. OR IF INSURANCE •,14 CORRESPONDENCE. CARRIERS DO NOT PAY ANY ART OF THE AMOUNT SHOWN. o • q• . o • - • �. • - � . • �. • • :53G-i33 --f -33) PLEASE MAA ,.: IMPORTANT:INSUPA' ___ / ,J,. �1:,.,l.:f.i0 A NON PROFIT ORGANIZATION ' PHONE(5101 235-7006 01-24'-1994 14:28 5106585138 N.O.H.C. P.02 - t NORTH OAKLAND MEDICAL CLINIC FAMILY AND INDUSTRIAL MEDICINE BRUCE E. THOMPSON,M.D. 6105 SAN PABLO AVENUE OAKLAND,CALIFORNIA 94608 : '• TELEPHONE 658-7660 STATEMENT 12/22/93 PATIENTi EDWARD CANTRELL 12157 DATE OF INJURY:10/16/93 DIAGNOSIS:CERVICAL SPINE STRAIN LS SPRAIN 4.i!A A A A f f f!f A &&A A f!a A!f a 1 A A A f A i A f A!A A a!a A A s a a a A a A A A A A A■A A A A A f A A A A M A A A A FOR PROFESSIONAL SERVICES 11/04/93 90020 NEW OFFICE VISITiCOMPREHENSIVE 275.00 11/04/93 81000 URINALYSIS W/MICRO 13.00 11/04/93 99070 MEDICATIONtMOTRIN 600MG #45 24.00 11/04/93 99070 MEDICATIONSiPARAFON FORTE #30 45.00 11/04/93 99002 FITTING ORTHOTICS 27.50 11/04/93 99070. MATERIALS:CERVICAL COLLAR 28.00 11/04/93 99070 MATERIALS:JACKIE CERVICAL PILLOW 61.00 11/04/93 99070 MATERIALS:L/S CORSETTE 78.50 11/04/93 99070 MATERIALS:ANKLE SUPPORT 23.00 11/04/93 97010 PT-HOT OR COLD PACKS 36.00 11/04/93 97012 PT-TRACTION, MECHANICAL 33.00 11/04/93 97139 PT-MOBILITY ROM 33.00 11/04/93 97110 PT-THERAPEUTIC EXCERCISES 30 MIN. 45.00 11/04/93 97026 PT-INFARED 33.00 11/04/93 97145 PT-ADD 15 MIN. 21.00 11/08/93 97010 PT-HOT OR COLD PACKS 36.00 11/08/93 97012 PT-TRACTION, MECHANICAL 33.00 11/08/93 97139 PT-MOBILITY- ROM 33.00 11/08/93 97026 PT-INFARED 33.00 11/08/93 97145 PT-ADD 15 MIN. 21.00 .A a A a A.A a A a A A.a a a A A a A a a A .a A A A A A A A f a a.A f•a f A A A.A!a a. .A A A a A f A A•.r .A a A A f a TOTAL DUE 932.00 BRUCE E.THOMPSON.M 4. - IRS#t.94=2162760 - JACOBY .&-MEYERS.. - inn Atmw Henn - 01-24-1994 � ag 510658SI38 � w'o.n.C. p.0314:29 . . ' WORTH OAKLAND MEDICAL CLINIC FAMILY AND INDUSTRIAL MEDICINE BRUCE E. THDMPSON,M'D. 6105 SAN PABLO AVENUE ` OAKLANO,CALIFORN%H 94608 � TELEPHONE 658-7680 STATEMENT l2/22/93 PATIENT: EDWARD CANTRELL 12157 ^ DATE OF INJURYx1O/16/93 DIAGNOSJS:CERV}C8L SPINE STRAIN LS SPRAIN ^^^^A^°^^^^"~^^^°"^.~°^""^^A,^^^^^°"^A^^.^^,^.^"°^°"^^°",°°.^°A^^^4°^*^. FOR PROFESSIONAL SERVICES 11/10/93 90060 OFFICE VI8IT:lNTERMEDlATE 71.00 11/10/93 72050 , X-RAY SPINE" MIN 4 VIEWS 110.00 I1/10y93 721I0 X-RAYxLUNB0SAC SPINE COMP W/ODL%Q 134.00 11/10/93 73582 X-RAY:KNEE, LEFT 87.00 I1/10/93 97010 PT-HUT DR COLD PACKS 36.00 11/10/93 97012 PT-TRACTION, MECHANICAL 33.00 11/10/93 97026 PT-INFARED 33.00 11/10/93 97145 PT-A00 15 MIN.' 31.00 I1� 12/93 97010 PT-MOT OR COLD PACKS 36.00 11/12/93 97012 PT-TRACTION, MECHANICAL 33-.00 I1/12/93 9.7012 PT�-TRACTION^ MECHANICAL 33.00 11/12/93 97026 9T-lNFAQEU 33.00 11/12/93 97145 PT-ADD 15 MIN. 21 .00 11/15/93 97010 PT-HOT OR COLO PACKS 36.00 11/15/93 97012 PT-TRACTION, MECHANICAL 33.00 I1/15/93 97012 PT-TRACTION, MECHANICAL 33.00 I1/15/93 97026 PT-INF8QED . 33.00 I1/15/93 97145 'PT-ADD 15 MIN. - 21.00 I1/15/93 99070 NEDICATlONSxPARAFON FORTE #]O 45.00 11/17/93 90060 OFFICE VISIT: lNTERMEDlATE 71.00 - ^^^^~~°°°°~^^^^^ ^."^°^^^~.^° .^AAA.^^°^°"^~.^^^^^~~^^^~^°^^.^.°.~°°~"^"^ . ' TOTAL DUE 953,00 ' - ' - - - BRUCE E.THONP3ON�N.D, - ' - lR50x94-21*63760 - JALOBY & MEYERS - 100 BUSH . #700 S8N� FRANCl�CO CA�94lO4 ` - '- '- - ' ` 01-24-1994 14:29 5106585138 N.0.tl.C. P.04 NORTH OAKLAND MEDICAL -CLINIC . FAMILY AND INDUSTRIAL MEDICINE BRUCE E, TKOMPSON,M.D. 6105 SAN PABLO AVENUE OAKLAND,CALIFORNIA 94608 TELEPHONE 658-7660 STATEMENT 12/22/93 PATIENT: EDWARD CANTRELL 12157 DATE OF INJURY:10/16/93 DIAGNOSIS:CERVICAL SPINE STRAIN LS SPRAIN AAA A A A A*A 0,A A*A A A A A A k A A.A A a A A A A a A A A it A A A A A A A A A A A A A A A A A.A A A A A A A A A A A A A 0%A a A A FOR PROFESSIONAL SERVICES 11/17/93 97010 PT-HOT OR COLD PACKS 36.00 11/17/93 97012 PT-TRACTION, MECHANICAL 33.00 11/17/93 97012 PT-TRACTION, MECHANICAL 33.00 11/17/93 97026 PT-INFARED 33.00 11/17/93 97145 PT-ADD 15 MIN. 21.00 11/19/93 97010 PT-HOT OR COLD PACKS 36.00 11/19/93 97012 PT-TRACTION, MECHANICAL 33.00 11/19/93 97012 PT-TRACTION, MECHANICAL 33.00 11/19/93 97026 PT-INFARED 33.00 11/19/93 97145. PT-ADD 15 MIN. 21.00 ^,AAAAA^^AAA A w A A w w A w A w A w w w w A A Yl A w A A w wAAA**.*A*A A A a A*A A A.A A A A A A A A TOTAL DUE 312.00 BRUCE E.THOMPSON,M.D.- " IRSN:94-2162760 JACOBY & MEYERS 100 BUSH 1700 SAN .FRANCISC'O.CA 94104 01-24-1994. 14:30 5106585138 N.0.M.C. P.05 NORTH OAKLAND MEDICAL CLINIC FAMILY AND INDUSTRIAL MEDICINE BRUCE E. THOMPSON,M.D. 6105. SAN PABLO AVENUE OAKLAND,CALIFORNIA 94608 TELEPHONE 658-7660 STATEMENT 12/22/93 PATIENT: EDWARD CANTRELL 12157 DATE OF INJURY:10/16/93 DIAGNOSIS:CERVICAL SPINE STRAIN LS SPRAIN A A A A A#w A r A A A A w w A A A A it A A A A A A A A w A A A A A A A A A A A A A A A w A A A A A A w A A A w w w w A A A A A A A A A r r A FOR PROFESSIONAL SERVICES 11/22/93 97010 PT-HOT OR COLD PACKS 36.00 11/22/93 97012 PT-TRACTION, MECHANICAL 33.00 11/22/93 97012 PT-TRACTION, MECHANICAL 33.00 11/22/93 97026 PT-INFARED 33.00 11/22/93 97145 PT-ADD 15 MIN. 21.00 11/26/93 97010 PT-HOT OR COLD PACKS 36.00 11/26/93 97012 PT-TRACTION, MECHANICAL 33.00 11/26/93 97012 PT-TRACTION, MECHANICAL 33.00 11/26/93 97026 PT-INFARED 33.00 11/26/93 97145 PT-ADD 15 MIN. 21.00 11/27%93 97010 PT'-HOT OR COLD PACKS 36.00 11/27/93 97012 PT-TRACTION,- MECHANICAL 33.00 11/27/93 97012 PT-TRACTION, MECHANICAL 33.00 11/27/93 97026 PT-INFARED 33.00 11/27/93 97145 PT-ADD 15 MIN. 21 .00 11/29/93 90060 OFFICE VISIT: INTERMEDIATE 71.00 11/29/93 97010 PT-HOT OR COLD PACKS 36.00 11/29/93 9.7012 PT-TRACTION, MECHANICAL 33.00 11/29/93 97012 PT-TRACTION, MECHANICAL 33.00 11/29/93 97026 PT-INFARED 33.00 •A A A A A A A A A A A A A A w A A w w w w A w A w A r w A A A A■w■r A A A A A w A A w A A A w A A A w A A A w w A A A A A w A w A w A A TOTAL DUE 674-00 BRUCE E.THOMPSON,M.D. IRS#:94-2162760 JACOBY & MEYERS 100 BUSH #700 _ - SAN --FRANCISCO CA 94104 01-24-1994 14:30 5106585138 N.0.M.C. P.06 NORTH OAKLAND MEDICAL CLINIC FAMILY AND INDUSTRIAL MEDICINE BRUCE E. THOMPSON,M.D, 6105 SAN PABLO AVENUE OAKLAND,CALIFORNIA 94608 . TELEPHONE 658-7660 STATEMENT 12/22/93 PATIENT: EDWARD CANTRELL 12157 DATE OF INJURY:10/16/93 DIAGNOSIS:CERVICAL SPINE STRAIN LS SPRAIN A r w w w w w w w w w w w r w w w w w w r w w r r w r r r w w r r w w r w r w w w w r w w r r w r r r r r r r r r A w r r r r w g w r w A A FOR PROFESSIONAL SERVICES 11/29/93 97145 PT-ADD 15 MIN, 21.00 12/01/93 97010 PT-HOT OR COLD PACKS 36.00 12/01/93 97012 PT-TRACTION, MECHANICAL 33.00 12/01/93 97012 PT-TRACTION, MECHANICAL 33.00 12/01/93 97026 PT-INFARED 33.00 12/01/93 97145 PT-ADD 15 MIN. 21.00 12/03/93 97010 PT-HOT OR COLD PACKS 36.00 12/03/93 97012 PT-TRACTION, MECHANICAL 33.00 12/03/93 97012 PT-TRACTION, MECHANICAL 33.00 12/03/93 97026 PT-INFARED 33.00 _ 12/03/93 97145 PT-ADD 15 MIN. 21.00 12/06/93 97010 PT-HOT OR COLD PACKS 36.00 12/06/93 97012 PT-TRACTION, MECHANICAL 33.00 12/06/93 97012 PT-TRACTION, MECHANICAL 33.00 12/06/93 97026 PT-INFARED 33.00 12/06/93 97145 PT-ADD 15 MIN. 21.00 12/06/93 99070 MEDICATIONS:PARAFON FORTE 030 45.00 12/08/93 97010 PT-HOT OR COLD PACKS ' 36.00 12/08/93 97012 PT-TRACTION, MECHANICAL 33.00 12/08/93 - 97012 PT-TRACTION, MECHANICAL 33.00 ••w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w w -TOTAL DUE - 636.00 - BRUCE E.THOMPSON,M.D. _ - _ IRS#:94-2162760 _ JACOBY & MEYERS 100 BUSH #700 _ -SAN FRANCISCO CA 94104 - -_ - - 01-24-1994 14:30 5106585138 N.O.H.C. P.07 NORTH OAKLAND MEDICAL CLINIC FAMILY AND INDUSTRIAL MEDICINE BRUCE E. THOMPSON,M.D. 6105 SAN PABLO AVENUE OAKLAND,CALIFORNIA 94608 TELEPHONE 658-7660 STATEMENT 12/22/93 PATIENT: EDWARD CANTRELL 12157 DATE OF INJURYt10/16/93 DIAGNOSIS:CERVICAL SPINE STRAIN LS SPRAIN A A A A A a•A A A MAP A A AAA•AAA A A A a A A A A A A A A A A A A A A A A A A A A A A A A A A A A P A RA a A a A a a a A A A A A A FOR PROFESSIONAL SERVICES 1.2/08/93 97026 PT-INFARED 33.00 12/08/93 97145 PT-ADD 15 MIN. 21.00 12/10/93 90080 OFFICE VISITiCOMPREHENSIVE 140.00 12/10/93 97010 PT-HOT OR COLD PACKS 36.00 12/10/93 97012 PT-TRACTION, MECHANICAL 33.00 12/10/93 97012 PT-TRACTION, MECHANICAL 33.00 12/10/93 97026 PT-INFARED 33.00 12/10/93 97145 PT-ADD 15 MIN. 21.00 A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A A a A A A A A A A A A A A A a a A A a a a a a a a a a a A TOTAL DUE 350.00 BRUCE E.THOMPSON,M.D. _ IRS#:94-2162760 JACOBY & MEYERS 100 BUSH #700 _ - _ SAN FRANCISCO CA 94104 _ - w _ _ m °' ao w 'r a a,' oW+ - a a a% Z Y a V W � a � O 7 � `O •�.t H � Z:n o+; rn zoo r' y x�a t)Km w: aKa 0i W4 P) na %, aa• a; N: ter• co' 0 za r w: r ' x1 Ln° t4 X00 3M! 0 0 W t Lj qC� 0 tv - 0 ,y,� 0 0 vt! t" ti o to a - a tv - a n K(D w 2 O z � n CC N to 0 0 z cn Ln 0 Ea w z 0 x7 V) 0 K u, p .a�z cn�� Cr it CD:00 z a s�zw Na>z z v�Ob cr a�.ro a s�•xcn coyz a n t roo w en o v+ �roz a ).-A Ln 10�+o a t� a t roo a 0 o�u+ 0mN oHzr r � N"%7tn -- .j Grow car t3 oto omv ro;a cr a ro a70W rr a ro N>to wa N a H• m z N 7y to �1� %0 u,z �+ to t0' ts�i Wow m W tz C Ln P� cWrt[��Z M .tn Z r x N tx'z to m in N +' �o cn oan a o ro Oa I H ►-' o�,� �°o►H-t N a 1oz x� tot-+ r I O ooa a 7 ooa °� 0- ro 0 000 o- ro xy o 0°a� roo ~ o rata tn�x o x ",ty ro`G U+ o w 7 o oyt4 HG 0 Hr w oho - 0� pay 4 0 zG K H 07t0" 0 r a t r W �o a '< Hy W a '� }, 41 %D a W wto ax to W HN am O �z en co HN E fJ aLn co� H k H a H'< o rn x1 H ►-' o :00 O 0� yty o m s to m� i a �Hc a °' roy�� WEn� a to 7a' N rC• H -a W as H b0 y'; N K• H W H a � a v °' opo � a `-•i `' ao t C)00 ` a o c to o to c \ - o 0 a %D %D us c< � — — N 00 — w ca ao ao •f+ en en Aft NN � to +� 1-+ N N i!! fR N N %0 %p t° t° 9 J 1D Ln LnC N N Ul N \ U7 Ln - G n C:)C) G W N ! tl e .i t3� i71 P W t, N f • �* r�cn t t i o cJ] t i x �. m *d t a o cam K a �� a xm rox+�a ca�< atm X '< o ,< nr.m � anmaa a p �m►< n < anmoamOcra a ~ -! 0 L4 ro o-. omo�< o g 0D Mfi i•'d�O0to•. 0 :3K'C0m 0 "' D. -"_ rr,�atnnonronon m � a rrroo.nKsnon o orr rrnamarra Woanoon amacraOE � m o m*C O ?CtN a cr3 a N ^•`y-- m C ra ❑ n G G a O•(D fA = � �, �, — 0crMN4ammcr3mna to it �+ — r rm rt P. 7 p r 4.^_ \ N m rrY-r•m H,��0 r. „� z _ taKt7< G P.O 'ti z � � Omna r-Ox -y-<1 Mmmm � a� � O• '� '� --�'= t•NMmnaaO aG Wm r• ro tfiPC m m n n�4 £ n �-+ y y `� "to a F-0 E n r p m rt ul m O a�•m K E Y•O z o z `- K m O O N £ Y•O t••'ip cr O• 0 K cr P.a 3 a•ft£ M m n n c N 3 O•rr£'< v' n y %� acrrrmramxm • a03 0 _ _ P.n m o ' Nr�r0 .400 : ter• 0 ° z 7r Om � � � r' nna ° —= GOOYGO as ° :71,C.'-, O' Gamy DSO (D r. G) n - c rt W r m ct W a t~m +� ° = �o o },_ - rt.O 0 m r•a t-m Q n m z C Oc prO'Onnm = ooGcrmoKc] m _ m rt%Q a m Y•O m H o o `:y re m Y•• m Y•O m cr m H o m 3 C _ •,,,,7 K < �• of - o =- a G C n C O tris - ct Q - _ YO Ka •CYO tr -_J G. t4 c o NO r -- -- -.ice ..s. — .. :t. - _, ys;-..•st..-_...•. __.. —.. -, .. .. •- _ .. - 8444 300 5;t! t'r:9LG TOW4 CTR. _09N PPEL4 CA 54Wi6 (510) 23214JEPJs .• ..�..y - .. — . _ .. ..: .. -'.• ,.. ELL�SIEDWARD'�,UNG 209728---�...�—.--- � —. � • -• C YCL?38LN1PPRIIvE ICA TABLi"! ifri�c� 11/08/93 Ou43.8-0751=10 R aC 1' {510) 8:1-410» ; � WE WILL CALL YOUR DOCTOR IF YCU NEED A Rc?=ILL. SELECTING THE GENERIC - SAVED $16. 30 : - $ C14 s1.0 ~AN PA"At r I OLN CTR. ....._-- --�•_- - �- 15101 ` .':r'::a.'a:.+s:c•s:.:ra}s.a.w ct�. .as•..e:a:wr - ;. CPNTyREL-20 i=a:_-�E�DWAR_D- ( .,.:.__ ... ....-..�:.t *1728 CYCL`B 1APRI+t_ IW-T»I FT 14VL{u� - - -- 1f' �.. PRESCRIPTION INFORMATION 10,11R3 W01178-0751=10 ;3 30 ''2© -34'r - - -- -- (5100 __x-410» j rs9R:EDWARD CANTRELL 1 refill by 1%i/ 3/94 t DR. HS;J _. ._.._-.-- .._____....__. ... SELECT ING THE tG;=E-NERIC r CYCLOBENZAPRINE IOMO TABLET =D $i5. .� % a COMMON USES OF THIS DRUG: . .. ? O t'eiJ.4c_:J= ::+{154=1G rGti t"'.:it:. . [: _.-..___... =•OOW Si.OULD -s TAKE E 1T s sd �� 1 !iCsdt d='C!tr'S. �t'Iv ii" Or 7eor'essa:1'Cs. _.. Fi3ild4S MD, S instructions. Me1:t :adn 0tii-r dt`!t^s `;C.4_i . _ ._ ...;-•--- .._. .... - -•--•-1.111--'-''' go-1ses C?.l rc� 2 take or di _ U or a'!t'�GT zkknt Cr" nur s I:kr-+. ,....... _.._. _..- - -..... .__.. _:.._.....__.._..... - _ _ r - -- ARE THERE ANY SIDE EFFECT; Drdv)sir:es5. dr-•y mo?tt'r*, tines=_ ston !tc'sac. rR=Porgy It l;scIe s it-f:!est}confusion. ne'. , sl�i� r.,5i-; or d.i'ftic'!t . �v . ....__.._..�. �....._. ...- '............:.............11. 1:. .1. ..--_:.-••--'._.. _ :•..•-.�_.... -. ' R'r.ARVICY PHONE: (510) 232-0203 ASK YOUR PHARMACIST _ - - - - _ _ _ _ fir}; ° >c z ;0 v r Z(Am *w F; i =rO „� o 0. Z Y * , �gc m D=ism -� 0 +`L5 . �'TJ •.,iC j rte' � 7:1i t Y ri A"r s 4 Yd v 6 1 3 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT MARCH 8, 1994 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by theme-,-Board-Nf(Supe�v�i�sors=y; (Paragraph IV below), given pursuant to 6overnment�Code .,.;R Amount: $389,899.00 Section 913 and 915.4. Please note a+11 •warnings". CLAIMANT: The C.C.C. 1st Clfice Employee Benefits Trust ( 4 ATTORNEY: Russell L. Richeda, Esq. L —CCL•::?"_�='- =5'-! Saltzman-L'.,& Johnson Law Corporation Date received ADDRESS: 120 Howard St. , Ste. 520 BY DELIVERY TO CLERK ON Februaryll, 1994 San Francisco, CA 94105 BY MAIL POSTMARKED: February 10, 1994 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. HIL ATCVELOR, Clerk DATED: ^ 1,4 . 14 X14 Iq: �epuy � .a .1I. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ✓ This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to-apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: � (� iy 4 (Cr IV BY: Lee Deputy County Counsel 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). IV. BOARD ORDER: By unanimous vote of the Supervisors present (✓<This Claim is refected 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. 0 0 Dated: PHIL BATCHELOR, Clerk. By , Deputy Clerk 4 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 went 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 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 UnitedCates stal 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 Al , Ia. lqqqBY: PHIL BATCHELOR by011A.1 De-0 L puty Clerk CC: County Counsel County Administrator _n SAIXZMAN & JOHNSON RICHARD C.JOHNSON LAW C012P01?ATI01.q WARREN H. SALTZMAN ISAIAH B.ROTER (1925-1988) PHILIP M.MILLER 120 HOWARD STREET, SUITE 520 RUSSELL L.RICHEDA SAN FRANCISCO. CA 94105 MURIEL B. KAPLAN (415) 882-7900 JOCELYN S. DUNBAR FAX: (415) 882-9287 LEGAL ASSISTANT February 10, 1994 A v VIA CERTIFIED MAIL _ FEB j jQo4 . RETURN RECEIPT REQUESTED =CLRKaAn , i CONTt,�OUSUr�rr�lS i Clerk, Board of Supervisors str�Co oRs - County Administration Building 651 Pine St. , Room 106 Martinez, California 94553 Attn: Shirley Re: Contra Costa County 1st Choice Employee Benefits Trust Dear Shirley: Pursuant to our February 8, 1994 telephone discussion, enclosed is another signed original of the trust's claim for November 1993 contributions I had earlier mailed to the clerk's office on January 6, 1994 (together with the trust's claim for December 1993 contributions) . S 'ncerely, Russell L. Richeda RLR:jb Enclosure cc (w/enclosure) : Joe Tonda Carl Doolittle 2\contra\supervisorA t ' yue -1 Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp The Contra Costa County 1st Choice ) Employee Benefits trust ) RECEIVED Against the County of Contra Costa ) or ) FEB I I IOQA District) Fill in name ) CLERK BOARD OF SUPERVISORS CONTNA COSTA CO. The undersigned claimant hereby makes claim aaggainst the County of Contra Costa or the above-named District in the sum of $ 389,899 and in support of this claim represents as .follows: 1. When did the damage or injury occur? (Give exact date and hour) November 20, 1993 2. Where did the damage or injury occur? (Include city and county) The non-payment of contributions presumab y occurred at the offices of the County's auditor- controller. The ascertainment of the non-payment was made by the (pls. see Attachment) 3. How did the damage or injury occur? (Give full details- use extra paper if required The damage to the trust occurred through the County's refusal (1) to pay its share o the 35% increase in the premium for the 1st Choice Health Plan, (2) to withhold from each employee-participant paycheck and each retiree-participant benefit check the participant's share of the increase and to transfer that amount to the (pls see Attachment) ----------- --------------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? The particular omissions by County off-i-cers Wh_C .,caused damage to the trust were (a) their omission to pay to the trust the county's share of the premium increase due for November 1993, (b.) their omission to withhold from participants' paychecks and benefit checks their share of the premium increase due for November 1993 and to transfer that sum to the .(p1:s. see Attachment) (over) 5. What are the names of county or district officers, servants or employees causing the damage or injury? We do not know the names of the County officers causing the damage. ---- ------------------------------------------------------------------------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. The trust's damages with respect to the non-payment of contributions for November 1993 are as follows: (pls. see Attachment) ----------------------------------------------- — 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) The amount of unpaid contributions for November 1993 was calculated on the basis of 35% multiplied by the amount of contributions paid in October. The interest calculation is the amount of unpaid principal multiplied by 6%, multiplied by 30 days, (pls. see Attachmen, ------------------------------------------------------------------------------------- 8. Names- and addresses of witnesses, doctors and hospitals. Witnesses: (1) Tim Eagan and personnel at UAS's office that receive the contributions from the County. Mr. Eagan's address is listed in - i.tem number 2 of this Attachment. Ms. see Attachment) ------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT The trust has not as yet made any expenditures with respect to this cliam, since Saltzman & Johnson has not as yet billed the trust for its services C* Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) o by some person on his behalf." Name and Address of Attorney Russell L. Richeda, Esq. Claimant's Signature Saltzman & Johnson Law Corporation 120 Howard Street, Suite 520 120 Howard Street, Suite 520 San Francisco, CA 94105 (Address) . San -Francisco, California 94105 Telephone No. (415) 882-7900 Telephone No. (415) 882-7900 NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. ATTACHMENT TO CLAIM FOR NOVEMBER 1993 SUBMITTED BY THE CONTRA COSTA COUNTY 1ST CHOICE EMPLOYEE BENEFITS TRUST 2, trust's third party administrator, United Administrative Services, 1120 So. Bascom Avenue, San Jose, CA 95128-3590. 3. trust, and (3) to notify the trust of its actions. The premium increase was effective November 1, 1993. 4. trust, and (c) the absence of advance notice to the trust. 5. We do not know the names of the County officers causing the damage. 6. (1) Unpaid contributions amounting to 35% of the contributions otherwise paid in November 1993, or approximately $385,000.00; (2) Interest on the sum in number (1) at the rate of 6% from November 20, 1993 until paid (amounting to approximately $1,899 as of December 20, 1993) ; and (3) Attorneys' fees incurred by the trust to secure collection, which as of December 22, 1993 totalled approximately $2,000 and continue to increase daily. 7. and divided by 365 days. The amount of legal fees is calculated by the amount of time spent on this collections matter by the trust's legal counsel, Saltzman & Johnson Law Corporation. 8. (2) Florence McConnell The Segal Company 525 Market Street, Suite 3750 San Francisco, CA 94105 (3) Trustees of the trust whose names and addresses you already possess. J 2\contra\attachment 020894 1 DECLARATION OF SERVICE BY MAIL I, Joyce ,Buchannan, declare that: I am employed in the County of San Francisco, California. I am over the. age of eighteen years and not a party to the within cause;-: my business address is 120 Howard Street, Suite 520, San Francisco, California 94105. On February 10, 1994 I served the following document(s) : CLAIM TO THE BOARD OF SUPERVISORS on the parties in said cause by placing true copies thereof in a sealed envelope with postage thereon fully pre-paid, in the United States.: Post Office mail box in San Francisco, California, addressed as follows: Clerk of the Board of Supervisors Room 106; County Administrators Building 651 Pine Street Martinez; California 94553 Carl Doolittle Joe Tonda 14 Dandridge Place 651 Pine St. , 6th Floor Pittsburg, CA 94565 Martinez, CA 94553 I declare under penalty perjury that the foregoing is true and correct and this Declaration was executed on February 10, 1994 at San Francisco, California. J yce Buchannan � f 0 • ,•~k.r.i:. y� yF .moi. ;Mt C •• •+•`C7 C+ �•cc eD = o' ' o to N tD 75 ca -� w 'n > x ' ta ;a + -h � ° Oz P Ln O w cn t+t a w � �� r ° Ir N o m > cc z 0 p cn co �• to N F yy��* C fn 0. 1.4 cfl m V m .a c� m 4 m v � SA rn 1^ A w i+ co 4. 7 Q0' .gyp B'48 t i r� Lill ' ? FYRRRRRRRRhRRR e k `J CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT MARCH 8, 1994 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant tp�Gover-nment--Cod1e- --f-��-�-y Amount: $2,365.53 Section 913 and 915.4. Please note of�Warnings"r �l �� 1 CLAIMANT: BAnvE, Harold E. FEB 4 ATTORNEY: Date received ;'"r+`L u CO5NTY C6LPiSE ADDRESS: 2520 Ryan Road 492 BY DELIVERY TO CLERK ON February 111, 1994 11NART1 !CALIF. _ Concord, CA 94520 BY MAIL POSTMARKED: Hand Delivered 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppH gg NN DATED: — tom_ 19 9 61'ZL DeputylOR, Clerk .I1. FROM: County Counsel TO: Clerk of the Board of Supervisors ( V1 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 lrotifying 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: �hu- �y , j�q�/ BY: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Mministrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). JV. BOARD ORDER: By unanimous vote of the Supervisors present ( ✓This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By—(L 01 6 ° . 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 an 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 2 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 Unitedtales stat Service in Martinez, California, postage fully prepaid a certified copy of this Board OrdeSl r and Notice to Claimant, addressed to the claimant as shown above. DatedA: BY: PHIL BATCHELOR by 10,41 a Deputy Clerk CC: County Counsel County Administrator Claim -.o: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating. to causes.of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or. before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause -of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 6911.2.) 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 flied against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * RE: Claim By NAR.ec.o E. BAV4& ) Reserved for Clerk's filing stamp c.oN coa.4 , GA 44 rzo � RECEIVED Against the County of Contra Costa ) FEB 111994 or ) S—BOARD District) CLERKCONTRA COSTA CO.ISORS Fill in name ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ Z . 3 (e T . S 3 and in support of this claim represents as follows: 1. When did the damage or injury occur?. (Give exact date and hour) ; SIEPT��•E+� �q�3 2. Where did the damage or injury occur? (Include -city and county) oFgle-E or- Toe risrzc.T ArTraw" '1 FAM.ioj SuivfbQX o4rFiCFL A*A"I I44. C AU&r- • 3. How did the damage or injury occur? (Give full details; use extra paper if required) Tut r^c"t.L4i SvoNar &ZFttA rK �S N•P C�2a PR.:, �,Q 2,%Ir, C3 1CM601 11�.co��r S4 y Mo . TOMw qua isa it morin irswml. M C&A,mm i . 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? ::Me ArMck&O &t-79 .1 To: Ro&&O of SvpMtSo RA OF cAuTrA toorg, cowry AAW (over) It 5. What are the names of county or district officers, servants or employees causing the damage or injury? pis rlucr '4rroa uel haw��c� Su PPOLr OPPICZ . 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Loss o1: 2 , 7. How was the amount claimed above computed? (Include the estimated amount of any prospective Injury or damage.) See cool 89 1-Ole-t D- 29 (AIW. 8 ;,71�� Fey m cr , 19ti 3 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT eeeeeeeeeeeeeee�eeeeeeeeeeeeeeeeeeeeee * ecce a Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant- SEND NOTICES TO: (Attorney) or by Daffe-)verson on his behalf." Name and Address of Attorney Claimant's S tune ZS2D FLf AAl JW � � �7 2. Address C.OMGoX4,j CA ofte Telephone No. Telephone'No.(." eeeeeee eeeeeeee :tee NOTICE ` Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or - officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. AzoA* o o Svi cow;asar a le� 9� o c. coa � vrc� - • Vic.. � �s'z 9Z. CO/f/GGvf;/J 44 4 41grad CAri�r,C OF eg..9 tq. -w. rw4e .!'•womw OF � ,Z Si r-. 43 owie-W Z///Of/ ro oar.rim " Aowr0 calf sapgowlsotA F.l.W�u� Ar 0,1;;;v Fi�`ice c�F ?ra►E ZrS.iWO" A77o"e �s - - ' ..� -QFi�I CSE._. •" ��1.0�� Fv�.i:r0.S.' r AJ '64 �. � � �L - . , F�A,�,�,: .�u, -J4cC�t:a'v� ,� S"4y�r-76� S�►c..grtlt,;� � ��x.! T� ' �sa,�4it aiF . rpt ID .A tg P. rK ^0t.0&J " WPC%' �:vl. � r Ar r.Rum,.R+b Ar .I � OCTws. •- o Q aE.� 0�.3 T. OIS Ory t We.L to yc^r- . - PiN&C) -' 144 SU FPoC—" TAWA96* . a Ga�+cx-. -oR�►.+�1►.�r�, Rr,�i. o�ur.�tior�3-. .� �o+�, o� - . IV�0 -xezrAt.L COUNTY AUDITOR-CONTROLLER 06000 COUNTY FINANCE BLDG.,ROOM 203 H E HAYNF 594876 MARTINEZ,CA 94553-1284 2520 RYAN ROAD 292 CONCORD CA 94518 AMOUNT PAID . DETACH TOP PORTION AND RETURN WITH PAYMENT TO ENSURE CREDIT REFERENCE CURRENT ARREARS DATE NUMBER TYPE OF TRANSACTION AMOUNT- AMOUNT 09/01/93 PP—DIS PREPAY RELEASE 09/02/93 706244 PAYMENT RECEIVED 4519e23 519.23 CR 09/16/93 710331 PAYMENT RECEIVED $519.23 519.23 . CR '::.' REFUND '634.46 09/30/93 .714344 PAYMENT RECEIVED 5519.23 519.23 CR ARREARS ADDED 2365.53 ..I I PHONE CALLS WILL NOT BE ACCEPTED. ALL INQUIRIES• MUST BE PUT IN WRITING T0: D.A. FAMILY SUPPORT• 50 DOUGLAS DR.• SUITE 1009 MARTINEZr CA 94553 S E P T E M B E R 1993 ARREARS BALANCE DOES NOT INCLUDE INTEREST OWED BALANCE SUPPORT PAYME7<7S AND BALANCE SUPPORT ARREARS J-:�� ,� BAL�NC� IST 0-f.SONTH. PAYMENT DUE ADJUSTL'ENTS .1ST OF MONTH PANIMENT DUE AIAOUNT DUE a � " 2711.53CR 750.00 1442.30 519.23CR 750.00 230.77 230.77 • ••1 F y a�,(;XX�(X'_XXXXXiX:X�; �X'�(XXXXXXX _ x fir' COLLECTIONS ACCOUNT NO. 594876 060DOPAYMENT DUE DATE 10/20/93 D-291REV.8-791 ® • C: �:;C. C:.� ^. ^ �_�: O ..J.._J J: J.J_J•J...J 7. 7 • • • C: C. • • 0:.-G-0. 0 -0-0. 3 J • J,J:J_0..J--J J • • � C: ® UCC C • C .� .v .0.00 � � J � JJJ.....J .J=-J J:._)-;-) • • • O • C.:-c- C, a • 3 :3.0 0_3 JJ. ) • • C 0 0CC:: -00000.3,3. 3033.0JO �Yz) J.J0J.::) • 0 • qJ_�.._J.:..JJ:�j •.O • CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOAR_ D ACT the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT MARCH 81, 1994 and Board Action. All Section references are to The copy of this document mailed to.�you_is.your.notice ,of.,.,_.. California Government Codes. ) the action taken on your claim by theBoaFd of Supe Zvi"sorsa (Paragraph IV below), given pursuantlt J 6overnment=Code=- °- Amount: Exceeds $25,000.00 Section 913 and 915.4. Please note' ill 'Warnings". ' OU FEB 14 CLAIMANT: NIXON, Ron & Dorothy COUNTY COUNSEL ATTORNEY: James D. Claytor & Kenneth W. Pritikin MARTINEZ,CA0F ._ _ �9 Foley, McIntosh & Foley Date received ADDRESS: 3675 Mt. Diablo Blvd. , Ste. 250 BY DELIVERY TO CLERK ON February 9. 1994 Idfayette, CA . 94549 BY MAIL POSTMARKED: February 8. 1994 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. QQ gg HH DATED: B�ll DeputyLOR, Clerk J _ 0,2 O _ ) .I1. FROM: County Counsel TO: Clerk of the Board of Supervisors ( dj 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: BY: A." / Deputy County Counsel 31I. 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. BOARD ORDER: By unanimous vote of the Supervisors present (This Claim is rejected in full. ( ) Other: 3 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. 0 Dated: PHIL BATCHELOR, 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 mil to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United Cates stat Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and No ice to Claimant, addressed to the claimant as shown above. Dated: BY: PHIL BATCHELOR by A.IL Deputy Clerk CC: County Counsel County Administrator Claim '.o: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 19879 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2.) 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. , FrdSpepenalty: 'or fraudulent claims,.,Pen1C9de Sec. 72. at, the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp ) DOROTHY NIXON ) RECEIVED ) - fT .�a. AND RON NIXON ) ; Against the County of Contra Costa ) 9 or ) CLERK BOARD OF SUPERVISORS District) CONTRA COSTA CO. Fill in name ) �. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ exceeding $25,000 and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) In or about November of 1993 and continuing thereafter 2. Where did the damage or injury occur? (Include city and county) 4 Marchant Gardens, Kensington, Contra Costa County, California NNN__N_N____NNN___ __N__NNNNN__N_NNNNN_NN__N_N_N 3. How did the damage or injury occur? (Give full details; use extra paper if required) . See attachment "A" attached hereto and incorporated herein by reference. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? See attachment "A" attached hereto and incorporated he.re nj. y reference.- (over) eference.(over) It 5. What are the names of county or district officers, servants or employees causing the damage or injury? Unknown 6. What damage or injuries do you claim resulted? (Give full extentof injuries or damages claimed. Attach two estimates for auto damage. See attachment "A" attached hereto and incorporated herein by reference. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See attachment,'""A4 attached hereto and incorporated herein by reference. NN-NN�N-------N -- -M- NN-N-N- 8. Names and addresses of witnesses, doctors and hospitals. See attachment "A" attached hereto and incorporated herein by reference. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT See attachment "A" attached hereto and incorporated herein by reference. - Gov. eference.Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES T0: (Attorney) or some erson"`on his behalf." Name and Address of Attorney James D. Claytor & Kenneth W. Pritikin zsq-2-�/- FOLEY, McINTOSH & FOLEY Claimant's Signature 3675 Mt. Diablo Blvd. , Suite 250 Dorothy Nixon and Ron_ Nixon by their Lafayette, CA 94549 attorney, nnet Address c/o FOLEY, MCINTOSH & FOLEY 3675 Mt. Diablo Blvd. , Suite 2+ Lafayette, CA 94549 Telephone No. (510) 284-3020 Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, :with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a.period of not more than one year, by a fine of.not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($1090009 or by both such imprisonment and fine. FOLEY, McINTOSH & FOLEY PROMISSIONAL CORPORATION ATTORNEYS AT LAW THOMAS J.McINTOSH 3675 Mf. DIABLO BLVD. 1225 SOLANO AVENUE WILLIAM R. FOLI!Y SUITE;250 POST OFFICE BOX 6247 JAMES D.CLAYTOR LAFAYETTE:.CALIFORNIA 94549 ALBANY.CALIFORNIA 94706-1734 DAVID L. FRI;Y (510)284-3020 (510)524-4123 JAY RICHARD STRAUSS FAX(510)284-3(r-9 FAX(510)524-7662 GREGORY O. SLATOIT TERRY J. LEACH TRACY L. WILLIAMS KENNIITH W. PRITIKIN February 8, 1994 VIA CERTIFIED/RETURN RECEIPT Clerk BOARD OF SUPERVISORS Room 106, County Administration Building 651 Pine Street Martinez, CA 94553 Re: Claim by Dorothy Nixon and Ron Nixon Dear Clerk: Enclosed please find an original and two (2) copies of the above-entitled Claim. Please file the original and return at least one (1) endorsed copy in the envelope provided. Thank you for your assistance with this matter. Very truly yours, J n . D. Claytor JDC:rj Enclosure ATTACHMENT "A" TO CLAIM BY DOROTHY NIXON AND RON NIXON AGAINST THE COUNTY OF CONTRA COSTA Claimants Dorothy Nixon and Ron Nixon ("Claimants") represent the following in support of this claim: 1. Claimants, whose address is 4 Marchant Gardens, Kensington, Contra Costa County, California, are the owners of the improved real property located at 4 Marchant Gardens, Kensington, Contra Costa County, California ("Claimants' Property"), and have owned Claimants' Property, and had lawful and actual right of possession thereof, at all times relevant to this claim. 2. This claim is based upon damage to Claimants' Property that happened on Claimants' Property in or about November, 1993, and continuing thereafter, under the following circumstances: Contra Costa County negligently and improperly approved, consulted, planned, designed, constructed, improved, re-modeled, controlled, and/or maintained a drop inlet structure and drainage pipe system connected thereto. The drainage pipe system is buried in shallow ground on the real property located at 68 Stratford, Kensington, Contra Costa County, California (the "Fineman Property"). The drop inlet structure is located nearby the Fineman Property. The Fineman Property is adjacent to, and upslope from, Claimants' Property. Claimants are informed and believe that the drop inlet structure and the drainage pipe system are part of Contra Costa County's drainage and flood control program, and are owned and/or controlled by Contra Costa County pursuant to its drainage and flood control responsibilities. Contra Costa County has a mandatory duty to potentially affected persons, including Claimants, to properly design and construct the drop inlet structure and drainage pipe system to adequately process water and debris generated by rains, and to conduct proper maintenance and repairs as needed. Said duty includes, where necessary, the retention of engineers and other professionals. Contra Costa County has negligently failed to fulfill this duty. As a proximate cause of said negligence, Claimants' Property has been damaged as hereinalleged. Said damage has resulted from the following circumstances: The drainage pipes in the aforesaid drainage pipe system, as a result of corrosion or other defects in their constriction, design or maintenance, contain substantial gaps and separations that permit water flowing through the pipes to leak into the surrounding ground. As a result of the inadequate design, construction, and/or maintenance of the aforementioned drop inlet structure, sediment and debris commonly brought by heavy rains ATTACHMENT "A" TO CLAIM BY DOROTHY NIXON AND RON NIXON AGAINST THE COUNTY OF CONTRA COSTA Page 2 of 3 are routinely permitted to enter the drainage pipe system and to thus block the pipes. When this occurs, water from the rains flows out through the gaps and separations in the pipes into the surrounding ground on the Fineman Property. The water then flows downslope directly onto Claimants' Property, causing flooding of Claimants' Property. This flooding is the direct cause of the damage to Claimants' Property that is the subject of this claim; the damage includes severe subsidence damage to Claimants' Property, and damage to the terrace wall and upper and lower retaining walls on Claimants' Property. Monetary damage to Claimants also includes costs of geotechnical consultations and other professional services. Additional damage may presently exist that has not yet been ascertained, and Claimants will amend this claim at such time that fiirther damage is discovered. 3. Claimants will sustain further damage if the defective, improperly designed, constructed and/or maintained drop inlet structure and drainage pipe system are not corrected. The injury, damage and loss expected to be incurred by Claimants in the future includes further injury, damage and loss to Claimants' Property and structures thereon caused by continuing and fiirther flooding of Claimants' Property due to the defective, improperly designed, constructed and/or maintained drop inlet structure and/or drainage pipe system. 4. The damage which is the subject of this claim was first discovered by Claimants in or about November, 1993, following a rainstorm. 5. Claimants have not yet obtained an estimate of the dollar amount of damage sustained to date, but such damages exceed $10,000.00. Jurisdiction for the claim will rest in Superior Court. The total of Claimants' expenditures to date have not been determined but can be obtained and provided upon request. 6. The aforementioned damage is the direct result of Contra Costa County's negligence in approving, planning, designing, constructing, improving, re-modelling, controlling, and/or maintaining the aforementioned drop inlet structure and drainage pipe system. As a result of Contra Costa County's negligent acts and omissions, the legal theories of recovery asserted against Contra Costa County include, without limitation, the following: a. Inverse condemnation; b. Negligence; C. Professional negligence; d. Trespass; and e. Private nuisance. ATTACHMENT "A" TO CLAIM BY DOROTHY NIXON AND RON NIXON AGAINST THE COUNTY OF CONTRA COSTA Page 3 of 3 7. Witnesses to the facts represented herein are known to include the foflowing: a. Dorothy Nixon and Ron Nixon 4 Marchant Gardens Kensington, California b. Alan Kropp, G.E. Alan Kropp & Associates, Inc. 2140 Shattuck Avenue Berkeley, California C. Elliot Fineman 68 Stratford Kensington, California P 872 32Q 0.51 N:AJG=�IOL� v P' :ter �ii ' �iHGE ! * . * KB 41 94 CA FROM: FOLEY, MCINTOSH & FOLEY PROFESSIONAL CORPORATION ATTORNEYS AT LAW 3675 MT.DIABLO BLVD. SUITE 250 LAFAYETTE,CALIFORNIA 94549 - Clerk _ BOARD OF SUPERVISORS - I Room 106, County Administration Building 651 Pine Street Martinez, CA 94553 CERTIFIED/RETURN RECEIPT REQUESTED . CLAIM BOARD OF SUPERVISORS Of CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT MARCH 8, 1994 and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by tht.9oard of Supervisors (Paragraph IV belch,), given pursuant-Lo"Go"emnient Cade Section 913 and 915.4. please note[ •Yarnngs"..�__�,;;,'!' Amount: $500,000.00 -` .r a; CLAIMANT: KEANE, Tracy ! FEB 14 } ATTORNEY: Michael A. Kelly, Esq. _ COL':'. .'CGt7iacFi� Walkup, Melodia, Kelly & Echeverria Date received ADDRESS: BY DELIVERY TO CLERK ON Fe�bnyary0;r 1994 650 California St. , 30th Floor February 9, 1994 San Francisco, CA 94108 BY MAIL POSTMARKED: 1. FROM: Clerk of the Board of Supervisors T0: County Counsel Attached is a copy of the above noted claim. pp H EVIL BATCUELOR, Clerk (" a,�JfJ.r e DATED: •�---- .11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( WThis 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: ) 1 B,Z4,,, Deputy County Counsel 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). IV. BOARD ORDER: By unanimous vote of the Supervisors present This Claim is rejected in full. ( ) Other: .__. 1 certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By 0 . Deputy Clerk WARNING (Gov. code section 9131 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. Vou may seek the advice of an attorney of your choice in connection 14ith 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 ates stat Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and No ice to Claimant, addressed to the claimant as shown above. Dated: QBY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator L 1 . CLAIM FOR PERSONAL INJURIES AGAINST THE COUNTY OF CONTRA COSTA ON BEHALF OF TRACY KEANE TO: CLERK, BOARD OF SUPERVISORS COUNTY OF CONTRA COSTA 651 Pine Street, Rm. 106 Martinez, CA 94553 The following claim for damages is hereby made by and on behalf of TRACY KEANE as a claimant for damages for personal injuries. _ A. Name and Address of Claimant: R E C E fv �� Tracy Keane 0 IoQ.� 41-45 St. Stephen's Green FB Dublin 2, Ireland ---- CLERK BOARD OF SUPERVISORS B. Address to Which Notices are tO be Sent: CONTRA COSTA CO. Michael A. Kelly, Esq. WALKUP,. MELODIA, KELLY & ECHEVERRIA 650 California Street, 30th floor San Francisco, CA 94108 D. Date, Place, and Other Circumstance Which Give Rise to this Claim: The incident which gives rise to this claim occurred on August 14, 1993 near Fisherman's Wharf in the City of San Francisco. That evening., Tracy Keane sustained severe injuries when she was shot Jason Treas, a ward of Contra Costa County. At all times herein, the Byron Boy's Ranch was a facility which was operated and maintained by Contra Costa County. Mr. Treas was under the custody, care and supervision of the County as a resident of the Byron Boy's Ranch. Respondent caused Mr. Treas to be negligently paroled, released and delivered into the general community, thereby enabling him to bring about the injuries caused to the plaintiff. Specifically, the County failed to follow the standard of due care in: 1. Releasing Jason Treas into the community despite knowledge of the danger he presented; 2. Negligently entrusted Jason Treas into the custody of his father, Randy Treas; 3. Negligently and carelessly contracted with Randy Treas, to serve as the County's agent to maintain custody of Jason Treas; 1- V Page 2 4. Violated internal policies, procedures ordinances and laws in the process of releasing Jason Treas from Byron Boy's Ranch. All of the above constituted actionable negligence which presented a recognizable, significant and preventable danger to the community, including Ms. Keane. The County, its employees and agents, failed to prevent this danger pursuant to mandatory duties and ministerial obligations. D. Description of Injuries and Damages As a result of the County's negligence, claimant was shot in the back, point blank, with a high caliber handgun. She has been caused to suffer significant pain, anguish, anxiety, distress, grief and misery as a result of this incident. Moreover, Ms. Keane has had a loss of wages and earning potential due to this incident. E. Employees causing Injuries and Damages: The name of the particular employee(s) of the public entities with specific responsibility for this occurrence is unknown. Damages exceed $500,000. DATED: February 8.., 1994 WALKUP, MELODIA, KELLY & . ECHEVERRIA By �. MICHAEL A. KE Y Attorneys or P ain Law Offices of BRUCE WALKUP WALKUP, MELODIA, KELLY & ECHEVERRu MARY E.ELLIOT PAUL V.MFLODIA RICHARD H.SCHOENBERGER DANIEL J.KFLIY A Professional Corporation CYNTHIA F.NEWTON JOHN ECHFVF.RRIA 650 CAI IFORNIA STREET,30TII FLOOR,SAN FRANCISCO,CALIFORNIA 94108 ANN M.RICHARDSON RICHARD S.GOETNALS,JR. TELEPHONE(41 5)981-7210 FACSIMILE(415)391-6965 ERIK BRUNKAL RONAID H.WECHT MICHAEL A.KELLY KEVIN L.DOMECUS - OF COUNSEL JEFFREY P.ROLL JOHN D.LINK DANIEL DELCOSSO WESLEY SOKOWSKY,M.D.,J.D. February 9, 1994 RECEIVED f CERTIFIED MAIL FEB 10 i4QA Clerk, Board- of Supervisors . CLERK BOARD OF SUPERVISORS Contra Costa County CONTRA COSTA CO. 651 Pine Street, Room 106 Martinez, CA 94553 Re: Keane v. Treas Dear Sir or Madam: Enclosed herewith please find the original and one copy of Claim for Damages in the above referenced matter. Please acknowledge receipt on the enclosed copy and return to us in the envelope provided. Thank you for your anticipated cooperation. Very truly yours, MICHAEL A. KE Y MAK/db Enclosures n b. i ' Y a 4:. Z ~ n r F a a 7 s. D 1' �t a a . r 10� a a N d w S y N N .� N W % ri �+ Nt Orn or �FR4,..... of IV��� �a to lSO CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County. or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements. ) NOTICE TO CLAIMANT MARCH 8, 179-4 and Board Action. All Section references are to ) The copy of this document sailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board,of'Supe�v'i—st its.,._.., (Paragraph IV below), given pursua�.1t ;o��overrn�n�eritCo-d-eS L j Amount: Unknown Section 913 and 915.4. Please n'Jt all "Warnings". fI 103- ► �� { CLAIMANT: GRANT, Barry [ ! ATTORNEY: Scott & Barsotti COUNTYCOUNS11 Date received MARTINEZ,CALIF Y ADDRESS: 315 East Leland Road BY DELIVERY TO CLERK ON February 2. 1994 Pittsburg, CA 94565 BY MAIL POSTMARKED: -Hand Delivered via Risk MQmt. 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. gClerk DATED. �aIl pepuMtylOR, .I1. FROM: County Counsel TO: -Clerk of the Board of Supervisors ( This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: , 19 g 3 BY: -C . Deputy County Counsel ]II. 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. BOARD ORDER: By unanimous vote of the Supervisors present Wr This Claim is refected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this data. Dated: PHIL BATCHELOR, Clerk. By gto IS A. . ° , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions. you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING 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 Unitedtates sial Service in Martinez. California, postage fully prepaid a certified copy of this Board Order. and No ice to Claimant, addressed to the claimant as shown above. Dated: D4 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator 1 LAW OFFICES OF SCOTT & BARSOTTI California Bar No. 47425 2 315 East Leland Road Pittsburg, California 94565 —— 3 (510) 432-2955 RECEIVED 4 Attorneys for Claimant FEB - 21994 5 CLERK BOARD OF SUPERVISORS 6 CONTRA COSTA CO. 7 HAND 011ELl'Ji.'R.e/ED 8 In the Matter of the Claim of 9 BARRY GRANT, 10 Claimant, CLAIM FOR PERSONAL INJURY 11 v. 12 CONTRA COSTA COUNTY 13 Respondent. 14 1. 15 Claimant, Barry Grant, through the Law Offices of Scott & 16 Barsotti hereby presents this claim to Contra Costa County 17 pursuant Government Code S 910 et. seq. 18 2. 19 ,. The name and post office address of claimant is as follows: 20 Barry Grant aLn 21 00 2217 Concord Drive 22 V 0 Pittsburg, CA 94565 Cn �x 23 E9 3. • 24 o� The post office address to which claimant desires notice of as cc 25 0 o this claim to be sent is as follows: Richard A. Barsotti, Law 26 o' Offices of Scott & Barsotti 315 E. Leland Rd. , Pittsburg, CA N 0 N 27 0 � N (, 94565. acn MLn 28 1 1 4. 2 On or about October 10, 1993, claimant received personal 3 injuries under the following circumstances: Plaintiff was 4 participating in a league soccer game at the O'Hara Park School 5 play field when plaintiff stepped on a piece of wood partially 6 buried in the soil causing plaintiff to slip and severely injure 7 plaintiff, in particular, plaintiff's knee. 8 5. 9 Prior to and at said time and place above mentioned, 10 employees of the public entity to which this claim is addressed 11 so negligently and carelessly painted over the piece of wood 12 buried in the O'Hara Park playing field and left said piece of 13 wood in the ground causing a dangerous condition for persons 14 using the playing field, and in particular, persons using the 15 playing field for sports activities, such as soccer, such that 16 the negligence and dangerous condition caused the hereinafter- 17 described injuries and damages to plaintiff. 18 6. 19 The public entity to which this claim is addressed knew or DoDo 20 in the exercise of reasonable care should have known of the a 21 dangerous condition and the negligence of its employees and had 22 the funds and the ability to remedy said condition. O °°LM 23 �. CI) �_X �y w 24 The names and addresses of the public employees responsible 25 for said dangerous condition are unknown to plaintiff's at this g 0 � 26 time. �o IL pO uFi eS 27 8. a(n M Ln 28 As a proximate result of the dangerous condition, the 2 I failure of the public entity to whom this claim is addressed to 2 remedy the dangerous condition and the negligence of the 3 employees of the public entity, claimant was hurt and injured in 4 his health, strength and activity sustaining injury to his body 5 and shock and injury to his nervous system and person, all of 6 which said injuries have caused and continue to cause him great 7 mental, physical, emotional and nervous pain and suffering. 8 Claimant is informed and believes and thereon alleges that said 9 injuries will result in some permanent disability to claimant 10 ' all to his general damages at this time in the amount of at 11 least TWO HUNDRED FIFTY THOUSAND DOLLARS ($250, 000. 00) . 12 9. 13 As a further direct and proximate result of the dangerous 14 condition, the failure of respondent to remedy said dangerous 15 condition and the negligence of the employees of the public 16 entity, claimant was required to and did employ physicians, 17 surgeons and hospitals to examine, treat and care for him and 18 did incur medical and incidental expenses. Said medical and 19 incidental expenses are ongoing. The exact amount of said 20 expense is unknown to claimant at this time but believes it to �o 00 21 be in excess of FIVE THOUSAND DOLLARS ($5,000.00) . 22 10. O 09; UU*) a 23 At the presentation of this claim, claimant claims general Qz • w 24 damages in the amount of at least TWO HUNDRED FIFTY THOUSAND �P.QJ I a T 25 DOLLARS ($250,000.00) and special damages in the amount of at � H �� � 26 least FIVE THOUSAND DOLLARS ($5, 000.00) for a total claim of at UE-4Zpaa o0 N 27 least TWO HUNDRED FIFTY-FIVE THOUSAND DOLLARS ($255, 000.00) . �C! M Ln 28 Claimant will advise the entity to whom this claim is addressed 3 1 of the exact amount of special damages when the same have been 2 ascertained by claimant. 3 11. 4 Claimant requests further communication or correspondence 5 in this matter be directed to his attorney Richard A. Barsotti, 6 Law Offices of Scott & Barsotti 315 E. Leland Road, Pittsburg, 7 CA 94565. 8 DATED: ���_ SCOTT & BARSOTTI 9 10 �. 11 D A. ARSOTTI, Attorney for Claimant 12 13 14 15 16 17 18 19 20 _ aLM 21 00 22 �Ln 23 � oC 24 _Fj� ac 25 �'V Q c [--+5 26 Qz Oen 27 3 U , N O �Cn<n n 28 4 LAW OFFICES SCOTT & BARSOTTI JAMES E SCOTT A PROFESSIONAL CORPORATION RICHARD A.BARSOTTI 315 FAST LELAND ROAD• PITTSBURG,CA 94565-4981 510/432-2955 510/689-2433 FAX:510/427-6185 ao�Nagel �E8 CERTIFIED MAIL February 1, 1994 County of Contra Costa Attention: Ron Harvey Risk Management 651 Pine Street, 6th Floor Martinez, CA 94553 Re: Claim for Personal Injury of Barry Grant Dear Sir: Enclosed is a CLAIM FOR PERSONAL INJURY and copy. Please file the original and return endorsed-filed copy in the envelope provided. Sincerely, SCOTT ARSOTTI R CHARD A. BARSOTTI RAB:jld Encl. . . - . I' IS CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Claim Against the County. or District governed by) BOAR_D ACTION the Board of Supervisors. Routing Endorsements, ) NOTICE TO CLAIMANT MARCH 8 1994 and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by-the-Board-o#SS�DD rv-fsor, (Paragraph IV below), given purs Qra&r�neHtl�pl i& A Amount:Urlknowik Section 913 and 915.4. Please n dill `Warnings". CLAIMANT: FORD, Laura G. F83 ATTORNEY: Brookman,,& Talbot, Inc. COUNTY COUNSEL ' Date received MARTINEZ,CALIF..��z� y ADDRESS: 1990 N. CAlifornia Blvd. , Ste. 740 BY DELIVERY TO CLERK ON February 2_ 1994 Walnut:;Creek%P'CA 94596 Hand Delivered BY MAIL POSTMARKED: via Risk'°:Mgmt. 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. 8 H DATED: Q9 �alL Deputy OR, Clerk n n O .11. FROM: County Counsel TO: Clerk of the Board of Supervisors This claim complies' substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.6). ( ) 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 /9 g BY: Deputy County Counsel NJ III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (V I Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk. By •o . Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection With this matter. If you want to consult an attorney, you should do so immediately. *For additional warning see reverse side of this notice. AFFIDAVIT OF MAILING I declare under penalty of Perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the Unitedtate: stat Service in Martinez. California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the cai nt as shown above. Dated: BY: PHIL BATCHELOR byjq Deputy Clerk CC: County Counsel County Administrator 0383AII30 MUM- RECEIVED CLAIM AGAINST PUBLIC ENTITY I (GOV CODE SECTIONS 905, 905.29 9109 910.2) CLERR BQARD OF SUPERVISORS TO: CONTRA COSTA COUNTY FIRE PROTECTION DISTRICT: CONTRA COSTA CO. LAURA G. FORD hereby makes claim against CONTRA COSTA COUNTY FIRE PROTECTION DISTRICT and makes the following statements in support of the claim: 1. Claimant, LAURA G. FORD's post office address is 15 Brush Creek Court, Pittsburg, CA 94565; claimant's date of birth is 8/4/53. 2. Notices concerning the claim should be sent to BROOKMAN&TALBOT, INC., 1990 N. California Blvd., Ste. 740, Walnut Creek, CA 94596; (510) 932-4008 3. The date and place of the incident giving rise to this claim are November 3, 1993 at Ygnacio Valley Road, approximately 800' west of San Carlos Drive, in the city of Walnut Creek, County of Contra Costa, California. 4. The circumstances giving rise to this claim are as follows: Claimant was driving and operating her 1985 Chevrolet van, travelling in a generally easterly direction on Ygnacio Valley Road in the #1 lane, when her vehicle was rear-ended by a certain 1987 Ford fire truck, license number E268015, owned by the Contra Costa County Fire Protection District and driven and operated by Calvin James Bedgood, employee of Contra Costa County Fire Protection District, pushing claimant's vehicle into the vehicle ahead of her. 5. General description of injury, damage, or loss incurred: As a result of said incident, claimant has sustained injuries to her neck and back, the full extent of which are still to be determined. 6. The amount of claim as of this date is to be determined. 7. The basis of computation of the above amount is as follows: Medical expenses incurred to date: $ 2,618.14 Estimated future medical expenses: To Be Determined Loss of Wages: To Be Determined General Damages: To Be Determined 8. Jurisdiction over this claim will rest in Superior Court. Dated: 1-31- , 1994 r2k=W a4pyk L-IL URA G. ORD, Claimant Receipt of a copy of the within claim is hereby acknowledged this .-..—.—.-- day of 1994. 1 PROOF OF SERVICE BY MAIL -- CCP. 62015.5 & 61013(A) 2 3 I, the undersigned, declare under penalty of perjury of the laws of the State of California: 4 That I am a citizen of the United States and over the age of eighteen years; that I am not a party to the within action or proceeding; that my business address is 1990 N. California 5 Boulevard, Suite 740, Walnut Creek, California 94596; that on the date set forth below,I served a true copy of- 6 CLAIM AGAINST PUBLIC ENTITY 7 8 9 by depositing said copy in the United States Mail, at Walnut Creek, California, in a sealed 10 envelope, postage thereon prepaid, addressed as follows: 11 12 Risk Management County of Contra Costa 13 Administration Building 651 Pine Street, 6th floor 14 Martinez, CA 94553 15 16 17 18 19 20 At said time, there was regular delivery of the United States Mail between said places of deposit and address(es). 21 22 Executed at Walnut Creek, Contra Costa County, California, on February 1, 1994. 23 24 SHAR�ONH�ANNEY 25 26 27 28