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Reyes v. Commissioner of Social Security

July 2, 2010


The opinion of the court was delivered by: Sandra M. Snyder United States Magistrate Judge


Plaintiff April D. Reyes, by her attorney, Geoffrey L. Hayden, seeks judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for disability insurance benefits (DIB) under Title II of the Social Security Act and for supplemental security income ("SSI"), pursuant to Title XVI of the Social Security Act (42 U.S.C. § 301 et seq.) (the "Act"). The matter is currently before the Court on the parties' cross-briefs, which were submitted, without oral argument, to the Honorable Sandra M. Snyder, United States Magistrate Judge.*fn1 Following a review of the complete record, this Court concludes that the ALJ's determination was not supported by substantial evidence. Accordingly, the Court reverses and remands for payment of benefits.

I. Administrative Record

A. Procedural History

On July 21, 2005, Plaintiff applied for disability benefits pursuant to Title II of the Social Security Act and for supplemental security income ("SSI"), alleging disability beginning July 15, 2003. AR 102-104. Her claims were initially denied on November 10, 2005, and upon reconsideration, on April 19, 2006. AR 20. On June 12, 2006, Plaintiff filed a timely request for a hearing. AR 20. Plaintiff appeared and testified at a hearing on December 11, 2007. AR 20, 30-49. On January 25, 2008, Administrative Law Judge Edward D. Steinman denied Plaintiff's application. AR 17-29. The Appeals Council denied review on October 27, 2008. AR 12-14. On January 8, 2009, Plaintiff filed a complaint seeking this Court's review (Doc. 1).

B. Factual Record

Plaintiff was born April 17, 1967. AR 150. Her mother, father and many other family members are alcoholics. AR 192, 195. Plaintiff's father physically abused Plaintiff, her mother, and her sister. AR 192.

Uncomfortable around others, Plaintiff hated school. AR 192. She was sick, anemic and undernourished. AR 192. Plaintiff left school after finishing tenth grade. AR 148, 192.

When Plaintiff was twelve years old, she began drinking alcohol. AR 195. She ran away from home to live with friends, relatives, and on the street. AR 192. Plaintiff and an older brother were sent to Oklahoma to live with their grandparents. AR 192. When Plaintiff was 13 and 14 years old, her older brother molested her. AR 192.

Plaintiff was imprisoned multiple times while a juvenile and young woman. AR 149, 191. While in prison, Plaintiff did janitorial work, landscaping and food preparation., AR 191.

Plaintiff has six children who were 17, 15, 12, 10, 7, and 4 years old on July 29, 2002. AR 195. Each child has a different father; each of the fathers abused Plaintiff. AR 192. California Protective Services removed Plaintiff's minor children from her care in or about September 2004. AR 173.

Plaintiff maintains that her stepfather molested Plaintiff's two daughters. AR 192. Plaintiff reported that he laughs at her, taunting her that she cannot prove it. AR 192. As a result, Plaintiff cannot live with her mother, who remains married to him.

Plaintiff alleged that since July 15, 2003, mental problems and suicidal urges limited her ability to work. AR 144-45. She became anxious, tired, and was unable to think. AR 145. In November 2004, Plaintiff attempted suicide. AR 147. From November 2004 through June 2005, she received counseling from Kern County Mental Health System, which provided no medication since Plaintiff attempted suicide by a drug overdose. AR 147.

Plaintiff last worked as a housekeeper from December 2003 to July 2005. AR 33, 112, 145. She dusted, mopped, swept, and cleaned baseboards, ceiling fans, and bathrooms in private homes. AR 34, 112, 145.

In an interview relating to Plaintiff's appeal of the agency's denial of disability benefits, Plaintiff reported that her depression had increased since her fiancé died. AR 161. She was then living on the streets and trying to get into a program. AR 161. Her vision had worsened, and she was crying and sleeping a lot. AR 161. She did not socialize and wanted to be left alone. AR 163. On November 2, 2006, Plaintiff had seen Dr. Valentine Birds at Budget Medical Clinic, who had prescribed Wellbutrin for depression.*fn2 AR 162.

Kern County Mental Health Records (AR 167-199). Kern County Mental Health Systems ("KCMH") treated Plaintiff from July 29, 2002 through November 29, 2004. At intake, Plaintiff reported extreme difficulty making decisions, getting places on time, finding and maintaining employment, adjusting to stresses in her relationships, and handling her emotions. AR 197. She had been using alcohol for 23 years and wanted to stop. AR 187, 189. She was homeless and had been sleeping in the park since her family "kicked her out." AR 195. Only two of her children were then living with her. AR 189. Working with others who had made it to recovery had inspired her to seek help. AR 195. Her psychiatric symptoms included`:

Can't sleep, feels phys[ically] shaky during day; keeping "day by day" schedule; feels depressed "wants to just [illegible] myself and I'm claustrophobic" isolates at home--"when I'm sober, I can't talk/be in a relationship"; low self esteem; can't conc[entrate] & remember; no motivation --"feels lost"; constantly fatigued; feels worthless.

AR 195.

Plaintiff reported experiencing severe depression, severe anxiety, and difficulty understanding others throughout her life and within the past thirty days. AR 184. In the past, Plaintiff had experienced hallucinations, had suicidal thoughts, and had attempted suicide. AR 184.

Plaintiff's diagnosis was:

Axis I: 296.32 Major Depressive Disorder, Recurrent, Moderate 303.90 Alcohol Dependence, Early Full Remission

Axis II: 799.9 [diagnosis or condition deferred]

Axis III: Axis IV: sober 1 month; can't find employment; children living with relatives (2 are in home)

Axis V: Current GAF: 41 Highest GAF: UK AR 190.*fn3 The clinician noted that Plaintiff had severe functional impairments in community participation, community contribution, relationships with others, and physical and emotional health. AR 190.

Plaintiff's first treatment goal was to reduce her depression from level eight to level four over eight months. AR 189, 198. Initially, she was scheduled for at least one weekly session of group therapy, one weekly life skills class, and regular medical follow up of her medications. AR 189, 198-199. Plaintiff was to continue attending Alcoholics Anonymous. AR 189, 199.

Although Plaintiff made some progress, her treatment at KCMH ended on or about September 6, 2002, when she secured a housekeeping job. AR 176, 180. Her hours of work conflicted with the times that therapy was offered. AR 180. KCMH closed Plaintiff's treatment file on November 14, 2002. AR 177.

Plaintiff returned to KCMH on or about September 20, 2004. AR 174. Plaintiff had attempted suicide by overdosing on Elavil, Methedrine, and PCP after her children were removed from her home by California Protective Services. AR 173, 174. She had been hospitalized for five days. AR 200. Her GAF score was 30.*fn4 AR 172. On November 24, 2004, KCMH referred Plaintiff for further service. AR 167. Nothing in the record indicates that Plaintiff received further treatment, however.

Correctional Mental Health Screening. On or about April 18, 2005, Plaintiff was arrested and charged with being under the influence of a controlled substance (PCP). AR 206-207. Plaintiff was depressed and hearing command voices. AR 206. On May 6, 2005, staff member Gillingham screened Plaintiff for mental health issues. AR 206-207. She recommended that Plaintiff receive crisis intervention counseling, stress reduction-relaxation exercises, and a psychiatric evaluation. AR 207.

Plaintiff's First Adult Function Report (SSA Form 3368). In an Adult Function Report dated August 31, 2005, Plaintiff reported that, because she did not sleep well, she didn't really remember what she did all day. AR 118. Instead of sleeping, she paced and drank warm milk because she heard voices and saw things that weren't there. AR 119. She took no medications. AR 120.

Plaintiff reported that she lived in an apartment with relatives. AR 118. She stayed inside because she had low self-esteem and did not like being around people. AR 118, 121. She felt secure if people she knew were with her. AR 121. Being out in public made her "anxious and nervous." AR 124. Going into stores made her so nervous that she broke out in hives. AR 119.

Others shopped for her twice a month if she could afford it. AR 121. Stress increased Plaintiff's depression so she stayed away from stressful situations. AR 124. Plaintiff spent her days crying and sleeping. AR 120.

Plaintiff enjoyed petting her cat, who was the first pet she had. AR 119. Her aunt was teaching her to care for the cat by feeding him and keeping him clean. AR 119. Her aunt also encouraged her to get up and dress nicely, and not to isolate herself. AR 120. Later in the same document, however, Plaintiff reported that she did not like going outdoors since her aunt died. AR 122.

Plaintiff ate very little. AR 120. She drank water and prepared ramen noodles in the morning and evening if she felt hungry. AR 120.

Plaintiff did her laundry and organized her belongings each day. AR 120. She reported that she was unable to pay bills, count change, or use a checking or savings account, explaining "I'm not good at counting any money, especially a lot of it." AR 121.

Plaintiff reported that she did not see or hear well. AR 123. She had a hereditary eye disease and did not drive. AR 121. She needed to wear glasses all the time but, although she had gotten glasses in or about 2002, she lost them and had not replaced them. AR 124. She watched television and read a little, but it strained her eyes. AR 122. She was easily discouraged and found completing tasks difficult. AR 123.

Cousin's Report. A third-party report from Plaintiff's cousin, Lupe Arrieta, dated September 1, 2005, reported that Plaintiff was homeless. AR 126. Plaintiff spent about one day a week at Arrieta's home, just sitting around and eating food Arrieta had prepared. AR 126. Arrieta did not know how Plaintiff filled her time on other days. AR 126.

Arrieta recalled that Plaintiff had once functioned normally: holding a job, paying bills, buying food. AR 130. Now Plaintiff sat alone by herself. AR 130. She had no hobbies. AR 130. Although Arrieta encouraged Plaintiff to help with household chores when she visited Arrieta's home, Plaintiff was afraid to help for fear of messing something up. AR 128. Plaintiff felt she could do nothing right. AR 129, 133. Despite encouragement, Plaintiff was reluctant to use Arrieta's washer to launder her clothes because she had no money to pay Arrieta. AR 128.

According to Arrieta, Plaintiff had a poor memory and had difficulty following instructions without assistance. AR 131. She could pay attention for no more than ten minutes, AR 131. Sometimes while speaking, Plaintiff suddenly and inexplicitly changed subjects. AR 131.

Arrieta reported that Plaintiff did not like to go out, fearing that people were staring at her. AR 129. Plaintiff believed she was "inferior," "always wrong," a "bad person" and a "nobody," and feared being hurt. AR 129, 131, 132. She feared offending people and being rejected. AR 133. Arrieta reported that in the past, others had treated Plaintiff badly and taken advantage of her. AR 133. Arrieta thought Plaintiff might have previously been attacked. AR 129. Plaintiff did not handle stress well, responding by crying, getting a headache, and withdrawing. AR 132. Arrieta thought Plaintiff needed psychiatric care. AR 133.

Others tried to shop for Plaintiff once a month. AR 129. If Plaintiff went out, someone had to accompany her and do most of the task. AR 130. Arrieta was concerned that Plaintiff spent her time alone, instead of interacting with others. AR 129.

According to Arrieta, Plaintiff once drove but had not done so for years. AR 129. Plaintiff did not see well now. AR 131, 132. Characterizing Plaintiff's eye problem as "severe," Arrieta thought Plaintiff needed to see an optometrist and get glasses. AR 129, 130, 132. Plaintiff's hearing also seemed to be deteriorating. AR 131.

Agency Evaluation. On September 3, 2005, Dr. Chris Saindon conducted a "comprehensive psychiatric evaluation" under contract with the agency. AR 200-203. Plaintiff was present for an appointment. AR 200. Saindon reported that his review of Plaintiff's records consisted of an incomplete copy of SSA Form 3368. AR 200. Accordingly, Saindon's evaluation appears to have been based on Plaintiff's self-reports of her medical history and condition, and on a mental status examination that consisted of Saindon's evaluating Plaintiff's physical appearance and administering a series of questions to determine whether Plaintiff is (1) oriented in time, place, and person; (2) able to remember four words with prompting in three minutes; (3) able to name past presidents; (4) knows the governor and capital of California; (5) able to perform simple addition (7 5 = 12 and 12 13 = 25); (6) able to perform a three-step command; (7) able to express a similarity and difference for an apple and an orange (Plaintiff said that they both had vitamins but were different in color); (8) able to think abstractly (Plaintiff said that don't cry over spilt milk meant "Watch what you are doing"); and (9) able to exercise judgment and insight (Plaintiff said that if she found a stamped, addressed envelope on the sidewalk, she would take it to the nearest building). AR 202. Saindon noted that Plaintiff's mood was dysthymic (depressed). AR 201. He stated, "The claimant is a reliable historian," but does not explain why he believed this to be the case. AR 201.

Saindon's diagnosis of Plaintiff was

Axis I: Posttraumatic stress disorder. Axis II: Deferred.

Axis III: Anemia.


Axis IV: Social isolation.

Axis V: Current GAF: 55.

AR 202.*fn5 Saindon opined that Plaintiff's acute and chronic problems were treatable and that she was likely to recover within the next twelve months. AR 202. He concluded:

The claimant is capable of managing her own funds based upon her judgment and ability to calculate.

The claimant would be able to perform simple and repetitive tasks, as well as more ...

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