United States District Court, N.D. California
ORDER RE: CROSS-MOTIONS FOR SUMMARY JUDGMENT, RE:
DKT. NOS. 17, 29
MARIA-ELENA JAMES United States Magistrate
Phillip Mays ("Plaintiff") brings this action
pursuant to 42 U.S.C. § 405(g), seeking judicial review
of a final decision of Defendant Carolyn W. Colvin
("Defendant"), the Acting Commissioner of Social
Security, denying Plaintiff's claim for disability
benefits. Pending before the Court are the parties'
cross-motions for summary judgment. Dkt. Nos. 17, 29.
Pursuant to Civil Local Rule 16-5, the motions have been
submitted on the papers without oral argument. Having
carefully reviewed the parties' positions, the
Administrative Record ("AR"), and relevant legal
authority, the Court hereby DENIES Plaintiff's Motion and
GRANTS the Commissioner's Cross-Motion for the reasons
set forth below.
was born on July 16, 1975. AR 104. He attended Castlemont
Community High School from 1989 to 1993, where he received
grades ranging from A to F. AR 171-72. The record indicates
Plaintiff attended classes through the spring semester of his
twelfth grade year, but he did not graduate or get a GED. AR
171, 266, 322, 353. Although Plaintiff reported he attended
special education classes for "slow learners" (AR
219, 322, 353), the transcript in the Administrative Record
reflects that he was also enrolled in college preparatory
classes, including World Culture, Algebra, U.S. History,
English, and Economics. AR 171. Plaintiff has previous work
experience as a security guard and warehouse worker. AR 145.
reported that his father was violent and abused him as a
child, and that he witnessed abuse between his parents. AR
255, 266. He also reported that he sustained an injury to his
skull in a fight around 2005 (AR 219), he was stabbed about
20 times in various locations, including his head and right
hand (AR 266), and was stabbed in the head 20 times by a
jealous girlfriend (AR 353). Plaintiff frequently reported
being homeless or staying with family or friends. AR 266,
322, 326, 341, 346, 354, 361, 369. He was incarcerated at
Alameda County Jail between May 12, 2010 and October 24, 2011
(AR 173-86, 251-61), and at Santa Rita Jail between February
5, 2013 and May 21, 2013 (AR 355-67).
12, 2010, Plaintiff was initially screened for treatment at
the Alameda County Behavioral Health Care Services, Criminal
Justice Mental Health Program (Alameda County Behavioral
Health). AR 186, 213. At his initial screening, Plaintiff
reported hearing voices, having depression, paranoia, and
violent moods, and difficulties with impulse control. AR 184,
186, 212-13. He denied suicidal or homicidal ideation, or
planning a suicide attempt. AR 186, 213. On evaluation, F.
Rosenthal, M.D., noted that Plaintiff is "not always
consistent in his complaints" and "tends to change
focus - [be] evasive, " and that Plaintiff "decided
depression more of an issue [yet] refuses antidepressant
medication." AR 184, 212. Dr. Rosenthal also noted that
Plaintiff "is pressurred [sic], obsessive, and
delusional, has paranoid concerns c/o AH's and
depression", and "tends to be rambling, poorly
organized - and somewhat challenging." Id.
19, 2010, Plaintiff visited Alameda County Behavioral Health
and reported that he had never received psychiatric treatment
in the past, that he was not suicidal, and denied attempting
suicide in the past. AR 183, 210. The clinician at Alameda
County Behavioral Health reported that on mental status
examination, Plaintiff was evasive and reported hearing a
male voice tell him to harm others; the clinician referred
Plaintiff to a medical doctor for a medication evaluation.
11, 2010, Plaintiff went to Alameda County Behavioral Health
and requested medication to treat his auditory hallucination;
Dr. Rosenthal reported that Plaintiff appeared to be
"somewhat drug seeking and tends to be somewhat vague
when asked about details." AR 181, 207.
15, 2010, Sarah Ulloa, MFTI at Alameda County Behavioral
Health, reported that on mental status examination, Plaintiff
was well-groomed, anxious, had good eye contact, was clear
and coherent, and walked on crutches due to his leg being
broken in two places; Plaintiff reported that medications
were "helpful" and that he had problems sleeping.
AR 180, 206. On July 14, 2010, Ms. Ulloa reported that on
mental status examination, Plaintiff had good eye contact and
clear and coherent speech, was cooperative, well-groomed,
talkative, and "doing well" on psychiatric
medication, and his mood was "good." AR 178, 203.
September 10, 2010, Dr. Rosenthal reported that Plaintiff
"seems [to be] in [a] fairly good mood, " and that
he was not taking Risperdal but had continued with the
medication Paxil and was "apparently not troubled by AH
[auditory hallucinations] at this time - and may not have a
psychotic disorder - [he] feels he does well just w[ith]
Paxil and [his] mood is controlled." AR 202.
October 6, 2010, Plaintiff complained of continued insomnia
and decreasing appetite to a clinician at Alameda County
Behavioral Health. AR 200. He presented as "unsure of
AH[, ] as he first answered that he continues to have AH but
less than originally reported" and then "he said he
did not have AH at all." Id. Plaintiff's
appearance was within normal limits; he was in a wheelchair
but was able to step over to the office chair without
difficulty. Id. He was calm and cooperative, and
there was no evidence of psychosis or distress. Id.
Plaintiff denied having any suicidal and homicidal ideation.
October 6, 2010, Dr. Rosenthal noted that Plaintiff reported
"doing well on current med[ications]" without side
effects, and that Plaintiff had a good mood, was calm and
appropriate, and had been taking Risperdal and agreed to
continue taking his medication. AR 199. Dr. Rosenthal
completed a Treatment Continuity Plan for Plaintiff's
anticipated jail release date of October 28, 2010 for
Plaintiff to continue taking the medication Paxil and contact
mental agencies on a list to continue treatment. AR 195. He
continued Plaintiff's Paxil prescription. AR 201. On
October 15, 2010, Dr. Rosenthal reported that Plaintiff was
not compliant with his prescribed medication treatment and
that his prescription was extended. AR 196, 260.
October 21, 2010, Peter Slaubaugh, M.D., at Alameda County
Medical Center Highland Outpatient reported that Plaintiff
had decreased flexion in the right knee but had an overall
normal examination of the knee. AR 188.
November 9, 2010, licensed psychologist Patricia Spivey,
Psy.D., examined Plaintiff. AR 219-22. Dr. Spivey reported
that Plaintiff had taken public transportation to the
appointment and that he could shower, dress, and feed
himself. AR 220. On mental status examination, Dr. Spivey
reported Plaintiff was oriented to person, place, time, and
purpose, his thought processes and content included evidence
of poor reality testing, Plaintiff did not respond to
internal stimuli or any loose associations, and Plaintiff
presented a flat affect and had fair mood, good attention,
and poor insight and judgment. Id. Dr. Spivey
reported Plaintiff had a full scale IQ score of 79, which was
consistent with his presentation and history of being in
special education, Plaintiff performed fairly well on the
memory subtests, and Bender drawing tests revealed no severe
deficits. AR 219, 221. Dr. Spivey opined that Plaintiff had
no impairment in his abilities to follow simple and complex
instructions and communicate effectively in writing. AR 221.
Dr. Spivey commented that Plaintiff had mild impairment in
his abilities to maintain adequate pace or persistence to
complete 1-2 step simple repetitive tasks or to maintain
adequate pace or persistence to complete complex tasks,
maintain adequate attention or concentration, and verbally
communicate effectively with others. Id. Dr. Spivey
also stated that Plaintiff had moderate impairment in his
abilities to adapt to changes in job routine and withstand
the stress of a routine workday, and moderate to marked
impairment in his abilities to maintain emotional stability
or predictability and interact appropriately with coworkers,
supervisors, and the public on a daily basis. Id.
November 17, 2010, State agency reviewing psychiatrist D.
Lucila, M.D., reviewed the record evidence and found that
Plaintiff had an affective disorder and a personality
disorder (AR 223) that caused mild restriction of activities
of daily living, and moderate difficulties in maintaining
social functioning, concentration, persistence, or pace (AR
231). Dr. Lucila also found that there was insufficient
evidence of any repeated episodes of decompensation. AR 231.
Also on November 17, Dr. Lucila completed a Mental Residual
Functional Capacity Assessment form. AR 234-35. On this form,
Dr. Lucila opined that Plaintiff was moderately limited in
his abilities to understand, remember, and carry out detailed
instructions, complete a normal workday and workweek without
interruptions from psychologically-based symptoms, interact
appropriately with the general public, accept instructions
and respond appropriately to criticism from supervisors, get
along with coworkers or peers without distracting them or
exhibiting behavioral extremes, and maintain socially
appropriate behavior and adhere to basic standards of
neatness and cleanliness. Id. Dr. Lucila stated that
otherwise, Plaintiff was not significantly limited in most
areas of mental functioning, including in the abilities to
understand, remember, and carry out very short instructions,
maintain attention and concentration for extended periods,
sustain an ordinary routine without special supervision, work
in coordination with or in proximity to others without being
distracted by them, and respond appropriately to changes in
the work setting. Id.
21, 2011, L. Crumpler, M.D., at LifeLong Medical Care,
reported that Plaintiff was cooperative and pleasant, was
alert and oriented times three, and had an antalgic gait. AR
257-58. Dr. Crumpler ordered x-rays after Plaintiff's
complaints of leg pain, reported that Plaintiff's asthma
was controlled and that Plaintiff was given an inhaler, and
stated that Plaintiff would start Paxil for his depression.
AR 258. Plaintiff denied having any current suicidal or
homicidal ideation, reported sleeping too much, and reported
that his appetite was okay. AR 257.
August 25, 2011, Plaintiff's clinician at Alameda County
Behavioral Health noted that his last dose of Paxil was on
July 20, 2011. AR 255. The clinician reported that on mental
status examination, Plaintiff was cooperative, had behavior,
orientation, thought content, and thought processes within
normal limits, and had depressed and dysthymic mood, flat
affect, fair insight, fair impulse control, fair judgment,
and no hallucinations. AR 255-56.
August 29, 2011, a doctor at Alameda County Behavioral Health
reported that Plaintiff was "clear" and
cooperative, had no observed abnormal movements, had speech
within normal limits, and found the change in medication to
Remeron "helpful" and asked for medication "to
control his anxiety." AR 254.
October 28, 2011, Dr. Crumpler saw Plaintiff for his asthma,
mental health, and sores on his penis. AR 335. Dr. Crumpler
assessed Plaintiff's asthma as mild and intermittent,
found Plaintiff's depression controlled by his taking
Remeron and Buspar, and found that the sores had healed.
November 7, 2011, registered psychological assistant
Katherine Wiebe, Ph.D., examined Plaintiff upon referral by
the Homeless Action Center. AR 265-80. Dr. Wiebe reported
that Plaintiff was well-groomed and casually dressed, had an
anhedonic mood, was mildly dysphoric, was generally
dissociated, had normal affect, was cooperative during the
interview, had normally flowing thoughts, appeared to have
"slow" thinking with delayed responses, had vague
speech, expressed suicidal ideation without intent, denied
current auditory or visual hallucinations while stating he
had them "in the past, " and was oriented to
person, place, and time. AR 268. She also noted that
Plaintiff did not have a cane with him though he usually did.
Wiebe found that Plaintiff had severe impairment in memory,
visual and spatial fields, executive areas, and attention,
concentration, and persistence, as well as moderate sensory,
motor, and language impairments, and mildly to moderately
impaired intellectual functioning. AR 276. She also stated
that Plaintiff's symptoms made him unlikely to be able to
complete tasks assigned to him in a work setting; he was
easily fatigued; he required reminders to accomplish tasks;
had difficulty leaving his home due to paranoia, anxiety, and
depression; was limited in his ability to manage daily tasks
and affairs; and had trouble with interpersonal relationships
because of his personality disorder symptoms. Id.
Dr. Wiebe diagnosed Plaintiff with major depressive disorder
- recurrent, chronic, severe, and with psychotic features.
Id. She reported that Plaintiff was in the <0.1
to 4 percentile for the RBANS tests. AR 278. Dr. Wiebe opined
that Plaintiff had mild impairment in intellectual
functioning, minimal impairment in orientation, moderate
impairment in language and motor and praxis skills, severe
impairment in attention and concentration, short-term memory,
long-term memory, visual and spatial organization, judgment
and insight, executive functioning, and social functioning,
marked impairment in the ability to understand, remember, and
carry out very short and simple instructions, get along and
work with others, and accept instructions and respond
appropriately to criticism from supervisors, and extreme
limitation in the rest of the abilities, including the
ability to maintain attention and concentration for two hour
segments, perform at a consistent pace without an
unreasonable number and length of rest periods, interact
appropriately with the general public, respond appropriately
to changes in a routine work setting and deal with normal
work stressors, complete a normal workday and workweek
without interruptions from psychologically-based symptoms,
and maintain regular attendance and be punctual within
customary, usually strict tolerances. AR 279-80.
December 14, 2011, William Spivey, Ph.D., filled out a Mental
Impairment Questionnaire. AR 283-87. Dr. Spivey indicated
that Plaintiff had mild impairments in understanding and
remembering very short and simple instructions, making simple
work-related decisions, asking simple questions or requesting
assistance, maintaining socially appropriate behavior, and
adhering to basic standards of neatness and cleanliness, and
moderate impairment in carrying out very short and simple
instructions, sustaining an ordinary routine without special
supervision, accepting instructions and responding
appropriately to criticism from supervisors, being aware of
normal hazards and taking appropriate precautions,
interacting appropriately with the general public, traveling
in unfamiliar places, and using public transportation. AR
285-86. He also indicated that Plaintiff otherwise had marked
or extreme limitations in the rest of the mental abilities
and aptitudes needed to do unskilled, semiskilled, and
skilled work, and to do particular jobs. Id. Such
abilities and aptitudes include remembering work-like
procedures, maintaining attention for two hour segments,
maintaining regular attendance and being punctual within
customary, usually strict tolerances, working in coordination
with or in proximity to others without being unduly
distracted, and completing a normal workday and workweek
without interruptions from psychologically-based symptoms.
Id. They also include performing at a consistent
pace without an unreasonable number of and lengths of rest
periods, getting along with coworkers or peers without unduly
distracting them or exhibiting behavioral extremes,
responding appropriately to changes in a routine work
setting, and dealing with normal work stress. Id.
Dr. Spivey opined that Plaintiff had marked restriction of
activities of daily living, difficulties in maintaining
social functioning, deficiencies in concentration,
persistence, or pace, and three repeated episodes of
decompensation within a twelve-month period, each of at least
two weeks duration. AR 286.
March 20, 2012, Board certified internist Jenna Brimmer,
M.D., conducted a consultative internal medicine examination,
as Plaintiff complained of a leg injury. AR 291-95. Dr.
Brimmer reported that Plaintiff suffered a right leg fracture
around late 2010 when he fell off a second story balcony and
subsequently underwent surgery with hardware placed. AR 291.
Dr. Brimmer reported that Plaintiff was pleasant and
cooperative, spoke in full sentences and used hand gestures
while talking, and was casually dressed with adequate
grooming and hygiene. AR 292. Plaintiff reported to Dr.
Brimmer that he could dress himself but needed help with
putting on his pants and washing his feet due to his leg
pain, he could heat food in the microwave, do dishes, and
vacuum, and that he fed birds during the day as a hobby. AR
291-92. Dr. Brimmer reported that Plaintiff came with a cane
and walked with a limp, but that he had no difficulty moving
about the exam room, getting onto the exam table,
manipulating his clothing and personal items, opening the
door, and writing his name independently. AR 292.
Brimmer reported that on physical examination, Plaintiff had
full 5/5 strength in the lower extremities, had no evidence
of muscle atrophy, was able to stand on his tiptoes and
heels, and could walk heel-to-toe in a straight line. AR
293-94. She opined Plaintiff could stand or walk for six
hours in an eight-hour workday, could sit without limitation,
could walk with a cane, could lift up to 50 pounds
occasionally and 25 pounds frequently, could occasionally
take part in climbing, balancing, stooping, kneeling,
crouching, and crawling, could perform manipulative
activities without limitation, and could perform workplace
environmental activities without limitation. AR 294-95.
April 19, 2012, State agency reviewing physician L. Pancho,
M.D., reviewed the medical evidence in the record. AR 301-02.
Dr. Pancho opined that Plaintiff was able to lift and carry
50 pounds occasionally and 25 pounds frequently, stand or
walk for a total of about six hours in an eight-hour workday,
and sit for a total of about six hours in an eight-hour
workday. Id. Dr. Pancho also determined that
Plaintiff was unlimited in pushing or pulling, and could
occasionally climb ramps and ladders, balance, stoop, kneel,
crouch, and crawl. Id.
7, 2012, Plaintiff completed an Adult Medical History form
for LifeLong Medical Care. AR 330-33. On the form, he
indicated that he had a history of asthma, that he took the
medications Remeron and Burspuren [sic] and used an asthma
pump, and that he had a history of problems involving
dizziness, forgetfulness, headaches, sinus problems, tooth
pain, pain or loss of strength or feeling in the hips and
legs and knees, depression, and biting his skin. AR 330-31.
Plaintiff indicated that he did not feel threatened by
anyone, that he felt safe in his home, and that he had a gun
and smoke detector in his home. AR 332.
5, 2012, a medical provider at LifeLong Medical Care
continued Plaintiff on Ibuprofen, asthma inhaler treatment,
and Remeron and Buspar treatment for his leg pain, asthma,
and depression. AR 324, 326.
26, 2012, Rene Thomas, M.D., conducted a psychiatric
evaluation. AR 322-23. Plaintiff denied, to Dr. Thomas,
having any prior psychiatric treatment or hospitalizations
prior to his being in Santa Rita Jail starting in 2010. AR
322-23. Plaintiff reported to Dr. Thomas that the
antidepressant Remeron had been effective in controlling his
depressive symptoms and helped him sleep better, but the
symptoms returned when he had not taken Remeron in three
mental status examination, Dr. Thomas noted that Plaintiff
was alert, neatly dressed, calm, and appropriate, and had a
normal speech rate and rhythm. AR 323. Dr. Thomas also stated
that Plaintiff had a depressed mood, had a positive affect
within the normal range, did not appear depressed, had
logical and coherent thought processes, had no suicidal or
homicidal ideation, had no auditory or visual hallucination,
did not exhibit any evidence of delusions or paranoid
ideation, and appeared to have normal cognition. Id.
Dr. Thomas diagnosed Plaintiff with a recurrent major
depressive disorder, as borderline intellectual functioning
by history, and as taking part in marijuana use. AR 323. Dr.
Thomas recommended that Plaintiff restart Remeron and another
medication, Buspar, for Plaintiff's nail biting, and that
Plaintiff follow up in one month. Id. Dr. Thomas
continued Plaintiff on asthma inhaler treatment. AR 321.
August 30, 2012 and January 14, 2013, Plaintiff periodically
received treatment from Health Care for the Homeless via the
TRUST Clinic. AR 339-46. On August 30, 2012, he reported to
Nurse Practitioner Laurel Barber that he was currently taking
the medications Remeron and Risperdal, that Remeron was the
only reason he could sleep, that he took Risperdal to make
the voices go away, and that his last auditory hallucination
was about a year prior. AR 345. Ms. Barber reported that on
mental status examination, Plaintiff was casually dressed,
had poor eye contact, was "very cooperative, " had
slow and soft speech, described his mood as depressed and
affect as sad, had linear and logical thought process, denied
auditory and visual hallucination, denied paranoia and
delusions, was fully alert and oriented, and had fair insight
and poor judgment. AR 346.
September 6, 2012, Dr. Thomas at Lifelong Medical Care
reported that Plaintiff was alert, calm, engageable, neatly
dressed, and exhibited a flat affect. AR 320. Plaintiff
reported sleeping well on Remeron but had a poor appetite.
Id. He reported having no side effects from taking
Remeron and Buspar, denied having any suicidal ideation,
homicidal ideation, or feelings of hopelessness, and
complained of being irritable with his brother for
"little things." Id. Dr. Thomas assessed
Plaintiff as having a recurrent major depressive disorder,
with no improvement yet. Id. Dr. Thomas increased
Plaintiff's prescriptions for Remeron and Buspar, and
discussed counseling referrals with Plaintiff. Id.
September 24, 2012, Adisa Wilmer, M.D., at Lifelong Medical
Care, reported that Plaintiff had right leg pain and strain,
reduced strength in his right hamstring, and that his asthma
and depression were stable. AR 318.
September 26, 2012, Plaintiff received treatment at LifeLong
Medical Care for his complaints of leg pain and a cold. AR
316. Plaintiff continued using an asthma inhaler. AR 374.
October 22, 2012, Plaintiff visited LifeLong Medical Care,
complaining of leg pain and requesting an asthma pump; also,
the doctor, Dr. Wilmer, reported that Plaintiff's
depression was "stable." AR 315. Dr. Wilmer
referred Plaintiff for x-rays of his right knee. AR 317.
October 31, 2012, Plaintiff saw Michael Boroff, M.D., at the
TRUST Clinic and complained of leg pain, anger issues,
depression, problems sleeping, auditory hallucinations,
fainting spells, and frequent biting of his fingers. AR 343.
Dr. Boroff reported that on mental status examination,
Plaintiff was cooperative and engaged, struggled to
articulate his symptoms and was often vague when questioned.
AR 343. Dr. Boroff also stated that Plaintiff denied having
any suicidal ideation but self-reported having a severely
depressed mood and frequent auditory hallucinations, though
he did not appear to be attending to them in the session.
Id. Plaintiff also self-reported having feelings of
significant paranoia, denied and gave no obvious indications
of mania or depersonalization, had apparently impaired memory
and focus, and had estimated below-average intelligence. AR
December 13, 2012, Plaintiff saw Dr. Boroff again and
reported experiencing leg pain that kept him from standing or
walking for long periods of time. AR 341. Plaintiff also told
Dr. Boroff that he was relying on others to help him keep
track of things in his life, about his history of being in
special education, about dropping out of school to support
his wife, and that he had a poor memory, problems focusing,
and difficulties with reading comprehension. Id.
December 27, 2012, Plaintiff reported to Dr. Boroff that his
mood was "down" due to his being out of medication,
and that "When on medication, he feels much better,
" although "even with medication, he has to avoid
people, as they trigger his anger." AR 340. Plaintiff
gave vague answers about his psychotic symptoms but denied
hearing voices, although he reported that he talks to
January 14, 2013, Plaintiff saw Dr. Boroff while in distress,
as he was hearing voices again and was out of medication. AR
Boroff conducted a psychological evaluation based on meetings
with Plaintiff on August 30, 2012, October 31, 2012, December
13, 2012, December 27, 2012, and January 14, 2013. AR 353-54.
In his psychological evaluation, Dr. Boroff reported that
Plaintiff struggled to make it to his appointments and gave
vague answers to questions posed to him, but on mental status
examination, Plaintiff was oriented times four, and was
cooperative and engaged. AR 354. Dr. Boroff stated that
Plaintiff self-reported that his mood was depressed, but his
affect was not mood-congruent, and that Plaintiff smiled at
inappropriate times. Id. Dr. Boroff also noted that
Plaintiff denied having any suicidal or homicidal ideation,
though he reported hearing voices that commanded him to hurt
himself, and self-reported having intense feelings of
paranoia, although neither paranoia nor auditory
hallucinations were apparent in sessions. Id. The
doctor also mentioned Plaintiff's coherent speech, and
that Plaintiff denied experiencing and did not display
obvious signs of mania or depersonalization, and had limited
insight, had severely impaired judgment, demonstrated clear
deficits in memory and focus, and had estimated below-average
February 5, 2013, intern Sarah Ulloa at Alameda County
Behavioral Health Care Services reported that Plaintiff was
prescribed the medication Risperdal at Lifelong Clinic and
that Plaintiff stated that the medication was helpful. AR
359. Plaintiff denied having any suicidal ideation, and on
mental status examination, Plaintiff was alert, had clear
speech and "good" grooming, made good eye contact,
and was cooperative (though a poor historian). Id.
February 14, 2013, Dr. Boroff completed a Mental Impairment
Questionnaire. AR 347-51. Dr. Boroff stated that Plaintiff
exhibited signs and symptoms included paranoia and
suspiciousness, his list of prescribed medications showed
Remeron and Risperdal, and he experienced side effects of
drowsiness, lethargy, and weight gain. AR 347-48. Dr. Boroff
gave a prognosis of "Poor. Permanently disabled"
and the list of clinical findings demonstrating the severity
of Plaintiff's mental impairment and symptoms shows that
Plaintiff has: depressed mood, incongruent affect, impaired
memory and focus, below-average intelligence, limited
insight, poor judgment, and reports of auditory
hallucinations and paranoia. AR 347.
Boroff opined that Plaintiff was seriously limited, but not
precluded from carrying out very short and simple
instructions, making simple work-related decisions,
responding appropriately to changes in a routine work
setting, and adhering to basic standards of neatness and
cleanliness. AR 348-49. Dr. Boroff also noted that Plaintiff
had limited but satisfactory ability to ask simple questions,
be aware of normal hazards and take appropriate precautions,
travel in an unfamiliar place, and use public transportation.
AR 349. Dr. Boroff opined that Plaintiff was unable to meet
competitive standards or had no useful function in all other
mental abilities and aptitudes needed to do unskilled work
and semiskilled to skilled work, and to do particular types
of jobs. Id. Such abilities and aptitudes include
maintaining regular attendance, working in coordination with
or proximity to others without being unduly distracted,
completing a normal workday and workweek without
interruptions from psychologically-based symptoms, getting
along with coworkers or peers without unduly distracting them
or exhibiting behavioral extremes, dealing with normal
stress, interacting appropriately with the general public,
and maintaining socially-appropriate behavior. Id.
Boroff reported that Plaintiff's anger and paranoia
severely impaired Plaintiff's social functioning. AR 349.
He opined that Plaintiff had moderate restriction of
activities of daily living, extreme difficulties in
maintaining social functioning, marked deficiencies in
concentration, persistence, or pace, and one or two episodes
of decompensation within a twelvemonth period, each of at
least two weeks duration. AR 350. He also opined that
Plaintiff had a "Medically documented history of a
chronic organic mental, schizophrenic, etc. or affective
disorder of at least [two] years' duration that has
caused more than a minimal limitation of ability to do any
basic work activity, with symptoms or signs currently
attenuated by medication or psychosocial support, " and
"A residual disease process that . . . resulted in such
marginal adjustment that even a minimal increase in mental
demands or change in the environment would be predicted to
cause the individual to compensate." AR 350-51. Dr.
Boroff noted that the impairments lasted or can be expected
to last at least twelve months. AR 351.
February 5, 2013, Plaintiff was initially screened for
psychiatric treatment at Alameda County Behavioral Health
Care Services, but he eventually asked to be rescheduled
because he felt it was too long a wait. AR 357-60.
February 19, 2013, Neelam Sachdev, M.D., at Alameda County
Behavioral Health Care Services reported that Plaintiff was
alert, oriented, and cooperative, made fairly good eye
contact, and had clear speech, anxious and depressed mood, a
somewhat dysthymic affect, linear thought processes, and no
suicidal or homicidal ideation or auditory or visual
hallucinations. AR 361. Plaintiff reported that the
medication Buspar helped him with his problem of biting the
skin on his fingers. Id.
March 5 and 19, 2013, Dr. Sachdev reported that Plaintiff did
not attend his scheduled appointments. AR 363-64.
April 9, 2013, Plaintiff informed Dr. Sachdev that he had
been to Santa Rita Jail more than twenty-five times since
1998, that he had taken the medications Buspar and Remeron,
which had helped him, and that he had received treatment at
LifeLong. AR 365. Dr. Sachdev reported that Plaintiff denied
experiencing feelings of paranoia, having auditory or visual
hallucinations, and having any suicidal or homicidal
ideation. Id. Plaintiff told Dr. Sachdev that he was
sleeping and eating "good." Id. Dr.
Sachdev reported that on mental status examination, Plaintiff
appeared to be somewhat guarded but spoke clearly and mostly
coherently, described his own mood as "fine, " had
a guarded affect, and was a little hypomanic, with what
appeared to be some loose and circumstantial thought
processing. AR 365-66. Dr. Sachdev described Plaintiff as
"grandiose" based on his statements that his uncle
is the famous baseball player Willie Mays, that all his
incarcerations were a result of being "set up, "
and that many women wanted Plaintiff and would say untrue
things about him if he tried to leave them. AR 365-66. Dr.
Sachdev recommended that Plaintiff continue with the
medications Remeron and Buspar and that he follow up with Dr.
Sachdev in four months. AR 366. Plaintiff refused to take any
anti-psychotic medication, such as Risperdal, Lithium, or
21, 2013, Dr. Sachdev reported that Plaintiff was a no-show
for his appointment, but he was continued on the medications
Remeron and Buspar. AR 367.
September 5, 2013, Plaintiff visited LifeLong Medical Care
after previously seeing Dr.
in 2012; he was returning after his recent incarceration at
Santa Rita Jail in order to reestablish care. AR 373.
Plaintiff had no changes in medication, denied having any
suicidal or homicidal ideation or auditory hallucinations,
reported that medication helped his mood, and requested a
referral for physical therapy because of a leg injury he
suffered in 2011. AR 373.
January 13, 2014, Plaintiff visited Serena Wu, M.D., at
LifeLong Medical Care because he was experiencing pain in his
right knee and he additionally wanted to get his medication
refilled. AR 369. Dr. Wu noted that although Plaintiff was
previously referred for physical therapy, he never
followed-up, and although he was referred to a psychiatrist
during his previous ...