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Goolsby v. Berryhill

United States District Court, E.D. California

March 21, 2017

NANCY A. BERRYHILL[1], Acting Commissioner of Social Security, Defendant.



         Clifford Dean Goolsby asserts he is entitled to a period of disability, disability insurance benefits, and supplemental security income under Titles II and XVI of the Social Security Act. Plaintiff argues the administrative law judge erred in evaluating the medical record and seeks judicial review of the decision to deny his application for benefits. Because the ALJ failed to apply the proper legal standards, as discussed below, the administrative decision is REMANDED for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g).


         In his applications for benefits, Plaintiff asserted that he became disabled as of June 9, 2012, due to an aneurism, speech difficulties, depression, bad memory, and low mobility in his right arm. (Doc. 14-6 at 2, 8) The Social Security Administration denied Plaintiff's applications at both the initial level and upon reconsideration. (See generally Doc. 14-4; Doc. 14-3 at 9) After requesting a hearing, Plaintiff testified before an ALJ on October 16, 2014. (Doc. 14-3 at 9, 27) The ALJ determined Plaintiff was not disabled and issued an order denying benefits on November 25, 2014. (Id. at 9-20) When the Appeals Council denied Plaintiff's request for review of the decision (id. at 2-3), the ALJ's findings became the final decision of the Commissioner of Social Security (“Commissioner”).


         District courts have a limited scope of judicial review for disability claims after a decision by the Commissioner to deny benefits under the Social Security Act. When reviewing findings of fact, such as whether a claimant was disabled, the Court must determine whether the Commissioner's decision is supported by substantial evidence or is based on legal error. 42 U.S.C. § 405(g). The ALJ's determination that the claimant is not disabled must be upheld by the Court if the proper legal standards were applied and the findings are supported by substantial evidence. See Sanchez v. Sec'y of Health & Human Serv., 812 F.2d 509, 510 (9th Cir. 1987).

         Substantial evidence is “more than a mere scintilla. It means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971) (quoting Consol. Edison Co. v. NLRB, 305 U.S. 197 (1938)). The record as a whole must be considered, because “[t]he court must consider both evidence that supports and evidence that detracts from the ALJ's conclusion.” Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985).


         To qualify for benefits under the Social Security Act, Plaintiff must establish he is unable to engage in substantial gainful activity due to a medically determinable physical or mental impairment that has lasted or can be expected to last for a continuous period of not less than 12 months. 42 U.S.C. § 1382c(a)(3)(A). An individual shall be considered to have a disability only if:

his physical or mental impairment or impairments are of such severity that he is not only unable to do his previous work, but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy, regardless of whether such work exists in the immediate area in which he lives, or whether a specific job vacancy exists for him, or whether he would be hired if he applied for work.

42 U.S.C. § 1382c(a)(3)(B). The burden of proof is on a claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th Cir. 1990). If a claimant establishes a prima facie case of disability, the burden shifts to the Commissioner to prove the claimant is able to engage in other substantial gainful employment. Maounois v. Heckler, 738 F.2d 1032, 1034 (9th Cir. 1984).


         To achieve uniform decisions, the Commissioner established a sequential five-step process for evaluating a claimant's alleged disability. 20 C.F.R. §§ 404.1520, 416.920(a)-(f). The process requires the ALJ to determine whether Plaintiff (1) engaged in substantial gainful activity during the period of alleged disability, (2) had medically determinable severe impairments (3) that met or equaled one of the listed impairments set forth in 20 C.F.R. § 404, Subpart P, Appendix 1; and whether Plaintiff (4) had the residual functional capacity (“RFC”) to perform to past relevant work or (5) the ability to perform other work existing in significant numbers at the state and national level. Id. The ALJ must consider testimonial and objective medical evidence. 20 C.F.R. §§ 404.1527, 416.927.

         A. Relevant Medical Evidence[2]

         Plaintiff's records from the Veteran's Administration indicate that he had a history of “[a]lcohol dependence, dysphoric mood, suicidal ideations and intent.” (Doc. 14-11 at 92) In addition, he was diagnosed with a depressive disorder. (Id. at 93) In November 2007, Plaintiff was hospitalized “with a long history of depression and multiple suicide attempts, ” and remained hospitalized for four days. (Doc. 14-12 at 65)

         On June 8, 2012, paramedics transported Plaintiff for emergency care after he “called the ambulance for a headache.” (Doc. 14-10 at 101) The paramedics reported “they witnessed [Plaintiff] seizing with [altered mental status] upon arrival.” (Id. at 104; see also Doc. 14-10 at 106) Plaintiff had a low level of consciousness, and his motor responses were “only to painful stimuli.” (Id. at 104) Further, he was unable to speak, and only opened his eyes “with painful stimuli.” (Id.) Plaintiff had a CT scan on his head, which showed “subarachnoid blood dominantly within the basal cisterns, suggesting a possible underlying aneurysm.” (Id. at 10) Dr. Heidi Dambach determined this was a “critical abnormality, ” and Plaintiff was transferred to the San Francisco VA facility for surgery. (Id.; Doc. 14-8 at 24) On June 12, Plaintiff had a right frontal craniotomy and “clipping” of the ruptured carotid artery. (Doc. 14-8 at 24)

         Following the surgery, Plaintiff was transferred back to the Fresno VA hospital for “acute rehab” beginning July 17, 2012. (Doc. 14-8 at 92) Plaintiff began physical therapy “for increasing mobilization.” (Id. at 25) During the physical therapy consultation, Plaintiff was able to follow a two-step command, and no barriers to learning were identified. (Id. at 42) On July 27, Plaintiff was discharged to a skilled nursing facility for a thirty-day stay, with the following diagnoses: “[h]istory of subarachnoid hemorrhage, status post right internal carotid artery clipping;” “left femoral deep venous thrombosis;” gout; hypertension; hyperlipidemia; and depression. (Id. at 24-25, 30) At the nursing facility, Plaintiff received “occupational therapy” for four weeks. (Id. at 31) He was discharged on August 29, 2012. (Id.)

         Plaintiff met with Timothy Jones, a social worker for homeless veterans, on September 6, 2012. (Doc. 14-8 at 69) Plaintiff reported he was able to “adequately” perform his activities of daily living, though he continued to have “some health issues.” (Id.) Plaintiff expressed “interest[] in going back to school… [and] looking for employment.” (Id.) In responding to the intake questions, Plaintiff indicated he did not have mental health concerns. (Id. at 73) However, Plaintiff also reported he had PTSD, anxiety, and depression. (Id. at 79-80)

         Dr. Christina Hernandez examined Plaintiff as part of a “routine visit” following his discharge from the nursing facility on September 7, 2012. (Doc. 14-8 at 65) Plaintiff reported he “usually [had] headaches, 4/10 in intensity, on the right temporal area, ” for which he was told to take Tylenol. (Id.) In addition, Plaintiff described depression but had no suicidal or homicidal ideation. (Id.) According to Dr. Hernandez, Plaintiff did not have any confusion and had an “[a]ppropriate affect.” (Id. at 66)

         In November 2012, Plaintiff was “referred to Speech Therapy for 'memory deficits'” after a social worker noticed a recommendation had been made in July 2012 but failed to be placed by a medical provider. (Doc. 14-11 at 79, 80) After the social worker made the request, Plaintiff met with Dr. Dorythea Williams to begin therapy on December 6, 2012. (Id. at 38) Dr. Williams observed that Plaintiff had “[m]ild speech assimilations and “slight hyponasal resonance” but used “intact linguistic syntax, grammer (sic) and references.” (Id.) Plaintiff told Dr. Williams that he was having difficulty handling four college courses at that time. (Id. at 39) Dr. Williams noted Plaintiff “admitted having only mild memory” difficulties. (Id. at 39)

         Dr. Fariba Vesali performed a comprehensive neurological evaluation on December 14, 2012. (Doc. 14-11 at 16) Plaintiff reported that he had “difficulties to concentrate and [got] drowsy all the time.” (Id.) Plaintiff told Dr. Vesali that he was living “in a housing facility through Veterans Administration Hospital, ” where Plaintiff did chores such as dishes, laundry, and vacuuming. (Id.) According to Dr. Vesali, Plaintiff “did not have any difficulties to hear questions and answer appropriately, ” and “was oriented to times, place, and person.” (Id. at 17) Dr. Vesali opined Plaintiff “should be able to walk and stand six hours in an eight-hour day with breaks every one hour for stretching, ” “sit with no limitations, ” and “lift/carry 50 pounds occasionally and 25 pounds frequently.” (Id. at 18-19) Dr. Vesali did not offer any functional assessment conclusions related to Plaintiff's mental abilities. (See id.)

         On January 7, 2013, Dr. Williams noted that Plaintiff was thirty minutes late for his appointment. (Doc. 14-11 at 59) She administered the Ross Information Processing Assessment (“RIPA”), and found Plaintiff's “lowest score was for organization.” (Id. at 60) In addition, Plaintiff demonstrated “moderate losses” for problem solving, immediate memory and remote memory;” and “mild losses” for “recent memory, spatial orientation, orientation to environment and general information.” (Id. at 60) Dr. Williams noted that Plaintiff's “highest scores were for auditory processing and retention and ...

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