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Goytia v. Berryhill

United States District Court, N.D. California, San Jose Division

March 28, 2017

TINA A. GOYTIA, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.



         Plaintiff Tina A. Goytia (“Plaintiff”) brings this action pursuant to 42 U.S.C. § 405(g) to obtain review of a final decision by the Commissioner of the Social Security Administration[1]denying her claim for Supplemental Security Income (“SSI”). In a Motion for Summary Judgment, Plaintiff seeks an order reversing the decision and awarding benefits, or alternatively, remanding the action to the Commissioner for further administrative proceedings. Dkt. No. 18. The Commissioner opposes Plaintiff's motion and seeks summary judgment affirming the decision denying benefits. Dkt. No. 21.

         Because the record reveals the Commissioner's decision is not supported by substantial evidence, Plaintiff's motion will be granted and the Commissioner's cross-motion will be denied.

         I. BACKGROUND

         A. Procedural History

         Plaintiff applied for SSI on September 7, 2012, alleging a disability beginning on April, 1, 2012.[2] Tr., Dkt No. 15, at 165. Plaintiff's claim was initially denied by the Commissioner on November 27, 2012. Id. at 103-107. Plaintiff requested reconsideration of that decision, which was denied by the Commissioner on July 1, 2013. Id. at 108-114.

         Plaintiff subsequently requested a hearing before an administrative law judge (“ALJ”), which occurred before ALJ Betty Roberts Barbeito on May 22, 2014. Id. at 31-69; 115-117. Plaintiff, represented by counsel, testified on her own behalf. Id. at 35-38. The ALJ also heard testimony from an expert psychiatrist, Dr. Robert McDevitt, and a vocational expert, Thomas Linvill. Id. at 38-69. In a written decision dated May 30, 2014, the ALJ ultimately found that Plaintiff was not disabled and had the residual functional capacity to perform “light work” limited to “simple, repetitive tasks characteristic of unskilled work.” Id. at 17-26.

         Plaintiff sought administrative review of the ALJ's determination. Id. at 8-9. On August 7, 2014, the Appeals Council denied the request for review, and the ALJ's decision became the final decision of the Commissioner. Id. at 1-6. Plaintiff then commenced this action, and the instant summary judgement motions followed.

         B. Plaintiff's Personal, Vocational and Medical History

         According to her testimony before the ALJ, Plaintiff was born on September 10, 1981, and was 32 years old at the time of the hearing. Id. at 36. She attended school to the eleventh grade, did not complete a GED, and did not have any vocational training after high school. Id. at 36-37. Plaintiff is single and has three children, who were seventeen years old, fourteen years old and twelve years old when she appeared before the ALJ. Id. at 36. She was most recently employed as a caretaker of non-verbal and immobile patients in 2010. Id. at 37.

         Plaintiff claims an inability to work due to Post-Traumatic Stress Disorder (“PTSD”), Obsessive-Compulsive Disorder (“OCD”), diabetes mellitus, and obesity. Id. at 277. Plaintiff began receiving medical treatment for physical and psychiatric conditions at the Eureka Community Health Center in 2011. Records obtained from that facility show that on December 21, 2011, Plaintiff reported “severe anxiety” lasting for “several minutes” which “spontaneously goes away.” Id. at 340. She was diagnosed with diabetes mellitus on or about March 5, 2012, and began checking her blood glucose levels shortly thereafter. Id. at 337-38. On April 23, 2012, Plaintiff reported she had “a lot of anxiety” over the diabetes diagnosis, but also reported having anxiety “for years and it is getting worse.” Id. at 334. On May 7, 2012, Plaintiff was “tearful, ” said anxiety was “taking over her life, ” and stated she could not visit her mother. Id. at 329. Plaintiff also stated she was checking her blood glucose level five times per day. Id.

         On May 8, 2012, Plaintiff underwent an initial psychiatric assessment with Dr. David Villasenor. Id. at 299-303. Dr. Villasenor diagnosed Plaintiff with “General Anxiety Disorder with agoraphobia and panic, rule out anxiety due to a general medical condition, methamphetamine dependence, in full remission.” Id. He discussed the “three pillars” of anxiety treatment with Plaintiff (psychopharmacology, behavioral measures and psychotherapy), and indicated that Plaintiff was agreeable to all three. Id. Dr. Villasenor also prescribed Zoloft for Plaintiff. Id.

         Plaintiff also received treatment from Gardner Health Center through December, 2013. Relevant records from that facility show that on July 19, 2012, Plaintiff reported worsening anxiety symptoms, such that she could not go out of the house and experienced panic in public areas. Id. at 367-69. She also stated Klonopin was helpful with panic attacks, which were occurring one to two times per week. Id. Dr. Michelle Dinh referred Plaintiff for psychiatric treatment. Id. On August 13, 2012, Plaintiff's prescription for Zoloft was increased from 25 milligrams to 50 milligrams, and though she was checking her blood glucose level four to six times per day, she was advised to check it only once per day. Id. at 357-59.

         Plaintiff began psychiatric treatment with Dr. Viet Le on August 30, 2012. Id. at 390-91. On that date, Dr. Le observed that Plaintiff had “moderate anxiety and panic attack symptoms, ” and Plaintiff's prescription for Zoloft was increased to 100 miligrams. Id. Dr. Le also prescribed BuSpar and Trazodone. Id. On September 27, 2012, Dr. Le reported that Plaintiff “continued to struggle with panic attack episodes and agoraphobia behavior.” Id. at 391.

         On November 30, 2012, Dr. Le reported that Plaintiff “missed her last appointment because of lack of transportation, complicated by panic attack symptom and agoraphobic behavior.” Id. at 484. Plaintiff continued to “struggle with panic attack episodes.” Id. On May 9, 2013, and July 25, 2013, Dr. Le reported that Plaintiff had anxiety throughout the day, and on October 24, 2013, he reported that Plaintiff had “recurred symptoms of depressed mood and anxiety.” Id. at 481-83. On November 21, 2013, Dr. Le reported that Plaintiff “still struggled with anxiety and panic attack symptoms.” Id. at 480.

         On January 2, 2014, Dr. Le reported that Plaintiff's anxiety symptoms persisted and were complicated by diabetes mellitus. Id. at 480. In a Mental Medical Source Statement completed that same date, Dr. Le noted that Plaintiff's psychological conditions and symptoms included depression, anxiety/panic attacks, sleep disturbance, problems interacting with the public, difficulty with concentration, and “OCD symptoms of increased checking of her finger stick blood glucose . . . in stressful situation.” Id. at 516-19. Dr. Le noted that Plaintiff could remember locations and work-like procedures, and could understand and remember short and simple instructions without limitation. Id. She had a mild limitation in her ability to carry out short and simple instructions, and moderate limitations in several other areas of sustained concentration and persistence, social interaction, and functional limitation. Id. Plaintiff had a marked limitation in her ability to understand, remember and carry out detailed instructions, and her ability to accept instructions and to respond appropriately to criticism from supervisors. Id. Dr. Le concluded that Plaintiff's limitations had lasted or were expected to last twelve continuous months, was incapable of low stress jobs, and would likely be absent from work more than four days per month. Id.

         Plaintiff attended a comprehensive psychiatric evaluation with Dr. Maria Antoinette Acenas on June 11, 2013. Id. at 301-302. Dr. Acenas diagnosed Plaintiff with generalized anxiety disorder, dysthymia and history of polysubstance abuse. Id. She determined that Plaintiff was capable of managing funds, has basic mathematical skills, can perform simple and repetitive tasks, and can accept instructions from supervisors. Id. Dr. Acenas also determined that, because Plaintiff's depression was being appropriately treated, she would be able to perform work on a consistent basis, maintain regular attendance and finish a normal work week. Id. Dr Acenas also found that Plaintiff could “deal with the usual stress encountered in a competitive workplace.” Id.

         At the hearing before the ALJ, Plaintiff testified that she is afraid of dying. Id. at 51. She has a valid drivers' license but does not drive. Id. at 53. She is able to bring her children to school, shop for groceries, attend medical appointments, and attend church and Bible study with assistance from family. Id. at 51, 56, 57. However, Plaintiff described panic attacks lasting twenty to forty minutes and issues with incontinence and regular hygiene. Id. at 55-56, 59.


         A. Standard for Reviewing ...

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