United States District Court, E.D. California
ORDER ON PLAINTIFF'S SOCIAL SECURITY COMPLAINT
(DOC. 1)
SHEILA
K. OBERTO, UNITED STATES MAGISTRATE JUDGE.
I.
INTRODUCTION
On
August 21, 2018, Plaintiff Esmeralda Berenisia Madrigal
(“Plaintiff) filed a complaint under 42 U.S.C. §
1383(c) seeking judicial review of a final decision of the
Commissioner of Social Security (the
“Commissioner” or “Defendant”)
denying her application for Supplemental Security Income
(SSI) under the Social Security Act (the “Act”).
(Doc. 1.) The matter is currently before the Court on the
parties' briefs, which were submitted, without oral
argument, to the Honorable Sheila K. Oberto, United States
Magistrate Judge.[2]
II.
BACKGROUND
On June
9, 2014, Plaintiff protectively applied for SSI, alleging
disability beginning May 11, 2011, due to major depression,
acid reflux, low back problems, anxiety, and migraine
headaches. (Administrative Record (“AR”) 33,
35-36, 39, 71-72, 85-86, 190-91, 216, 218, 224.) Plaintiff
was born on September 6, 1975, and was 35 years old on the
alleged disability onset date. (AR 33, 35-36, 39, 50, 71-72,
85-86, 190-91, 216, 218, 224). Plaintiff has a ninth-grade
education and can communicate in English. (AR 50, 190-92.)
A.
Relevant Medical Evidence[3]
On
August 29, 2014, licensed psychologist Pauline Bonilla,
Psy.D., performed a comprehensive psychiatric examination of
Plaintiff. (AR 387-92.) She observed Plaintiff to have fair
hygiene and grooming. (AR 389.) Plaintiff was pleasant and
cooperative throughout the interview and was considered a
“reliable historian.” (AR 387, 389.) She
complained of symptoms of depression due to an increase in
medical issues, chronic pain, physical limitations, decrease
in quality of life, and the inability to provide for her
family financially. (AR 387-88.) Plaintiff described her
depressive symptoms as feelings of sadness, hopelessness, and
worthlessness; a lack of interest in activities; decreased
motivation and energy; difficulty concentrating; low
frustration tolerance; and increased irritability and
occasional anger. (AR 388.) She also complained of anxiety
and reported that she often has “significant
nervousness in public and crowds, ” resulting in a
“need to escape and avoid.” (AR 388.) Plaintiffs
anxiety symptoms included shortness of breath; heart
palpitations; chest tightening; muscle tension; sweatiness
and shakiness; dizziness and nausea; and increased pain and
migraine headaches. (AR 388.)
Plaintiff
reported completing her adaptive living skills independently.
(AR 389.) She stated that she does not engage in household
chores or cooking and that she requires assistance from her
daughter to shop for groceries and run errands. (AR 389.)
Plaintiff does not drive. (AR 389.)
Upon
mental examination, Dr. Bonilla found Plaintiffs thought
content was appropriate with no indications of hallucinations
or delusions. (AR 389.) Plaintiffs mood appeared to be
dysphoric with poor appetite. (AR 390.) Plaintiff reported
that she did not sleep through the night and slept only in
the daytime as a result of her medications. (AR 390.)
Dr.
Bonilla found Plaintiffs remote memory intact, although she
encountered difficulty reciting digits forward and backward.
(AR 390.) Plaintiffs fund of knowledge was found to be
consistent with her educational level and socioeconomic
background. (AR 390.) She had difficulty performing simple
mathematical calculations. (AR 390.) Dr. Bonilla found
Plaintiffs concentration to be within normal limits, her
abstract thinking inadequate, and an adequate ability to
differentiate. (AR 390.) Plaintiff s judgment and insight
were within normal limits. (AR 390.) Dr. Bonilla assessed
Plaintiff with a mood disorder; an anxiety disorder; a pain
disorder; a personality disorder with dependent traits; and a
Global Assessment of Functioning (“GAF”) score of
64. (AR 391.)
According
to Dr. Bonilla, Plaintiffs symptoms “appear[ed] to be
in the mild to moderate range” and she
“appear[ed] to be suffering from a major mental
disorder.” (AR 391.) The likelihood of recovery by
Plaintiff was deemed to be good with psychotherapy. (AR 391.)
Dr. Bonilla noted that Plaintiffs limitations appeared to be
“primarily due to a combination of medical and mental
health issues.” (AR 391.)
Dr.
Bonilla opined that Plaintiff is mildly impaired in the
following: the ability to perform simple and repetitive
tasks; the ability to accept instruction from a supervisor;
the ability to interact with coworkers and the public; the
ability to sustain an ordinary routine without special
supervision; and the ability to maintain regular attendance
in the workplace. (AR 391.) Dr. Bonilla further opined that
Plaintiff is mildly to moderately impaired in the ability to
perform detailed and complex tasks, and that Plaintiff is
moderately impaired in the ability to complete a normal
workday or workweek without interruptions from a psychiatric
condition and the ability to deal with stress and changes
encountered in the workplace. (AR 391-92.) Dr. Bonilla found
the likelihood of Plaintiff “emotionally deteriorating
in a work environment” is minimal to moderate. (AR
392.)
B.
Administrative Proceedings
The
Commissioner denied Plaintiffs application for benefits
initially on September 19, 2014, and again on reconsideration
on February 3, 2015. (AR 100-103, 105-109.) Consequently,
Plaintiff requested a hearing before an Administrative Law
Judge (“ALJ”). (AR 112-22.) The ALJ conducted a
hearing on September 20, 2016. (AR 53-70.). Plaintiff
appeared at the hearing with her counsel and testified. (AR
57-68.) A vocational expert also testified. (AR 68-69.)
C.
The ALJ's Decision
In a
decision dated January 13, 2017, the ALJ found that Plaintiff
was not disabled, as defined by the Act. (AR 33-52.) The ALJ
conducted the five-step disability analysis set forth in 20
C.F.R. § 416.920. (AR 35-51.) The ALJ decided that
Plaintiff had not engaged in substantial gainful activity
since June 9, 2014, the application date (step one). (AR 35.)
At step two, the ALJ found Plaintiffs following impairments
to be severe: degenerative disc disease of the lumbar spine,
status post laminectomy; obesity; depressive disorder;
anxiety disorder; and personality disorder. (AR 35-36.)
Plaintiff did not have an impairment or combination of
impairments that met or medically equaled one of the listed
impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1
(“the Listings”) (step three). (AR 36-38.)
The ALJ
then assessed Plaintiffs residual functional capacity
(RFC)[4] and applied the RFC assessment at steps
four and five. See 20 C.F.R. § 416.920(a)(4)
(“Before we go from step three to step four, we assess
your residual functional capacity . . . . We use this
residual functional capacity assessment at both step four and
step five when we evaluate your claim at these
steps.”). The ALJ determined that Plaintiff had the
RFC:
to perform light work as defined in 20 C.F.R.
[ยง]416.967(b) except [Plaintiff] can lift and or carry
20 pounds occasionally and 10 pound [sic] frequently; she can
stand and or walk for six hours in an eight hour day with
normal breaks; she can sit for six hours in an eight hour day
with normal breaks; she can occasionally balance, stoop,
kneel, crouch, and crawl; she can occasionally climb ...