Dominguez v. Saul

District Court, N.D. California·Decided October 29, 2020·No. 3:19-cv-07594·Unknown

Opinion

RAYMOND D.,1 Case No. 19-cv-07594-TSH

Plaintiff, ORDER RE: CROSS-MOTIONS FOR v. SUMMARY JUDGMENT

COMMISSIONER OF SOCIAL Re: Dkt. Nos. 20, 29 SECURITY, Defendant. Plaintiff Raymond D. brings this action pursuant to 42 U.S.C. § 405(g), seeking judicial review of a final decision of Defendant Andrew Saul, Commissioner of Social Security, denying his claim for disability benefits. Pending before the Court are the parties’ cross-motions for summary judgment. ECF Nos. 20 (Pl.’s Mot.), 29 (Def.’s Mot.). Pursuant to Civil Local Rule 16- 5, the motions have been submitted without oral argument. Having reviewed the parties’ positions, the Administrative Record (“AR”), and relevant legal authority, the Court hereby GRANTS Plaintiff’s motion, DENIES Defendant’s cross-motion and REMANDS this case for further proceedings consistent with this order. A. Age, Education and Work Experience Plaintiff is 42 years old. AR 192. The records show a history of ADHD as a child and special education classes for a math disability. AR 890. He graduated from high school and has

1 Partially redacted in compliance with Federal Rule of Civil Procedure 5.2(c)(2)(B) and the previous experience as a maintenance worker at a shopping center, restaurant cook, and grocery store courtesy clerk. AR 43-48, 255. B. Medical Evidence 1. San Quentin State Prison Plaintiff received mental health treatment from March 7 to April 19, 2014 while incarcerated at San Quentin State Prison. AR 307-65. He was diagnosed with mood disorder NOS and polysubstance dependence and prescribed individual therapy and medication management. AR 338-39. Plaintiff reported a history of three significant traumatic head injuries that resulted in loss of consciousness and/or coma. AR 338, 348. He was housed in administrative segregation and told clinicians: “I’m happy in the hole.” AR 346-47. He experienced anxiety, sleep difficulties and cognitive dissonance due to worrying about being released. AR 355, 357-58. 2. Washington Hospital Plaintiff sought treatment at Washington Hospital for cellulitis of his right hand on March 27, 2016. AR 377. Clinicians noted he had a normal mood and affect, no sensory deficit, and was alert and oriented to person, place and time. AR 381. 3. Santa Rita Jail During Plaintiff’s incarceration at Santa Rita Jail, clinicians noted a history of suicidal ideation and attempt. AR 748. On April 22, 2015, Raymond Carlson, LCSW, diagnosed Plaintiff with mood disorder and polysubstance dependence. AR 820. On April 29, Khenu Singh, M.D., diagnosed anxiety disorder NOS, polysubstance dependence, and gave Plaintiff rule-out diagnoses for post-traumatic stress disorder and attention deficit hyperactivity disorder. AR 823. Plaintiff was prescribed fluoxetine (Prozac), an antidepressant. AR 822. On July 21, 2016, Mcheko Graves-Matthews noted depressive disorder NOS and likely polysubstance dependence. AR 830. Plaintiff was again prescribed fluoxetine. AR 829. On March 1, 2017, Plaintiff reported feeling down, crying a lot, having mood swings, difficulty sleeping, feeling very anxious, and changes in his appetite. AR 812. Farah Khan, M.D. cooperative behavior, fully oriented, depressed mood, constricted affect, no auditory or visual hallucinations, no delusions, and limited insight and judgment. AR 813. On March 29 and May 30, Plaintiff’s mental status was notable for poor grooming, soft and slow speech, a constricted affect, calm and cooperative behavior, fully oriented, logical thought process, “good” mood, no auditory or visual hallucinations, no delusions, and limited insight and judgment. AR 815, 817. Dr. Khan diagnosed bipolar disorder and cannabis, opioid, and stimulant-related disorder. AR 813, 815, 817. Plaintiff was prescribed fluoxetine and olanzapine (Zyprexa), an antipsychotic. Id. (all). On March 13, 2017, a test of Plaintiff’s vision showed he had 20/20 vision in his right eye and no light perception in his left eye. AR 633. On June 21, 2017, Elizabeth Walser, M.S.W., Psy.D., supervised by Lesleigh Franklin, Ph.D., performed a psychological evaluation. AR 890-900. Drs. Walser and Franklin reviewed Plaintiff’s records and performed seven testing procedures – a clinical interview, mental status examination, Quality of Life Rating Scale, Wechsler Adult Intelligence Scale, Wide Range Assessment of Memory and Learning, Amen Brain Checklist, and Behavior Rating Inventory of Executive Function. AR 890. Plaintiff reported that he had not used any substances since he went to jail in January 2017, and his symptoms had persisted despite his sobriety. AR 890-91. He was diagnosed with ADHD as a child and placed in special education for a mathematics disability. AR 890. He was repeatedly disciplined for fighting in high school and middle school. AR 891. He was arrested about 20 times or more as a juvenile. Id. At the time of the evaluation, Plaintiff was housed in administrative segregation and had repeatedly been placed there due to mental health concerns and former gang affiliations. AR 891- 92. His brother was his cellmate at the time of the evaluation. AR 892. He denied using drugs and there was no evidence of substance use. AR 893. Plaintiff rated his overall quality of life as satisfactory when he is incarcerated because he is fed, housed with his brother, medicated, able to stay clean, and protected from others. AR 892. Dr. Walser explained that “[t]hese conditions feel good to him despite the lack of freedom; Plaintiff presented with a somewhat arrogant demeanor, flat expression, intermittent eye contact, a depressed mood, irritability, anxious, and a restricted affect. AR 893. The examination also showed adequate grooming, adequate ability to pay attention with structure, below average work pace, long term memory gaps and difficulties with working memory and adequate effort in testing. Id. Plaintiff was cooperative and spoke in normal tone with logical thought process, low insight and marginal judgment, and tended toward some “unusual thinking.” Id. Drs. Franklin and Walser stated that the evaluation was a good representation of Plaintiff’s psychological functioning at the time. Id. They noted he cooperated and put forth adequate effort. AR 898. Plaintiff’s composite scores for perceptual reasoning and working memory on the Wechsler Adult Intelligence Scale were far below average. AR 893, 895. He worked more slowly on tasks requiring careful attention and timed out on several problems. AR 895. On the Wide Range Assessment of Memory and Learning assessment, Plaintiff’s composite score for attention and concentration was far below average. AR 894. The Behavior Rating Inventory of Executive Function test indicated he has significant difficulty with inhibition, emotional control, working memory, and monitoring. Id. The Amen test indicated he has significant problems with depression, attention and impulse control, anger, and anxiety. Id. Plaintiff had average range in his general ability index, average range for language, low average verbal memory, and clinical significant range for attention. AR 895-96. Drs. Walser and Franklin noted that Plaintiff has had longstanding problems following rules and managing impulses, and his ADHD had a serious impact on his development. AR 896. He exhibited an irritable depression and bad temper and reported feeling moody, unhappy, irritable, pessimistic, and having difficulty concentrating. Id. They noted that his poor decision- making ability led to his conviction for a sex offense, and that he believes his status as a sex offender has unfairly ruined his life. Id. Drs. Franklin and Walser diagnosed Plaintiff with bipolar disorder; ADHD combined type; antisocial personality disorder; amphetamine use disorder, severe, in early remission in a controlled e

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