Vicenta W. v. Commissioner of Social Security

• Court: District Court, N.D. California
• Decided: March 20, 2026
• Docket: 3:25-cv-01991
• Status: Unknown

Opinion

1 2 3 4 UNITED STATES DISTRICT COURT 5 NORTHERN DISTRICT OF CALIFORNIA 6 7 VICENTA W., Case No. 25-cv-01991-SI

8 Plaintiff, ORDER REMANDING ACTION TO 9 v. AGENCY FOR FURTHER PROCEEDINGS 10 COMMISSIONER OF SOCIAL SECURITY, Re: Dkt. Nos. 16, 18 11 Defendant. 12

13 Plaintiff Vicenta W., who is self-represented, has filed this appeal from the Social Security 14 Administration’s decision denying her disability benefits. Plaintiff seeks reversal of the unfavorable 15 decision issued on February 22, 2024, by Administrative Law Judge (“ALJ”) Elias Xenos. The 16 Court has reviewed the administrative record (“AR”) and the parties’ motions. See Dkt. Nos. 16, 17 18. For the reasons stated below, the Court GRANTS plaintiff’s motion for summary judgment, 18 DENIES defendant’s cross-motion for summary judgment, and REMANDS this action for further 19 administrative proceedings pursuant to sentence four of 42 U.S.C. § 405(g). 20 Today’s decision does not mean that plaintiff has won her disability claim. This Order 21 agrees with plaintiff that the ALJ made several errors that impacted her case. This Order sends 22 plaintiff’s case back to the Social Security Administration and orders that the ALJ should reevaluate 23 the medical opinions and plaintiff’s testimony and should hold a second administrative hearing and 24 issue a new decision on plaintiff’s claim. 25

26 BACKGROUND 27 In the fall of 2019, plaintiff was involved in an on-site work-related accident while working 1 for a moving company. AR 196, 276, 513. On March 17, 2020, plaintiff had rotator cuff surgery 2 on the right shoulder.1 AR 366. Nevertheless, the pain continued and plaintiff complained of 3 difficulty using her right arm/shoulder. Plaintiff also suffers from asthma and from depression 4 stemming from her injury and inability to work. AR 274-275, 513, 517. Medical records from 5 Kaiser Permanente show that she also suffered a left foot fracture in July 2023 and was in a cast for 6 several months. AR 972-973. 7 On March 16, 2022, plaintiff protectively filed an application for Social Security Disability 8 Insurance Benefits under Title II of the Social Security Act. AR 34, 73. Plaintiff alleged April 1, 9 2020, as the onset date for her disabilities. She alleged disability due to: “torn rotator cuff; surgery; 10 still torn rotator cuff; depression; anxiety; pain; asthma.” AR 34. The Social Security 11 Administration denied her benefits application both initially and on reconsideration. AR 47-49, 67- 12 69. On January 9, 2024, ALJ Xenos held an administrative hearing by telephone. AR 11, 13. 13 Plaintiff appeared at the hearing without representation. Vocational expert Dr. Leslie Lloyd also 14 testified. AR 11. On February 22, 2024, the ALJ issued a decision denying plaintiff’s disability 15 claim. AR 73-82. 16 In the ALJ’s decision, at step two of the five-step disability inquiry, the ALJ found plaintiff 17 has the severe impairments of: status post right rotator cuff tear, asthma, and adjustment disorder 18 with mixed anxiety and depressed mood. AR 76. At step three, the ALJ found that plaintiff does 19 not have an impairment or combination of impairments that meets or medically equals the severity 20 of a listed impairment in 20 C.F.R. Part 404, Subpart P, Appendix 1 (20 C.F.R. §§ 404.1520(d), 21 404.1525, 404.1526). AR 76-77. The ALJ specifically considered Listing 1.18 (abnormality of a 22 major joint(s) in any extremity), Listing 3.03 (asthma), Listing 12.04 (depressive, bipolar and related 23 disorders), and Listing 12.06 (anxiety and obsessive-compulsive disorders). The ALJ then found 24 plaintiff has the following residual functional capacity (“RFC”):

25 to perform light work as defined in 20 CFR 404.1567(b) except can occasionally climb ramps and stairs, but never climb ladders, ropes or 26 scaffolds; can occasionally crawl; can frequently handle and finger 27 with the right upper extremity; can never push or pull with the right 1 upper extremity; can frequently reach in all directions with the right upper extremity except only occasionally overhead; can never work 2 around unprotected heights or hazardous machinery; can never have concentrated exposure to temperature extremes or pulmonary 3 irritants; and due to a combination of severe mental deficits, work limited to simple, routine tasks, in a work environment free of fast- 4 paced production requirements, involving only simple, work-related decisions, with few, if any, work-place changes; and can have only 5 occasional interaction with the general public, co-workers, and supervisors. 6 AR 77.2 7 Plaintiff filed a request for review before the Appeals Council, which denied the request on 8 January 2, 2025. AR 1-5. The ALJ’s February 22, 2024 decision therefore became the final decision 9 of the Social Security Commissioner. AR 1. 10 Plaintiff then filed an appeal before this Court under 42 U.S.C. § 405(g). Dkt. No. 1. 11 Plaintiff requested, and the Court granted, several extensions of the deadline to file her brief. Dkt. 12 Nos. 12, 13, 14, 15. Plaintiff then filed her brief by the deadline the Court set, and defendant filed 13 a responsive brief. See Dkt. Nos. 16 (“Pl.’s Mot.”), 18 (“Def.’s Mot.”). Plaintiff’s optional reply 14 brief was due September 2, 2025. See Dkt. No. 15. Plaintiff did not file a reply brief. This matter 15 is therefore ready for the Court’s ruling. 16

17 LEGAL STANDARD 18 The Social Security Act authorizes an Article III court to review final decisions of the 19 Commissioner. 42 U.S.C. § 405(g). This Court may enter a judgment affirming, modifying or 20 reversing the decision of the Commissioner, with or without remanding the case for a rehearing. Id. 21 Factual findings of the Commissioner are conclusive if supported by substantial evidence. 22 Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1193 (9th Cir. 2001). The Court may set 23 aside the Commissioner’s final decision when that decision is based on legal error or where the 24 findings of fact are not supported by substantial evidence in the record taken as a whole. Tackett v. 25 Apfel, 180 F.3d 1094, 1097-98 (9th Cir. 1999). Substantial evidence is “more than a mere scintilla 26

27 2 According to Social Security regulations, “Light work involves lifting no more than 20 1 but less than a preponderance.” Id. at 1098. “Substantial evidence means such relevant evidence 2 as a reasonable mind might accept as adequate to support a conclusion.” Molina v. Astrue, 674 F.3d 3 1104, 1110 (9th Cir. 2012) (internal quotation marks omitted). To determine whether substantial 4 evidence exists, the Court must consider the record as a whole, weighing both evidence that supports 5 and evidence that detracts from the Commissioner’s conclusion. Tackett, 180 F.3d at 1098. “Where 6 evidence is susceptible to more than one rational interpretation,” the ALJ’s decision should be 7 upheld. Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). 8 9 DISCUSSION 10 Plaintiff states that the ALJ made several errors in the decision. She argues that the ALJ 11 improperly rejected her testimony regarding her symptoms. Pl.’s Mot. at 6.3 She also argues that 12 the ALJ erred by not considering the medical opinion of her treating physician, Dr. Centeno. Id. at 13 11-13, 17. The Court agrees with plaintiff that the ALJ made several errors: the ALJ improperly 14 rejected plaintiff’s statements regarding how her symptoms impact her daily life and the ALJ did 15 not consider the opinion of plaintiff’s treating physician, Dr. Centeno. Because the Court agrees 16 with plaintiff that the ALJ made errors that impacted the decision, the Court does not address each 17 additional argument plaintiff raises in her brief. 18 19 I. Plaintiff’s Symptom Testimony 20 A. Legal Standard 21 The Ninth Circuit follows a two-step test for deciding what weight to give to a plaintiff’s 22 symptom testimony. At step one, the ALJ must ascertain whether the plaintiff has presented 23 “objective medical evidence of an underlying impairment which could reasonably be expected to 24 produce the pain or other symptoms alleged.” Trevizo v. Berryhill, 871 F.3d 664, 678 (9th Cir. 25 2017) (quoting Garrison v. Colvin, 759 F.3d 995, 1014-15 (9th Cir. 2014)). If the plaintiff satisfies 26

27 3 Because plaintiff’s brief does not have a consistent page numbering system, the Court refers 1 step one, and there is no evidence of malingering, then at step two, the ALJ can reject the plaintiff’s 2 testimony about the severity of his symptoms only by providing specific, clear, and convincing 3 reasons for doing so. Id. If the ALJ finds that the plaintiff’s testimony regarding the severity of his 4 symptoms is not credible, “[t]he ALJ must state specifically which symptom testimony is not 5 credible and what facts in the record lead to that conclusion.” Smolen v. Chater, 80 F.3d 1273, 1284 6 (9th Cir. 1996). This clear and convincing standard is the most demanding standard required in 7 Social Security cases. Trevizo, 871 F.3d at 678. 8 9 B. Discussion 10 Plaintiff argues that the ALJ failed to provide specific reasons for finding plaintiff’s 11 testimony not credible and failed to take into consideration plaintiff’s hearing testimony that she 12 now requires a caretaker to assist her with “a lot of [her] restrictions at home.” Pl.’s Mot. at 6, 13. 13 Defendant responds that plaintiff’s argument is made “with no specificity” and that the ALJ 14 provided clear and convincing reasons to reject her symptom complaints. Def.’s Mot. at 4-5. 15 Here, when the ALJ found plaintiff capable of performing “light work,” the ALJ rejected 16 plaintiff’s statements concerning the intensity of her symptoms. See AR 77-78. The ALJ 17 acknowledged that plaintiff’s function report states that “she has issues accomplishing her daily 18 tasks[,]” has reduced grip strength in her right hand, and cannot lift or carry things over 7 pounds. 19 AR 78. Even so, the ALJ found these statements were not consistent with the evidence. Id. (citing 20 Ex. 16E). In particular, the ALJ noted that plaintiff’s December 2022 function report “listed she 21 could still perform duties such as cleaning, laundry, household repairs, walk, run, and attend the 22 gym.” Id. (citing Ex. 16E at 1, 3). 23 The Court finds that the ALJ’s rejection of plaintiff’s symptom statements based on the list 24 of daily activities in the function report is not supported by substantial evidence in the record. 25 Instead, it appears that plaintiff misread this question, listing activities she could do before her 26 injury, not activities she currently does. Plaintiff’s function reports, third-party function reports, 27 and the hearing testimony consistently describe that plaintiff was limited in her ability to do daily 1 Earlier in the December 2022 function report, plaintiff said that before her injury she “was 2 able to live life, very proactive going to the gym. All of my jobs (previous) all active many things, 3 walking, running, carrying.” AR 263. She said that now she needs assistance to dress, bathe, care 4 for her hair, and use the toilet. Id.; see also AR 224 (May 2022 Function Report, stating same). She 5 wrote that walking, with the movement of her swinging arm, tremendously hurts. AR 262. She can 6 no longer prepare meals because of her reduced grip strength in her right hand. AR 264. She said 7 she “needs assistance completing all previous chores I was able to do by myself.” Id. She said she 8 “rarely go[es] outside.” AR 265. 9 Her friend Nisha Hill completed a Third-Party Function Report at the same time. See AR 10 254-261. This report corroborated the limitations on daily activities that plaintiff listed. See AR 11 255-256; see also AR 216 (May 2022 Third-Party Function Report, stating same). Ms. Hill further 12 stated: “Cleaning, ironing, laundry, shampoo carpets are all put to a hault [sic]. Grip is not good in 13 dominant hand.” AR 256. Ms. Hill stated it may take plaintiff all day if she tries to do chores alone, 14 sometimes going into the next morning “due to frequent pauses, or in too much pain to continue.” 15 AR 256. 16 At the February 2024 hearing, plaintiff also testified that she now has a caregiver to assist 17 her. AR 16. She moved in with her mother a few months earlier because “[i]t just became that I 18 couldn’t do much[,”] that her shoulder was getting worse and locking up, and that they decided it 19 was best for her mother to be around for when plaintiff’s caregiver was not there. Id. 20 Thus, taken in context, it appears to have been a misunderstanding that plaintiff listed all of 21 the activities that the ALJ quoted, AR 78, as ones that she can currently perform rather than listing 22 them in the space asking which activities she used to perform before her injury. 23 The Court notes that plaintiff’s function report does state in several places that plaintiff 24 continues to go to the gym. AR 265, 266. However, the function report does not indicate what 25 plaintiff does at the gym and the ALJ did not ask about this at the hearing. “Recognizing that 26 disability claimants should not be penalized for attempting to lead normal lives in the face of their 27 limitations,” the Ninth Circuit “ha[s] held that only if her level of activity were inconsistent with a 1 759 F.3d at 1016 (internal quotation marks and brackets omitted) (quoting Reddick v. Chater, 157 2 F.3d 715, 722 (9th Cir. 1998)). If the ALJ found the references to the gym ambiguous or confusing, 3 then it was incumbent on the ALJ “to fully and fairly develop the record and to assure that the 4 claimant’s interests are considered.” See Smolen, 80 F.3d at 1288 (quoting Brown v. Heckler, 713 5 F.2d 441, 443 (9th Cir. 1983)). Without knowing what plaintiff did at the gym, this was not a clear 6 and convincing reason for the ALJ to reject plaintiff’s testimony regarding her pain symptoms. 7 8 II. Medical Opinions 9 A. Legal Standard 10 For applications filed on or after March 27, 2017, such as here, “the former hierarchy of 11 medical opinions—in which we assign presumptive weight based on the extent of the doctor’s 12 relationship with the claimant—no longer applies.” Woods v. Kijakazi, 32 F.4th 785, 787 (9th Cir. 13 2022). Under the revised regulations, 20 C.F.R. § 404.1520c and § 416.920c, the ALJ will consider 14 medical opinions “using the factors listed in paragraphs (c)(1) through (c)(5) . . . .” 20 C.F.R. 15 § 416.920c(a). Those factors are: (1) supportability, (2) consistency, (3) relationship with the 16 claimant, (4) specialization, and (5) “other factors that tend to support or contradict a medical 17 opinion or prior administrative medical finding.” Id. § 416.920c(c). In determining how persuasive 18 a medical opinion is, the most important factors are supportability and consistency. Id. 19 § 416.920c(a), (b)(2). “Therefore, [the agency] will explain how [it] considered the supportability 20 and consistency factors for a medical source’s medical opinions . . . .” Id. § 416.920c(b)(2). The 21 agency “may, but [is] not required to, explain how [it] considered the factors in paragraphs (c)(3) 22 through (c)(5) . . . .” Id. “Even under the new regulations, an ALJ cannot reject an examining or 23 treating doctor’s opinion as unsupported or inconsistent without providing an explanation supported 24 by substantial evidence.” Woods, 32 F.4th at 792. “The agency must articulate . . . how persuasive 25 it finds all of the medical opinions from each doctor or other source.” Id. at 791 (citing 20 C.F.R. 26 § 404.1520c(b) (internal quotation marks omitted)). 27 1 B. Discussion 2 Plaintiff argues that the ALJ failed to take into account the limitations assigned by Dr. 3 Centeno, who performed her rotator cuff surgery and continued to see her for many months post- 4 surgery. See Pl.’s Mot. at 11-13, 17. She states, “I do not see my treating physician’s report which 5 is the main key to this case. His findings and restrictions are not taken into consideration given Dr. 6 Centeno was my surgent [sic] at the time . . . .” Id. at 11. Plaintiff also states that her treating doctor 7 limited her to lifting 7 pounds, which the record shows was Dr. Centeno’s recommendation at 8 various points. 9 Defendant does not address plaintiff’s argument regarding the exclusion of Dr. Centeno’s 10 findings. Defendant states that the State agency medical consultants (Dr. H. Jone, MD and Dr. L. 11 DeSouza, MD), who reviewed plaintiff’s disability claim at the initial and reconsideration stages, 12 found plaintiff capable of a reduced range of medium work. Def.’s Mot. at 6. Defendant also states 13 that the consultative examiner who conducted a physical examination (Dr. Rose Lewis, MD) found 14 plaintiff able to perform a reduced range of light work and that the examiner who performed a mental 15 status evaluation (Dr. Aparna Dixit, PsyD) found plaintiff could do unskilled work with some social 16 limitations. Id. Defendant goes on, “No other providers offered opinions to contradict these 17 assessments.” Id. 18 Defendant is incorrect, both by mischaracterizing the findings of Dr. Lewis and because Dr. 19 Centeno provided a contradictory assessment numerous times over the course of 2020 and 2021. 20 Defendant’s brief also incorrectly states that plaintiff alleges disability from October 2022, rather 21 than April 2020. See Def.’s Mot. at 7 (citing AR 73). Defendant then goes on to argue that “[t]he 22 ALJ, in detail, discussed evidence beginning in October 2022 in chronological order, up to evidence 23 in the record dated shortly before the hearing decision.” Id. 24 The problem is that the ALJ skipped over the many months of detailed treatment records and 25 correspondence with the claims adjuster from plaintiff’s post-surgery visits to her orthopedic 26 provider.4 Dr. Centeno, who performed her surgery, saw plaintiff almost monthly following her 27 1 March 2020 surgery and through the beginning of 2021. The ALJ scarcely discussed these notes 2 and did not at all address Dr. Centeno’s repeated work restrictions limiting plaintiff to lifting no 3 more than 5 or 7 pounds. 4 To summarize, Dr. Joseph Centeno, MD performed plaintiff’s March 2020 rotator cuff 5 surgery. AR 366. Following the surgery, he saw her about monthly, through early 2021. On June 6 23, 2020, Dr. Centeno placed plaintiff on work restriction of “No lifting more than 5 pounds 7 occasionally reaching above shoulder height.” AR 331. Dr. Centeno stated that plaintiff’s 8 anticipated “MMI” (maximum medical improvement) was 6 to 8 months postoperatively. Id.; see 9 also AR 390. A few weeks later, he changed her MMI to “Unknown at this point.” AR 331-332. 10 The restriction that plaintiff lift no more than 5 pounds and only occasionally reach above shoulder 11 height remained in place through visits on July 9, July 28, August 11, August 25, and September 8, 12 2020. See AR 328, 331-332, 420, 432. On October 13, 2020, Dr. Centeno changed her work 13 restrictions to no lifting more than 7 pounds and no reaching above shoulder height. AR 427. These 14 restrictions remained in place through visits on November 24, 2020; December 11, 2020; January 15 26, 2021; and February 23, 2021. AR 425, 487-488, 493, 499. A March 2021 treatment note from 16 PA-C Catherine Doss at Bay Area Orthopedic (where Dr. Centeno practiced) repeated these 17 restrictions.5 See AR 480. 18 Despite the numerous and detailed treatment records from Dr. Centeno and others at Bay 19 Area Orthopedic, the ALJ did not discuss Dr. Centeno’s opinions at all. Failing to address Dr. 20 Centeno’s opinions at all violates the Social Security regulations. See Woods, 32 F.4th at 791-92. 21 In addition, by failing to address Dr. Centeno’s opinion, the ALJ may have erroneously 22 evaluated other medical opinions in the record. One of the “most important factors” for the ALJ to 23 consider in deciding how much weight to give a medical opinion is consistency. See 20 C.F.R. 24 § 404.1520c(a), (c)(2). “Consistency means the extent to which a medical opinion is ‘consistent . . . 25

26 5 The record also contains a letter dated October 20, 2021, from RTGR Law LLP to a claims administrator, referencing a September 28, 2021 report by Dr. Centeno. The law firm states that Dr. 27 Centeno placed plaintiff on permanent work restrictions “of no lifting, pushing and pulling more 1 with the evidence from other medical sources and nonmedical sources in the claim.’” Woods, 32 2 F.4th at 792 (quoting 20 C.F.R. § 404.1520c(c)(2)). In finding that plaintiff could do “light work” 3 with some restrictions, the ALJ found the opinion of Dr. Lewis “grossly unpersuasive, as it is not 4 consistent with the medical evidence of record.” See AR 79. Dr. Lewis, who was brought in to do 5 a consultative physical examination of plaintiff in August 2022, stated that plaintiff could lift only 6 10 pounds on the left and less than 10 pounds on the right and could stand and walk up to four hours. 7 AR 520. The ALJ rejected this opinion as “not consistent” with the record, even though it was 8 consistent with Dr. Centeno’s opinion. 9 Dr. Centeno’s and Dr. Lewis’s opinions were also consistent with the opinion of Dr. Jeffrey 10 Lee Gao, MD, who treated plaintiff at Kaiser following a July 2023 left foot fracture she suffered 11 while at work.6 At an August 22, 2023 visit, Dr. Gao placed plaintiff on modified work duty, 12 limiting her to standing and walking occasionally (up to 25% of a shift), not climbing ladders or 13 using scaffolds, and no lifting/carrying/pushing/pulling more than 10 lbs. AR 973-974. The foot 14 fracture occurred after the Social Security agency had evaluated plaintiff’s claim at the initial and 15 reconsideration levels but before her administrative hearing in January 2024. Although there was 16 evidence in the record from this injury, along with the work restrictions imposed by Dr. Gao, the 17 ALJ did not ask about the foot fracture at the hearing or address Dr. Gao’s opinion in his decision. 18 To summarize, the Court finds that it was error for the ALJ not to address Dr. Centeno’s 19 opinions at all and that this error could have impacted the entire residual functional capacity finding, 20 including the weighing of Dr. Lewis’s opinion. It was also error for the ALJ not to address the 21 opinion of Dr. Gao. Plaintiff is entitled to further administrative proceedings, including a new 22 hearing to develop the record further as well as a new decision on her disability claim. Should the 23 agency find it appropriate, the agency may also reopen the record to receive new medical evidence, 24 particularly on the impact of the recent foot fracture. 25 26 27 1 CONCLUSION 2 For the reasons stated above, the Court GRANTS plaintiff's motion for summary judgment 3 and DENIES defendant’s cross-motion for summary judgment. The Court REMANDS this case 4 || pursuant to sentence four of 42 U.S.C. § 405(g) for further administrative proceedings consistent 5 || with this Order. 6 7 IT IS SO ORDERED. 8 || Dated: March 20, 2026 Site WU tee 9 Oe eS SUSAN ILLSTON 10 United States District Judge 1] a 12

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