Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-01302/USCOURTS-casd-3_16-cv-01302-1/pdf.json

Nature of Suit Code: 550
Nature of Suit: Prisoner - Civil Rights (U.S. defendant)
Cause of Action: 42:1983pr Prisoner Civil Rights

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

VICENTE ARRAIGA ALVAREZ,

Plaintiff,

v.

DR. S. KO, M.D., et al.,

Defendants.

Case No.: 16-CV-1302-CAB-NLS

REPORT AND 

RECOMMENDATION FOR 

ORDER DENYING 

DEFENDANTS’ MOTION TO 

DISMISS

(Dkt. No. 24)

Before the Court is Defendants Dr. S. Ko’s, Dr. Connall McCabe’s, Dr. A. 

Sangha’s and Deputy Director J. Lewis’ (collectively, “Defendants”) motion to 

dismiss Plaintiff Vicente Alvarez’s Complaint under Federal Rule of Civil 

Procedure 12(b)(6). (Dkt. No. 24.) Plaintiff filed an opposition, and Defendants 

filed a reply. 1 (Dkt. Nos. 29, 32.) This matter was referred to the undersigned for a 

report and recommendation under Local Civil Rule 72.3.f and 28 U.S.C. § 

 

1 Plaintiff’s opposition brief is thirty-eight pages long. (Dkt. No. 29.) The 

Court notifies Plaintiff that for future filings, Local Civil Rule 7.1.h. requires that 

“[b]riefs or memoranda in support of or in opposition to all motions noticed ... 

must not exceed a total of twenty-five (25) pages in light, per party” and [n]o reply 

memorandum will exceed ten (10) pages without leave of the judge.” 

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636(b)(1)(B). For the reasons explained below, the Court RECOMMENDS that 

Defendants’ motion be DENIED.

I. Factual Allegations2

a. Plaintiff Complains of Chest Pains, and Requests To See A 

Doctor

Plaintiff alleges that sometime before October 24, 2014, and while housed at 

Corcoran State Prison, he submitted a medical slip to request medical assistance but 

the slip was ignored. (Id. at ¶ 12.) On October 24, 2014, Plaintiff submitted a 

second medical slip. On approximately October 25, 2014, Plaintiff saw and told a

nurse he had been suffering from chest pains for a long time. The nurse refused to 

refer him to a doctor and gave him ibuprofen for pain. (Id. at ¶ 13.) About eight 

days later, on November 2, 2014, Plaintiff submitted an Emergency CDC 602 

Health Care Appeal, Log #: COR HC 14057207 (hereafter “Log # 207”). (Id. at 

65.)

b. Plaintiff is Transferred to Centinela, and Sees a Nurse

On November 18, 2014, Plaintiff transferred from Corcoran to Centinela State 

Prison. He told medical staff about his chest pains and requested to see a doctor. 

(Id. at ¶ 16.) About a month later, on December 17, 2014, Plaintiff saw a nurse and 

told the nurse his chest was in pain. The nurse conducted an echocardiogram

(“EKG”), which “revealed an abnormal low heart rate.” (Id. at ¶¶ 18-19.) 

c. Corcoran Staff Review and Deny Plaintiff’s 602 Appeal 

and His Request To See A Doctor (First Level)

On December 18, 2014, S. Russell, a Health Care Appeals Coordinator, 

interviewed Plaintiff over the phone about the 602 Appeal, Log # 207, that Plaintiff 

previously submitted at Corcoran. Plaintiff told Russell about his continued chest 

 

2 The following factual allegations are taken from Plaintiff’s Complaint.

(Dkt. No. 1.)

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pains, that he had not yet seen a doctor despite his requests, and asked to see a heart 

specialist. (Id. at ¶ 21.) Russell told Plaintiff that because he is no longer at 

Corcoran, they cannot prescribe medication or treatment. (Id. at ¶ 22.) On 

December 22, 2014, Dr. McCabe signed Plaintiff’s 602 Appeal denial at the first 

level.

On January 6, 2015, Plaintiff submitted his 602 Appeal for the next level of 

review. He argued his request to see a heart specialist should have been granted 

because his chest pains demonstrate a significant illness. (Id. at ¶ 24.) He stated 

his pains may cause a severe limitation of his abilities to perform daily activities or 

may cause premature death. (Id. at ¶ 25.) 

d. Plaintiff Suffers Severe Chest Pains, Is Taken to An 

Emergency Room, and Sees a Doctor

On January 22, 2015, about three months from the date Plaintiff initially 

complained of chest pains and asked to see a doctor, Plaintiff suffered severe chest 

pains and went to the emergency room. Plaintiff saw Dr. S. Ko, and told him about 

his “excruciating chest problems” that had been ongoing, and that at times the pain 

was so unbearable he had to sit down. (Id. at ¶ 28.) Dr. Ko gave him a “verbal 

examination” but did not order an X-ray or diagnostic testing.3 Dr. Ko diagnosed 

Plaintiff with “musculoskeletal problems” and told him to take a break from 

working out too much. (Id.) Plaintiff responded that working out could not be 

causing his pain because the pain is preventing him from working out. (Id.) 

Plaintiff asked for an X-ray or to see a heart specialist for further examination. (Id. 

at ¶ 31.) Dr. Ko told him no, and that he would prescribe Naproxen for the chest 

pain, and that if Plaintiff had an issue with his decision then he could file a 602

Appeal.

4

 (Id. ¶ 33.)

 

3 An exhibit to Plaintiff’s Complaint indicates that on January 22, 2015, 

“[t]he doctor ordered an EKG ....” (Dkt. No. 1 at 57.)

4 On February 3, 2015, Plaintiff filed another 602 Appeal about Dr. Ko’s 

(continued...)

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e. Dr. Ko Interviews Plaintiff About His 602 Appeal, Log #

207; and Drs. Sangha and Reilly Review and Deny His 

Appeal (Second Level)

On February 4, 2015, Dr. Ko interviewed Plaintiff about his 602 Appeal, Log 

#207, at the second level of review. (Id. ¶ 35.) Plaintiff told Dr. Ko the Naproxen 

was not working, that a nurse previously told him his EKG showed an abnormal 

heart rate and that it was a sign his heart was not properly working, and Plaintiff 

again asked to see a heart specialist. (Id. ¶¶ 36, 37.) Dr. Ko responded with a 

hostile attitude that nothing was wrong with his heart, that the nurse did not know 

what he was doing, and that Plaintiff should rest and stop working out. (Id., ¶ 38.) 

Plaintiff asked if he needed to actually fall out from a heart attack to be 

referred to a heart specialist, and Dr. Ko nodded his head up and down to respond 

“yes.” (Id., ¶ 40.) Dr. Ko then told Plaintiff if he was not happy with the care he 

received, then he could seek medical care at his own expense, which would cost 

thousands of dollars. (Id. ¶ 41.) Plaintiff asserts he believes Dr. Ko deprived him 

of adequate care because he was financially motivated not to refer him to a 

specialist. (Id. ¶ 43.)

On February 21, 2015, Drs. Sangha and Reilly partially granted and partially 

denied Plaintiff’s appeal at the second level. The appeal was partially granted on 

grounds that when Plaintiff initially arrived at Centinela he received an EKG study. 

(Dkt. No. 1 at 57.) The appeal was denied to the extent Plaintiff requested to see a 

cardiologist or get a CT scan. (Id.) On March 3, 2015, Plaintiff resubmitted his 

602 Appeal for the third level of review. (Id., ¶ 44.)

 

(...continued)

alleged inadequate care. (Id. at ¶ 34, referencing Log # CEN HC 1507230; see also

Dkt. No. 1 at 72.) On or about May 4, 2015, Plaintiff was informed this additional

appeal was denied and cancelled because it was duplicative of his previous 602 

Appeal to see a heart specialist. (Id. ¶ 45.)

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f. Plaintiff Sees Dr. Ko In the Ad-Seg Clinic, And Again 

Requests to be Referred to a Heart Specialist

On May 5, 2015, Plaintiff went to Ad-Seg Clinic to see a doctor for his chest 

pains; the Naproxen was not relieving his pain and instead gave him stomach 

cramps and sharp pain on his right side. (Id., ¶¶ 46-47.) Plaintiff saw Dr. Ko, and 

again asked to be referred to a heart specialist. Dr. Ko ignored Plaintiff’s complaint 

and told him he could prescribe Tylenols to ease the stomach pain. (Id., ¶ 49.) 

Plaintiff finally warned Dr. Ko that he would pursue a civil rights complaint for 

deliberate indifference to his medical needs because a reasonable doctor would not 

treat him this way. (Id., ¶ 47.) Dr. Ko sarcastically responded that he would look 

forward to that day in court.5 (Id., ¶ 48.)

g. Deputy Director J. Lewis Reviews And Denies Plaintiff’s 

602 Appeal, Log #207 (Third Level)

On June 1, 2015, Deputy Director Lewis denied Plaintiff’s 602 Appeal, Log # 

207. Plaintiff alleges Director Lewis denied the appeal despite knowing that 

Plaintiff was in pain and suffering, and despite knowing about Dr. Ko’s deliberate 

indifference to his serious medical need. (Id. ¶¶ 58-59.)

 

5

 Also on May 5, 2015, Plaintiff filed another 602 Appeal, Log # CEN HC 

15027248, to again request to be seen by another doctor or heart specialist, and to 

complain about Dr. Ko’s alleged deliberate indifference to his medical needs. (Id. ¶

51; id. at 69.) Approximately four days later, Plaintiff received an X-ray; the 

results were unremarkable. Plaintiff believes Dr. Ko ordered the X-ray in response 

to Plaintiff’s warning that he would file a civil rights complaint. (Id. ¶ 52.) 

Plaintiff also believes that because his X-ray did not show skeletal abnormalities, 

and because the Tylenol did not take his chest pain away, his chest pains are not 

musculoskeletal. (Id., ¶ 53.) On May 26, 2015, Dr. Ko interviewed Plaintiff about 

this 602 Appeal and his request to see another doctor or heart specialist. (Id. ¶ 56.) 

Plaintiff asserts Defendant Dr. Sangha referred the appeal interview to Dr. Ko

despite Plaintiff’s allegations that Dr. Ko was deliberately indifferent to his medical 

needs. (Id. ¶ 55.) Plaintiff does not allege appeal Log # CEN HC 15027248 

progressed beyond the first level.

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h. Plaintiff Goes to the Hospital Again

In late June or early July of 2015, Plaintiff suffered “excruciating chest pains” 

and went again to the hospital via ambulance. (Id. ¶ 61.) The hospital’s doctor 

took blood work and did an X-ray, but the results were unremarkable. (Id. ¶ 63.)

The doctor told Plaintiff that any further testing would need to be ordered by the 

doctors at the prison or they would need to refer Plaintiff to a cardiologist. (Id. ¶ 

64.) 

i. Plaintiff Files His Civil Rights Complaint

On May 31, 2016, Plaintiff filed a Complaint against Defendants. Plaintiff 

alleges Eighth Amendment claims for deliberate indifference to his serious medical 

needs. (Dkt. No. 1 at 17-22.) Plaintiff alleges he still has not been seen by a 

cardiologist or referred for further diagnostic testing. He alleges he continues to 

suffer from chest pains and pain to his right-side, and that he continues to suffer 

from pain throughout the day. (Id., ¶¶ 66-70.) He alleges he is in serious mental 

anguish and anxiety from fear of having a heart attack, and that it affects his ability 

to sleep and regularly exercise. (Id. ¶¶ 65-73, 87.)

Plaintiff seeks monetary damages and injunctive relief. He asks the Court to 

issue an order requiring Defendants to stop their ineffective course of treatment, 

and to order diagnostic tests for cardiac disease or refer him to a heart specialist. 

(Id., ¶ 97.)

II. Legal Standard

To determine whether a complaint states a claim, the court takes “all 

allegations of material fact” as true and construes them in the light most favorable 

to the plaintiff. Barnett v. Centoni, 31 F.3d 813, 816 (9th Cir. 1994). “To survive a 

motion to dismiss, a complaint must contain sufficient factual matter, accepted as 

true, to ‘state a claim to relief that is plausible on its face.’ A claim has facial 

plausibility when the plaintiff pleads factual content that allows the court to draw 

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the reasonable inference that the defendant is liable for the misconduct alleged.” 

Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting Bell Atlantic Corp. v. 

Twombly, 550 U.S. 544 (2007)). In determining a motion to dismiss for failure to 

state a claim, the court may consider materials properly submitted as part of the 

complaint, and “document[s] the authenticity of which [are] not contested, and 

upon which the plaintiff’s complaint necessarily relies,” even if they are not 

attached to the complaint. Parrino v. FHP, Inc., 146 F.3d 699, 706 (9th Cir. 1998), 

superseded by statute on other grounds as recognized in Abrego v. The Dow Chem. 

Co., 443 F.3d 676 (9th Cir. 2006).

III. Discussion

Defendants move to dismiss Plaintiff’s Complaint on grounds that (1) it fails 

to state a claim against Dr. Ko because a difference of opinion between an inmatepatient and a medical provider is not actionable; and (2) it fails to state a claim 

against the rest of the defendants because they only reviewed Plaintiff’s inmate 

appeal, which is not actionable. (Dkt. No. 24 at 2.) 

a. The Eighth Amendment 

The Eighth Amendment protects prisoners from “inhumane conditions of 

confinement.” Morgan v. Morgensen, 465 F.3d 1041, 1045 (9th Cir. 2006). 

Consequently, the government must “provide medical care for those whom it is 

punishing by incarceration,” and cannot act with deliberate indifference to a 

prisoner’s serious medical needs. Estelle v. Gamble, 429 U.S. 97, 106 (1976). A 

prison official acts with deliberate indifference if the official “knows of and 

disregards an excessive risk to inmate health or safety.” Farmer v. Brennan, 511 

U.S. 825, 837 (1994). Deliberate indifference is also known as the “unnecessary 

and wanton infliction of pain.” Estelle, 429 U.S. at 104 (internal quotations 

omitted). To prevail, a plaintiff must make (1) an objective showing that he had a 

serious medical need; and (2) a subjective showing that the specific defendants 

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were deliberately indifferent to that need. Colwell v. Bannister, 763 F.3d 1060, 

1066 (9th Cir. 2014).

b. Plaintiff’s Claim Against Dr. Ko

Plaintiff alleges Dr. Ko used an ineffective course of treatment – Naproxens 

and Tylenols – to supposedly treat Plaintiff’s serious medical need despite knowing 

about Plaintiff’s pain and permanent injury risks. (Id., ¶ 81.) He alleges Dr. Ko 

failed to order diagnostic testing for cardiac disease. (Id., ¶ 84.) He alleges Dr. 

Ko’s demand that Plaintiff would have to “fall out of a heart attack” to be referred 

to a heart specialist violated Plaintiff’s Eighth Amendment rights. (Id. ¶ 85.) He 

asserts Dr. Ko’s refusal to refer him to a heart specialist violated his Eighth 

Amendment rights. (Id. ¶¶ 76, 95.)

Defendants move to dismiss Plaintiff’s claim against Dr. Ko on grounds that 

Plaintiff’s claim amounts to a difference of opinion between the physician and the 

patient-inmate. They argue this does not constitute deliberate indifference. (Dkt. 

No. 24-1 at 5.) 

A mere difference of opinion between a patient-inmate and a physician about 

the appropriate treatment is insufficient to give rise to an Eighth Amendment claim. 

Toguchi v. Chung, 391 F.3d 1051, 1058 (9th Cir 2004), citing Jackson v. McIntosh, 

90 F.3d 330, 332 (9th Cir. 1996). Even a showing of medical malpractice or gross 

negligence is insufficient to establish a constitutional violation. Toguchi, 391 F.3d 

at 1060. Rather, the plaintiff must show that the chosen course of treatment “‘was 

medically unacceptable under the circumstances’ and was chosen ‘in conscious 

disregard of an excessive risk to [the prisoner’s] health.’” Id., quoting Jackson, 90 

F.3d at 332.

However, a prison official demonstrates deliberate indifference when he or she 

knows a course of treatment is ineffective but continues it anyway or delays 

necessary treatment without justification. See Jett v. Penner, 439 F.3d 1091, 1097-

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98 (9th Cir. 2006). Deliberateness may be inferred where a prison official is aware 

of the extent of the patient-inmate’s pain, but does not do anything to improve the

situation. Id. at 1098. 

Here, Plaintiff’s allegations state a claim of deliberate indifference against Dr. 

Ko. Plaintiff alleges severe continuing chest pains that affect his daily activities, 

which is sufficient to allege a serious medical need. Jett, 439 F.3d at 1096 (a 

“serious medical need” may be shown by demonstrating that “failure to treat a 

prisoner’s condition could result in further significant injury or the ‘unnecessary 

and wanton infliction of pain’”). 

Some, but not all, of Plaintiff’s allegations demonstrate a mere difference of 

opinion. See e.g., Dkt. No. 1, ¶ 31 (Plaintiff’s opinion that he should be referred to 

cardiologist or for further diagnostic testing, versus Dr. Ko’s opinion that Plaintiff 

has a musculoskeletal condition that could be treated with Naproxen and with 

Tylenol for side effects); Estelle, 429 at 107 (“the question whether an X-ray - or 

additional diagnostic techniques or forms of treatment - is indicated is a classic 

example of a matter for medical judgment. A medical decision not to order an Xray, or like measures, does not represent cruel and unusual punishment. At most it 

is medical malpractice”). If these types of allegations were all that Plaintiff alleged, 

his allegations would not state a claim. But Plaintiff does more than that.

Plaintiff alleges he informed Dr. Ko that the treatment plan – to rest and not 

work out as much, and to take Naproxen – was ineffective and that he continues to 

have chest pains. (Dkt. No. 1, ¶¶ 36-37.) Plaintiff further alleges that Dr. Ko 

nodded “yes” when Plaintiff finally asked if he would first need to fall out from a 

heart attack to be referred to a cardiologist. (Id., ¶ 40.) If true, Plaintiff’s facts 

could demonstrate Dr. Ko knew the treatment plan he placed Plaintiff on was 

ineffective and continued on that treatment plan anyway, and deliberately did not 

take steps to improve the situation. 

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Plaintiff further alleges the delay in treatment has caused him harm. See 

McGuckin v. Smith, 974 F.2d 1050, 1060 (9th Cir. 1991) (any delay in providing an 

appropriate course of treatment does not by itself show deliberate indifference, 

unless the delay is alleged to have caused harm). Here, Plaintiff alleges that to the 

present, he still currently suffers from chest pain, and from added pain to his right 

side. He alleges the pain sometimes feels as if someone hit him with a bat in the 

chest, and at other times as if someone is standing on his chest, and at other times, 

the pain feels as if someone is stabbing him with a dull knife. (Dkt. No. 1, ¶¶ 66-

70.)

Defendants’ arguments to the contrary are unpersuasive. Defendants point to 

an exhibit attached to Plaintiff’s Complaint that a doctor ordered an EKG on 

January 22, 2015. (Dkt. No. 1 at 57.) The exhibit, however, does not specify 

which doctor ordered the EKG, i.e., whether it Dr. Ko or was some other doctor on 

staff that day. Regardless, Plaintiff alleges that Dr. Ko gave him a verbal 

examination and did not order any diagnostic testing. Moreover, Defendants’ 

argument does not address Plaintiff’s allegations that he told Dr. Ko the treatment 

plan was not working and that Dr. Ko did nothing in response. At this preliminary 

stage, and viewing the allegations in the light most favorable to Plaintiff, they 

suffice to state a claim. 

Defendants also argue Plaintiff’s complaints of pain during the 602 Appeal 

interview do not count because he complained during the interview and not a 

scheduled medical appointment. Defendants, however, do not provide any 

authority to support that a patient-inmate’s complaints during a 602 Appeal 

interview should not be considered when determining whether the physician knew 

the treatment plan was ineffective. Defendants also argue Plaintiff fails to state a 

claim because Plaintiff’s 602 Appeal was partially granted because an EKG was 

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previously taken. That argument, however, is also a non-starter because it does not 

dispense with Plaintiff’s continued reports of chest pains despite the treatment plan.

For these reasons, the Court concludes Plaintiff’s Complaint states an Eighth 

Amendment claim for deliberate indifference to medical needs against Dr. Ko. The 

Court therefore recommends Defendants’ motion to dismiss the claim against Dr. 

Ko be denied.

c. Plaintiff’s Claims Against Dr. McCabe, Dr. Sangha, and 

Deputy Director Lewis

Defendants McCabe, Sangha and Lewis move to dismiss the claims against 

them on grounds they only reviewed and denied Plaintiff’s 602 Appeals and his 

requests for a referral to a cardiologist. (Dkt. No. 24-1 at 8.) Plaintiff argues that 

contrary to Defendants’ representations, Plaintiff did not base his claims on 

Defendants’ denial of his 602 Appeals. (Dkt. No. 29 at 26, 28.) Defendants reply

the Complaint lacks any allegations that Defendants McCabe, Sangha and Lewis 

were involved in Plaintiff’s care. (Dkt. No. 32 at 4.) The Court analyzes the 

allegations against each of these defendants below.

d. Dr. McCabe

Plaintiff alleges Dr. McCabe is responsible for Corcoran inmates’ medical 

care. (Dkt. No. 1, ¶ 7.) He alleges Dr. McCabe has authority and is responsible for 

deciding whether to order and approve tests and treatments for inmates, and to 

ensure inmates who are transferred to other institutions continue receiving proper 

medical care. (Id.) Plaintiff alleges Dr. McCabe denied his 602 appeal and his 

request to be referred to a heart specialist at the first level of review. (Id., ¶ 23.) He 

also alleges Dr. McCabe violated his Eighth Amendment rights by failing to make 

sure Plaintiff received adequate medical care when he transferred to Centinela. (Id. 

¶ 82.) 

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An action based on a prison official’s review of an inmate’s administrative 

appeal generally cannot serve as the basis for liability under section 1983 because 

“inmates lack a separate constitutional entitlement to a specific prison grievance 

procedure.” Ramirez v. Galaza, 334 F.3d 850, 860 (9th Cir. 2003) (no liberty 

interest in processing appeals because no entitlement to a specific grievance 

procedure), citing Mann v. Adams, 855 F.2d 639, 640 (9th Cir. 1988). However, 

prison administrators cannot willfully ignore constitutional violations being 

committed by subordinates. Starr v. Baca, 652 F.3d 1202, 1207 (9th Cir. 2011). 

Thus, circumstances may exist where individuals involved in reviewing an inmate 

appeal can be held liable under section 1983. For example, “an individual who 

denies an inmate appeal and who had the authority and opportunity to prevent an 

ongoing constitutional violation could potentially be subject to liability if the 

individual knew about an existing or impending violation and failed to prevent it.” 

Grant v. Cate, 2016 U.S. Dist. LEXIS 169440, *22 (E.D. Cal. Dec. 6, 2016), citing 

Jett, 439 F.3d at 1098.

Here, liberally construing the Complaint, Plaintiff states a cognizable Eighth 

Amendment claim against Dr. McCabe. Contrary to Defendants’ arguments, 

Plaintiff does not merely allege Dr. McCabe denied his administrative appeal. 

Rather, Plaintiff alleges Dr. McCabe knew about his continued chest pains and 

requests to see a heart specialist, had authority to prevent a constitutional violation,

and yet denied his request and delayed treatment for medical care that Plaintiff 

alleges was sorely needed. (Dkt. No. 1, ¶¶ 7, 76, 82.) Plaintiff further alleges the 

delay in treatment has caused him harm. See supra, p. 10. Accordingly, the Court 

recommends denying Defendants’ motion to dismiss the claims against Dr. 

McCabe.

/

/

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e. Dr. Sangha

Plaintiff alleges Dr. Sangha is responsible for Centinela inmates’ medical care, 

and is responsible for supervising, directing, and training the medical staff at 

Centinela, including Dr. Ko. (Dkt. No. 1 ¶ 8.) Plaintiff alleges Dr. Sangha referred 

Plaintiff’s 602 Appeal (Log #248) to Dr. Ko for the interview at the first level of 

review despite Plaintiff’s request to see another doctor and his allegations of 

deliberate indifference against Dr. Ko. (Id., ¶ 55.) An exhibit to Plaintiff’s 

Complaint indicates Dr. Sangha signed off on Plaintiff’s 602 Appeal denial (Log 

#248). (Id. at 69-70.) Plaintiff alleges Dr. Sangha condoned Dr. Ko’s improper 

actions. (Id., ¶¶ 77, 79.) For the reasons that follow, the Court concludes

Plaintiff’s allegations suffice to state a claim against Dr. Sangha. 

As previously noted, reviewing a prisoner’s administrative appeal generally 

cannot serve as the basis for liability under a § 1983 action. See Ramirez, 334 F.3d 

at 860. However, a plaintiff “may state a claim against a supervisor for deliberate 

indifference based upon the supervisor’s knowledge and acquiescence in 

unconstitutional conduct by his or her subordinates.” Starr, 652 F.3d at 1207. 

Knowledge and acquiescence may be shown where the supervisor reviewed the

inmate appeal and had the ability but failed to take corrective action. A defendant 

may be held liable as a supervisor under § 1983 for “(1) his or her personal 

involvement in the constitutional deprivation, or (2) if a sufficient causal 

connection between the supervisor’s wrongful conduct and the constitutional 

violation.” Id., quoting Hansen v. Black, 885 F.2d 642, 646 (9th Cir. 1989). “The 

requisite causal connection can be established . . . by setting in motion a series of 

acts by others,” or by “knowingly refus[ing] to terminate a series of acts by others, 

which [the supervisor] knew or reasonably should have known would cause others 

to inflict a constitutional injury.” Starr, 652 F.3d at 1207-08, quoting Dubner v. 

City & Cnty. of San Francisco, 266 F.3d 959, 968 (9th Cir. 2001). 

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Here, Plaintiff does not merely allege Dr. Sangha reviewed and denied his 602 

Appeal. Rather, he alleges facts stating a claim for deliberate indifference based on 

Dr. Sangha’s alleged knowledge and acquiescence in unconstitutional conduct. 

Liberally construing Plaintiff’s allegations, he alleges that Dr. Sangha knew Dr. Ko 

refused to provide effective treatment and refused to refer him to a specialist, and 

yet did not take actions to rectify the situation or to stop his subordinate’s acts. (Id., 

¶¶ 55, 77, 79.) Plaintiff further alleges Dr. Sangha referred a 602 Appeal interview 

to Dr. Ko for handling despite knowing Plaintiff complained of Dr. Ko’s treatment. 

(Id., ¶ 55.) Taken together, Plaintiff’s allegations consist of a claim that Dr. Sangha 

may be culpable for his own action or inaction as to the alleged constitutional 

deprivation. Plaintiff further alleges the delay in treatment has caused him harm. 

See supra, p. 10. Accordingly, the Court recommends denying Defendants’ motion 

to dismiss Plaintiff’s complaint against Dr. Sangha.

f. Deputy Director Lewis

Plaintiff alleges Deputy Director Lewis was responsible for the overall 

operation of the California Department of Corrections Health Care Department, 

including Centinela. (Dkt. No. 1, ¶ 9.) Deputy Director Lewis denied Plaintiff’s 

602 Appeal at the third director’s level of review. (Id., ¶ 58.) He alleges Deputy 

Direct Lewis “condoned [his] subordinate” Dr. Ko’s actions of directing Plaintiff to 

seek medical care at his own expense and denying him medical care because it was 

too expensive. (Id. ¶ 77.) Plaintiff alleges Director Lewis failed to take steps to 

ensure Plaintiff received adequate medical care from his subordinates, despite 

knowing about Plaintiff’s alleged pain, suffering and permanent injury risks. (Id., ¶ 

80.)

For similar reasons as stated in the section above (see supra, § III.e), the Court 

also concludes Plaintiff’s allegations suffice to state a claim against Deputy 

Director Lewis. Plaintiff does not merely allege Deputy Director Lewis reviewed 

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and denied his 602 Appeal. Liberally construing the allegations, Plaintiff alleges 

that Deputy Director Lewis knew Dr. Ko refused to provide effective treatment for 

Plaintiff’s continued chest pains and refused to refer him to a specialist. (Id., ¶¶ 77, 

80.) He alleges Deputy Director Lewis nonetheless denied his 602 Appeal. (Id., ¶ 

58.) Plaintiff further alleges the delay in treatment has caused him harm. See 

supra, p. 10. Accordingly, the Court recommends denying Defendants’ motion to 

dismiss the claim against Deputy Director Lewis.

IV. Conclusion

For the foregoing reasons, the Court RECOMMENDS that Defendants’ 

Motion to Dismiss Plaintiffs’ Complaint be DENIED. This report and 

recommendation is submitted to the United States District Judge assigned to this 

case pursuant to 28 U.S.C. § 636(b)(1). 

IT IS ORDERED that no later than April 7, 2017, any party to this action 

may file written objections and serve a copy on all parties. The document should 

be captioned “Objections to Report and Recommendation.” 

IT IS FURTHER ORDERED that any reply to the objections must be filed 

and served on all parties no later than April 21, 2017. 

The parties are advised that failure to file objections within the specified time 

may waive the right to raise those objections on appeal of the Court’s order. 

Martinez v. Ylst, 951 F.2d 1153, 1157 (9th Cir. 1991).

Dated: March 24, 2017

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