Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_11-cv-00507/USCOURTS-casd-3_11-cv-00507-0/pdf.json

Nature of Suit Code: 863
Nature of Suit: Social Security - DIWC/DIWW (405(g))
Cause of Action: 42:405 Review of HHS Decision (DIWC)

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

KATHLEEN A. OVERS,

Plaintiff,

v.

MICHAEL J. ASTRUE, Commissioner

of Social Security,

Defendant. 

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Civil No. 11cv00507 WQH(RBB)

REPORT AND RECOMMENDATION

GRANTING IN PART AND DENYING

IN PART PLAINTIFF'S MOTION FOR

SUMMARY JUDGMENT [ECF NO. 8]

AND GRANTING DEFENDANT'S

MOTION FOR REMAND [ECF NO. 9] 

On March 14, 2011, Plaintiff Kathleen A. Overs filed a

Complaint against Defendant Michael J. Astrue, Commissioner of

Social Security, for Review and Remedy on Administrative Decision

Under the Social Security Act [ECF No. 1]. Overs challenges the

denial of her claim for disability insurance benefits. (Compl. 1,

ECF No. 1.) Defendant filed an Answer to Complaint on September

27, 2011 [ECF No. 5], and filed the Administrative Record the same

day [ECF No. 6]. On January 30, 2012, Plaintiff's Motion for

Summary Judgment was filed, along with a Memorandum of Points and

Authorities [ECF No. 8]. Defendant filed a Motion for Remand and

Opposition to Plaintiff's Motion for Summary Judgment on February

23, 2012, along with a Memorandum of Points and Authorities [ECF

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No. 9]. Astrue refiled the same Motion for Remand and Opposition

to Plaintiff's Motion for Summary Judgment again on February 26,

2012, along with the same Memorandum of Points and Authorities;

however, it was docketed as a "Response in Opposition re 8

[Plaintiff's] Motion for Summary Judgment" [ECF No. 10].

The Court finds this matter is suitable for decision without

oral argument. See S.D. Cal. Civ. R. 7.1(d)(1). For the reasons

set forth below, the Court recommends that the district court GRANT

in part and DENY in part Plaintiff's Motion for Summary Judgment

[ECF No. 8], and GRANT Defendant's Motion for Remand [ECF No. 9].

I. MEDICAL EVIDENCE

On January 25, 2007, Plaintiff was evaluated at the San Diego

County Psychiatric Hospital by Dr. Young Ho Kang, the staff

psychiatrist. (Admin. R. Attach. #7, 234-37, ECF No. 6.) Overs

reported feeling depressed and anxious, as well as having

difficulty sleeping. (Id. at 234.) Plaintiff's depression

initially stemmed from a sexual assault that occurred more than

twenty years ago. (Id.) At the time of the assault, Plaintiff

claimed that she was forced into the bedroom of a police officer

who she was dating when two other police officers arrived; all

three officers participated in the sexual assault. (Id.) In

addition to her lingering depression from the incident, Plaintiff

stated that her depression had recently intensified because she was

terminated from her job at a bakery. (Id.) According to Overs,

she was fired after reporting to her supervisor that a fellow

employee had sexually fondled her. (Id.) Dr. Kang noted that the

subsequent assault brought back the sexual trauma and left

Plaintiff feeling scared, frustrated, helpless, and resentful. 

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(Id. at 234, 236.) Overs asserted she was experiencing additional

stress because her husband had been injured at work, causing

financial strain on the couple and ultimately leading them to

declare bankruptcy. (Id.)

At the time of her evaluation by Dr. Kang, Overs was not

taking any medication to treat her depression. (Id. at 234.) The

doctor noted that Plaintiff was visibly sad, frustrated, and

helpless, and he diagnosed her with post-traumatic stress disorder

("PTSD"). (Id. at 235.) Dr. Kang prescribed Prozac and Trazodone

for Overs, and he instructed her to pursue outpatient psychiatric

care. (Id. at 237.)

On March 14, 2007, the Plaintiff was evaluated at San Diego

County Mental Health Services by Dr. Majid Naficy, a staff

psychiatrist. (Id. at 241-44.) Again, she reported feeling

depressed and anxious, as well as having flashbacks and feelings of

terror related to her history of sexual abuse. (Id. at 241-42.) 

Specifically, Overs asserted that she frequently had nightmares

involving multiple men trying to harm her. (Id. at 241.) The

Plaintiff also complained that her anxiety caused her chest pain,

shortness of breath, and sensations of having a heart attack. (Id.

at 242.) Overs told Dr. Naficy that she had been prescribed Prozac

but never had formal psychiatric treatment. (Id.) Plaintiff also

indicated that she had taken the Prozac and noticed good results;

she stopped the medication, however, after four weeks because she

feared that it was aggravating her myotonia. (Id.) Dr. Naficy

observed that Overs was calm and cooperative during the meeting,

but her "affect was labile" when discussing her past sexual abuse 

(Id. at 243.)

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On June 29, 2007, Dr. Sandra M. Eriks treated Plaintiff for

myotonia, which caused her muscle pain and weakness in her legs,

neck, lower back, side, and arms. (Id. at 297.) Overs also

complained of pain and numbness in her wrists, hands, ankles, and

feet. (Id.) The pain was purportedly exacerbated by cold

temperature, exercise, and standing or sitting for any period of

time. (Id.) In her notes, Dr. Eriks indicated that Plaintiff "is

currently taking no medications." (Id.) Yet, another time, the

doctor lists Prozac, Clonazepam, and Trazodone as medications Overs

was currently taking. (Id. at 298.) Dr. Eriks determined that

Plaintiff could lift and carry thirty pounds occasionally and

twenty pounds frequently; she could sit, stand, or walk six hours

in an eight-hour workday. (Id. at 300.) Finally, the doctor

concluded that Overs could occasionally climb, stoop, kneel, and

crouch, and that she had no manipulative, visual, communicative, or

environmental limitations. (Id.)

Plaintiff, on August 24, 2007, sought treatment at the Sharp

Memorial Hospital emergency room, complaining of facial pain and

numbness that she had been experiencing for the past month. (Id.

at 333.) She also complained of headaches on the left side of her

forehead. (Id.) Overs was examined by Susan Rhinelander, a nurse

practitioner. (Id.) Plaintiff reported that she had been

prescribed Prozac, Trazodone, Klonopin, and Carbamazepine. (Id. at

335.) Yet, she had never taken the Carbamazepine and had not taken

Klonopin or Trazodone for some time. (Id.) Rhinelander gave

Plaintiff a prescription for Darvocet and diagnosed her with facial

pain, paresthesia, and "Rule out trigeminal neuralgia." (Id. at

336-37.) Rhinelander also started Overs on a steroid treatment and

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referred her back to her primary physician, Dr. Arthur Cardones. 

(Id.)

Over a year later, on October 6, 2008, Plaintiff saw Dr.

Albert Nester for her depression and post-traumatic stress

disorder. (Id. Attach. #8, 444.) Dr. Nester continued Overs on

her current Prozac and Remeron medications. (Id.) When she met

with him on November 3, 2008, the doctor observed that the

Plaintiff had suffered from increased anxiety and insomnia since

her last visit, most likely because she had missed some doses of

her Prozac. (Id. at 447.) Overs told Dr. Nester that the Prozac

made her feel "sluggish," so the doctor instructed her to split the

prescribed dosage and change the time of day that she took it. 

(Id.) He treated Overs again on December 4, 2008, when he

determined that her stress levels appeared "slightly better." (Id.

at 449.) On January 8, 2009, Dr. Nester opined that although

Plaintiff was "doing ok," her mood was "slightly anxious." (Id. at

453.)

Dr. Nester completed a "Mental Impairment Questionnaire" on

April 7, 2009, when he evaluated Overs's ability to perform workrelated activities on a day-to-day basis. (Id. at 474.) He

concluded that Plaintiff would be "[u]nable to meet competitive

standards" with regard to her ability to do the following:

D. Maintain attention and concentration for two hour

segments[;]

E. Maintain regular attendance and be punctual within

customary, usually strict tolerances[;]

F. Sustain an ordinary routine without special

supervision[;]

G. Work in coordination with or proximity to others

without being unduly distracted[;]

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. . . .

I. Complete a normal workday and workweek without

interruptions from psychologically based symptoms[;]

. . . .

K. Accept instructions and respond appropriately to

criticism from supervisors[;]

L. Interact appropriately with the general public[;]

[and]

M. Respond appropriately to changes in a routine working

setting[.]

(Id. at 474-75.)

II. THE ADMINISTRATIVE HEARING

On April 29, 2009, an administrative hearing was held before

Administrative Law Judge ("ALJ") Trembly. (Id. Attach. #2, 24.) 

Overs, her former attorney, Anthony Delollis, and vocational expert

Gloria Lasoff were present. (Id.) Judge Trembly heard testimony

from Plaintiff and her attorney, but not from the vocational

expert. (Id. at 24-42.) 

Overs's counsel testified that one of Plaintiff's most

disabling impairments was her trigemal neuralgia because it caused

her to suffer from disabling and painful headaches on a daily

basis. (Id. at 27.) Counsel further stated that Overs's myotonia

caused muscle cramping in her hands, feet, and legs. (Id.) 

Finally, Plaintiff's PTSD stemming from her history of sexual

trauma caused her to become a "shut-in" and fearful of venturing

into public without her husband. (Id. at 27-28.)

The Plaintiff testified about her history of sexual abuse. As

a child, she was molested by a teacher and a neighbor. (Id. at 29,

32.) She was later raped by police officers and sexually assaulted

by a former coworker. (Id. at 29-32.) Overs submitted that her

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myotonia caused constant pain and left her unable to sit or stand

for extended periods of time. (Id. at 32-33.) Her trigeminal

neuralgia made her nauseous and impaired her ability to read. (Id.

at 33.) Judge Trembly questioned Plaintiff about her prior jobs at

a daycare, a preschool, and a bakery. (Id. at 34-37.) The ALJ

noted that Overs had worked during the 1970's and 1980's, and

consistently from 1995 to 2006. (Id. at 37.) In 1987, the year

she was raped by the police officers, she earned almost $12,000.00. 

(Id.)

III. APPLICABLE LEGAL STANDARDS

A. Generally

To qualify for disability benefits under the Social Security

Act, an applicant must show two things: (1) He or she suffers from

a medically determinable impairment that can be expected to last

for a continuous period of twelve months or more, or would result

in death; and (2) the impairment renders the applicant incapable of

performing the work that he or she previously performed or any

other substantially gainful employment that exists in the national

economy. See 42 U.S.C.A. §§ 423(d)(1)(A), (2)(A) (West Supp.

2010). An applicant must meet both requirements to be classified

as "disabled." Id.

Sections 205(g) and 1631(c)(3) of the Social Security Act

allow applicants whose claims have been denied by the Social

Security Administration to seek judicial review of the

Commissioner's final agency decision. Id. §§ 405(g), 1383(c)(3). 

The district court may affirm, modify, or reverse the

Commissioner's decision. Id. § 405(g). The court should affirm

the decision unless "it is based upon legal error or is not

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supported by substantial evidence." Bayliss v. Barnhart, 427 F.3d

1211, 1214 n.1 (9th Cir. 2005) (citing Tidwell v. Apfel, 161 F.3d

599, 601 (9th Cir. 1999)). The district court may also remand the

matter to the Social Security Administration for further

proceedings. 42 U.S.C.A. § 405(g).

B. Treating Physicians

The administrative law judge must consider all medical opinion

evidence. 20 C.F.R. § 404.1527(b) (2011). According to the

regulations, a treating physician's opinion must be given

controlling weight if it is "well-supported by medically acceptable

clinical and laboratory diagnostic techniques and . . . not

inconsistent with the other substantial evidence in [the] case

record . . . ." Id. § 404.1527(d)(2). If the treating physician's

opinion is not given controlling weight, the following factors are

examined to determine what weight to give the opinion: (1) the

length of the treatment relationship and the frequency of

examination, (2) the nature and extent of the treatment

relationship, (3) the supportability of the opinion, (4) the

consistency of the opinion with the record as a whole, (5) the

specialization of the treating physician, and (6) any other factors

brought to the attention of the ALJ which tend to support or

contradict the opinion. Id. § 404.1527(d)(2)(i)-(ii), (d)(3)-(6).

Opinions of treating physicians may only be rejected under

certain circumstances. See Batson v. Comm'r of Soc. Sec. Admin.,

359 F.3d 1190, 1195 (9th Cir. 2004). "Cases in [the Ninth Circuit]

distinguish among the opinions of three types of physicians: (1)

those who treat the claimant (treating physicians); (2) those who

examine but do not treat the claimant (examining physicians); and

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(3) those who neither examine nor treat the claimant (nonexamining

physicians)." Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1995)

(footnote omitted).

The standard for determining whether an ALJ properly rejected

the opinion of a treating physician varies. If the treating

doctor's determination is not contradicted by another doctor, the

ALJ must give clear and convincing reasons for rejecting the

uncontradicted opinion. Thomas v. Barnhart, 278 F.3d 947, 957 (9th

Cir. 2002); see also Spelatz v. Astrue, 321 F. App'x 689, 692 (9th

Cir. 2009); Lester, 81 F.3d at 830. On the other hand, if the

treating physician's conclusion is contradicted by another doctor,

"'the ALJ must [resolve the conflict and] give specific, legitimate

reasons for disregarding the opinion of the treating physician.'" 

Batson, 359 F.3d at 1195 (quoting Matney v. Sullivan, 981 F.2d

1016, 1019 (9th Cir. 1992)); see also Lingenfelter v. Astrue, 504

F.3d 1028, 1042 (9th Cir. 2007). An ALJ may discredit opinions

"that are conclusory, brief, and unsupported by . . . objective

medical findings." Batson, 359 F.3d at 1195. Although a treating

physician's opinion is given the most weight, an opinion on the

ultimate issue -- disability -- is not binding on an ALJ. 

Tonapetyan v. Halter, 242 F.3d 1144, 1148 (9th Cir. 2011).

C. Remand for Further Proceedings

A district court may remand a Social Security disability

decision under sentence four of 42 U.S.C. § 405(g). Hoa Hong Van

v. Barnhart, 483 F.3d 600, 605 (9th Cir. 2007). That provision

states, "The court shall have power to enter, upon the pleadings

and transcript of the record, a judgment affirming, modifying, or

reversing the decision of the Commissioner of Social Security, with

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or without remanding the cause for a rehearing." 42 U.S.C.A. §

405(g). "A sentence-four remand is essentially a determination

that the Commissioner erred in denying benefits." Havrylovich v.

Astrue, No. 09-1113-HA, 2011 U.S. Dist. LEXIS 7187, at *19 (D. Or.

Jan. 25, 2011) (citing Hoa Hong Van, 483 F.3d at 605). After a

case is remanded and an additional hearing is held, the

Commissioner may modify or affirm the original findings of fact or

the decision. 42 U.S.C.A. § 405(g).

A remand to the Commissioner for further proceedings or to

award benefits is within the court's discretion. McAllister v.

Sullivan, 888 F.2d 599, 603 (9th Cir. 1989). "'If additional

proceedings can remedy defects in the original administrative

proceedings, a social security case should be remanded. Where,

however, a rehearing would simply delay receipt of benefits,

reversal [and an award of benefits] is appropriate.'" Id. (quoting

Lewin v. Schweiker, 654 F.2d 631, 635 (9th Cir. 1981)). "[T]he

proper course, except in rare circumstances, is to remand to an

administrative agency for additional investigation or explanation." 

INS v. Ventura, 537 U.S. 12, 16 (2002). 

IV. DISCUSSION

In her Motion for Summary Judgment, Plaintiff asks the Court

to reverse the Commissioner's final decision and remand the case

for an award of benefits or further proceedings. (Mot. Summ. J.

Attach. #1 Mem. P. & A. 12, ECF No. 8.) First, Plaintiff alleges

that the ALJ erred because he did not consider the opinion of

Overs's treating physician, Dr. Nester. (Id. at 6-7.) Second,

Plaintiff maintains that Judge Trembly's finding that Plaintiff can

do other work is not supported by substantial evidence. (Id. at 7-

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8.) Third, she alleges that the ALJ erred in relying on the "grid

rules." (Id. at 8-9.) Fourth, according to Overs, the judge

failed to consider a letter written by Plaintiff's husband. (Id.

at 9-10.) Finally, Judge Trembly improperly found that Overs was

not credible. (Id. at 10-11.) The Plaintiff argues that the Court

should reverse the final decision and remand the case for the

payment of benefits. (Id. at 12.) She contends that Dr. Nester's

opinion should be "accepted as a matter of law." (Id.)

In his Motion for Remand, Defendant concedes that the ALJ's

finding that Overs was not disabled at step five was not supported

by substantial evidence. (Mot. Remand Attach. #1 Mem. P. & A. 2

n.1, ECF No. 9.) "Defendant asked Plaintiff to stipulate to remand

this matter for further proceedings." (Id.) But at the time the

Motion to Remand was filed on February 23, 2012, Plaintiff had not

agreed to join in a motion to remand. (Id.) Defendant argues

that, nonetheless, remand is appropriate for consideration of the

medical source opinions. (Id. at 2.)

"Administrative law judges are responsible for reviewing the

evidence and making findings of fact and conclusions of law." 20

C.F.R. § 404.1527(f)(2). Conflicts in the evidence should be

resolved by the Commissioner, not the courts. See Laffoon v.

Califano, 558 F.2d 253, 254 (5th Cir. 1977); see also, Sprague v.

Bowen, 812 F.2d 1226, 1230 (9th Cir. 1987). The ALJ is the final

arbiter of ambiguities in the medical evidence. Tommasetti v.

Astrue, 533 F.3d 1035, 1041-42 (9th Cir. 2008). The Commissioner's

decision must be upheld when the evidence would support more than

one rational interpretation. Havrylovich, 2011 U.S. Dist. LEXIS

7187, at *4 (citing Thomas, 278 F.3d at 954).

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The Ninth Circuit has articulated the standard district courts

must apply when deciding whether to remand a matter for further

proceedings:

Remand for further administrative proceedings is

appropriate if enhancement of the record would be useful. 

Conversely, where the record has been developed fully and

further administrative proceedings would serve no useful

purpose, the district court should remand for an

immediate award of benefits. More specifically, the

district court should credit evidence that was rejected

during the administrative process and remand for an

immediate award of benefits if (1) the ALJ failed to

provide legally sufficient reasons for rejecting the

evidence; (2) there are no outstanding issues that must

be resolved before a determination of disability can be

made; and (3) it is clear from the record that the ALJ

would be required to find the claimant disabled were such

evidence credited.

Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004) (citations

omitted); see Strauss v. Comm'r of Soc. Sec. Admin., 635 F.3d 1135,

1138 (9th Cir. 2011) (applying the standard outlined in Benecke). 

"A claimant is not entitled to benefits under the statute unless

the claimant is, in fact, disabled, no matter how egregious the

ALJ's errors may be." Strauss, 635 F.3d at 1138.

A. Failure to Consider Dr. Nester's Opinion

Plaintiff initially contends that the ALJ improperly ignored

the opinion of Overs's treating physician, Dr. Nester. (Mot. Summ.

J. Attach. #1 Mem. P. & A. 6, ECF No. 8.) The doctor opined that

Plaintiff was unable to meet competitive standards in several work

areas but the ALJ did not weigh, or even mention, Dr. Nester's

opinion. (Id.) Because the treating physician's opinion was not

adequately rejected, it should be accepted as a matter of law and

the case should be remanded for an award of benefits. (Id. at 7.) 

Astrue concedes that the ALJ should have discussed Dr.

Nester's opinion and articulated the reasons for rejecting it. 

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(Mot. Remand Attach. #1 Mem. P. & A. 2-3, ECF No. 9.) He argues

that remand is the appropriate remedy, not an award of benefits. 

(Id. at 3.) On remand, Defendant asks for an instruction to

consider Dr. Nester's opinion and articulate specific and

legitimate reasons for rejecting the opinion, if appropriate. 

(Id.) The Commissioner also seeks an instruction to reassess

Overs's residual functional capacity and obtain vocational expert

testimony on what jobs exist for Plaintiff in light of her age,

education, residual functional capacity, and other vocational

factors. (Id.)

In his decision, the ALJ determined that Plaintiff was

impaired with myotonia, trigeminal neuralgia, and post-traumatic

stress disorder. (Admin. R. Attach. #2, 16, ECF No. 6.) Overs did

not have an impairment that meets one of the listed impairments. 

(Id. at 17.) Judge Trembly further concluded that after

considering the entire record, Plaintiff had the RFC to perform

light work, but she was limited to simple, repetitive tasks in a

nonpublic work environment. (Id.) The ALJ found that there were

jobs that existed in significant numbers that Overs could perform. 

(Id. at 22.) 

Dr. Nester treated the Plaintiff on October 6, November 3,

December 4, 2008, and January 8, 2009. (Id. Attach. #8, 444, 447,

449, 453.) Dr. Nester, opined on April 7, 2009, that Overs was

"[u]nable to meet competitive standards" for concentration and

punctuality, sustaining an unsupervised routine, working with

others, completing a normal work week, accepting criticism,

interacting with others, and responding appropriately to changes in

a work setting. (Id. at 474-75.) The opinion by Dr. Nester, a

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treating physician, that Overs was unable to meet competitive

standards in several work areas is inconsistent with, for example,

treating physician Dr. Eriks's finding that Plaintiff had no

visual, communicative, or environmental limitations. (See Admin.

R. Attach. #8, 300, 474-75, ECF No. 6.)

As discussed, to reject the opinion of an examining or a

treating physician that is contradicted by other medical opinions,

the ALJ is required to give specific and legitimate reasons for

doing so. See Batson, 359 F.3d at 1195; Lester, 81 F.3d at 830-31. 

Conflicts in the medical evidence are resolved by the Commissioner. 

Sprague, 812 F.2d at 1230.

Judge Trembly gave no reasons for rejecting Dr. Nester's

opinion that Overs could not adequately concentrate, attend work

regularly, or complete a workday without interruptions. See

Strauss, 635 F.3d at 1138. There may or may not be evidence in the

record that the ALJ can rely on to render the required "specific"

and "legitimate" reasons for disregarding Dr. Nester's opinions;

regardless, the ALJ is in a better position to perform the task

than this Court. See McAllister, 888 F.2d at 603; Gonzalez v.

Sullivan, 914 F.2d 1197, 1201 (9th Cir. 1990) ("We are wary of

speculating about the basis of the ALJ's conclusion . . . ."). The

Administration should address the outstanding issues before making

a decision as to Overs's disability. But see Strauss, 635 F.3d at

1138; see also Benecke, 379 F.3d at 595 (explaining that allowing

the ALJ on remand to decide and again explain his reasons for

discrediting the treating and examining doctors' opinions "would

create an unfair 'heads we win; tails, let's play again' system of

disability benefits adjudication[]"). Here, it is not clear from

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the record that ALJ Trembly would be required to find Plaintiff

Overs disabled if Dr. Nester's opinion was credited. See Strauss,

635 F.3d at 1138.

 In light of Judge Trembley's failure to articulate specific

and legitimate reasons for rejecting Dr. Nester's opinion that

Overs was unable to meet competitive standards in several areas,

the matter should be remanded to allow Judge Trembly to explain his

reasons for doing so. See id. Springer, 1996 U.S. App. LEXIS

18296, at *8 (upholding the district court's decision to remand to

allow the ALJ to explain his reasons for discounting the

evaluations of two of the five physicians when it was clear from

the record that the medical evidence from the five physicians was

conflicting); see also Benecke, 379 F.3d at 594, 594 n.3

(concluding that the decision to deny benefits should be reversed

because the ALJ gave a lengthy explanation for discrediting the

treating physicians' opinions, the reasoning was legally

insufficient, the record was fully established, and the evidence

compelled a finding of disability); Marquez v. Astrue, No. ED CV

09-1921-E, 2010 U.S. Dist. LEXIS 41054, at *7-8 (C.D. Cal. Apr. 27,

2010) (applying Harman v. Apfel, 211 F.3d 1172, 1178 (9th Cir.

2000), to decide whether reversal or remand is appropriate). In

Overs's case, there are outstanding issues that need to be

addressed before a disability determination can be made. 

B. Error in Applying the Grids

Next, Overs contends that because her impairments are

nonexertional, Judge Trembly erred in relying on the medicalvocational rules instead of referring to the expertise of a

vocational witness. (Mot. Summ. J. Attach. #1 Mem. P. & A. 8-9,

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ECF No. 8.) The Plaintiff argues that the ALJ's finding that her

limitations did not reduce the occupational base of unskilled light

work is not supported by the record. (Id. at 8.) Overs further

alleges that without some individualized explanation of what jobs

she can perform given her disabilities, the ALJ's determination is

not supported by substantial evidence. (Id.) Accordingly,

Plaintiff contends the case should be remanded for the ALJ to

consider the testimony of a vocational witness. (Id. at 9.)

Defendant suggests that, on remand, the Commissioner should be

instructed to reassess Overs's RFC and obtain supplemental

vocational expert testimony to determine what jobs are available to

Plaintiff in light of her age, education, functioning capacity, and

various vocational factors. (Mot. Remand Attach. #1 Mem. P. & A.

3, ECF No. 9.)

An ALJ typically may rely on the grids when the plaintiff's

impairments consist of exertional limitations. See Desrosiers v.

Sec'y of Health & Human Servs., 846 F.2d 573, 576-77 (9th Cir.

1988). When the plaintiff's impairments reflect significant

nonexertional limitations, however, "the grids are only a framework

and a [vocational expert] must be consulted." Moore, 216 F.3d at

870; see also Desrosiers, 846 F.2d at 579 ("If a claimant has an

impairment that limits his or her ability to work without directly

affecting his or her strength, that claimant is said to have a nonexertional (not strength-related) limitation that is not covered by

the grids.") (Pregerson, J. concurring).

The grids are inapplicable when the claimant has both

exertional and significant nonexertional limitations; then, the ALJ

must consult a vocational expert to determine whether jobs for the

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plaintiff exist in the national economy, despite her impairment. 

Moore, 216 F.3d at 869-70. In that situation, careful

consideration of an individual's RFC is required. See Soc. Sec.

Ruling 85-15, 1985 SSR LEXIS 20, at *10 (1985). The ALJ may base a

finding of not disabled "on the fact that a claimant can perform

some, although not all, . . . work only if such a finding is

supported by both the medical evidence and the testimony of a

vocational expert." Desrosiers, 846 F.2d at 580. To better assess

the plaintiff's prospects for work, the ALJ should give the 

vocational expert a hypothetical or series of hypothetical

scenarios that take into account all the claimant's limitations and

restrictions. Valentine v. Comm'r of Soc. Sec. Admin., 574 F.3d

685, 690 (9th Cir. 2009). The vocational expert must identify a

substantial occupational base to sustain a finding of not disabled. 

See Soc. Sec. Ruling 85–15, 1985 SSR LEXIS 20, at *8 ("If, despite

the nonexertional impairment(s), an individual has a large

potential occupational base, he or she would ordinarily not be

found disabled in the absence of extreme adversities in age,

education, and work experience.").

Although vocational expert Gloria Lasoff appeared at Over's

administrative hearing, Lasoff did not testify. (Admin. R. Attach.

#2, 24-42, ECF No. 6.) As previously noted, Judge Trembly

determined that Plaintiff was impaired with myotonia, trigeminal

neuralgia, and post-traumatic stress disorder. (Id. at 16.) He

then concluded that Overs had the capacity to perform light work,

limited to simple, repetitive tasks in a nonpublic work

environment. (Id. at 17.) Judge Trembly's determination that she

was limited to "light work" necessitates a finding that Plaintiff

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suffered from some exertional impairments. See 20 C.F.R. §

404.1567 ("To determine the physical exertion requirements of work

in the national economy, we classify jobs as sedentary, light,

medium, heavy, and very heavy.") Additionally, the conclusion that

Overs had post-traumatic stress disorder necessitates a finding

that she also had nonexertional impairments. See 20 C.F.R. §

404.1569a(c) (2012) (listing nervousness, anxiety and depression as

nonexertional limitations); Holohan v. Massanari, 246 F.3d 1195,

1208-09 & n.12 (9th Cir. 2001) (nothing that psychiatric

impairments are nonexertional limitations). Thus, ALJ Trembly

determined that Overs suffered from both exertional and

nonexertional limitations.

"[T]he fact that a non-exertional limitation is alleged does

not automatically preclude application of the grids." Desrosiers,

846 F.2d at 577. Rather, the ALJ must first determine whether a

claimant's "non-exertional limitations significantly limit the

range of work permitted by his exertional limitations." Id.

(citations omitted). If so, the guidelines would be inapplicable. 

Id. Here, the ALJ did not address why Plaintiff's nonexertional

limitations did not significantly limit her functional capacity,

thus making a vocational expert unnecessary. See id. In light of

Judge Trembly's failure to articulate any basis for failing to

consult with a vocational expert, the matter should be remanded to

permit him to explain his reasons for doing so or to obtain

supplemental vocational expert testimony. Holohan, 246 F.3d at

1208-09, 1211 (remanding the case when ALJ improperly relied solely

on the medical-vocational guidelines with no vocational expert

testimony). 

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C. Failure to Consider the Letter from Mark Overs

The Plaintiff also argues that ALJ Trembly improperly

disregarded a letter written by Overs's husband, Mark Overs, that

was attached to the administrative record. (Mot. Summ. J. Attach.

#1 Mem. P. & A. 9, ECF No. 8.) In support of Plaintiff's

application for benefits, her husband wrote a letter describing

Plaintiff's limitations. (Admin. R. Attach. #8, 470-71, ECF No.

6.) He discussed her lack of memory and concentration, mood

swings, and habit of humming during difficult moments. (Id.) 

Plaintiff argues that the ALJ improperly did not discuss the

letter. (Mot. Summ. J. Attach. #1 Mem. P. & A. 9-10, ECF No. 8.) 

She contends that the ALJ must consider observations from

nonmedical sources about how a claimant's impairments impact her

ability to work. (Id. at 9.) Defendant does not address this

issue in his Motion for Remand. (See generally Mot. Remand Attach.

#1 Mem. P. & A. 1-4, ECF No. 9.)

An ALJ may consider lay witness testimony to determine the

severity of a claimant's impairments and how the impairments affect

his ability to work. 20 C.F.R. §§ 404.1513(d)(4), (e),

416.913(d)(4), (e) (2012); Stout v. Comm'r, 454 F.3d 1050, 1053

(9th Cir. 2006); Smolen v. Chater, 80 F.3d 1273, 1288 (9th Cir.

1996). "Descriptions by friends and family members in a position

to observe a claimant's symptoms and daily activities have

routinely been treated as competent evidence." Sprague v. Bowen,

812 F.2d at 1232; see also Bojarski v. Astrue, No. C09-0833-MAT,

2010 U.S. Dist. LEXIS 24081, at *24-34 (W.D. Wash. Feb. 25, 2010)

(discussing numerous letters submitted by plaintiff's friends and

family members and determining that the ALJ erred in failing to

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provide germane reasons for rejecting statements made in the

letters). Lay witness testimony by friends and family members who

have observed a claimant on a daily basis "constitutes qualified

evidence" that the ALJ must consider. Sprague, 812 F.2d at

1231-32; see Smolen, 80 F.3d at 1289 (noting that testimony from

lay witnesses who see the plaintiff on a daily basis and are often

family members is particularly valuable); Dodrill v. Shalala, 12

F.3d 915, 919 (9th Cir. 1993) ("An eyewitness can often tell

whether someone is suffering or merely malingering . . . this is

particularly true of witnesses who view the claimant on a daily

basis . . . ."). The ALJ may discount the testimony of lay

witnesses only for "reasons that are germane to each witness." 

Dodrill, 12 F.3d at 919; see Regennitter v. Comm'r, 166 F.3d 1294,

1298 (9th Cir. 1999). 

Judge Trembly did not reference Mark Overs's letter in his

opinion. (See generally Admin. R. Attach. #2, 14-23, ECF No. 6.) 

The ALJ failed to provide specific reasons, germane to Mark Overs,

for discounting his statements about his wife's impairments. See

Dodrill, 12 F.3d at 919. Further proceedings would be useful

because the record is unclear as to whether the ALJ would be

required to find Plaintiff disabled if he had properly considered

Mark Overs's letter. Accordingly, remand is warranted to address

the letter from Plaintiff's husband. See Paap v. Astrue, No. 3:10-

CV-6303-HZ, 2012 U.S. Dist. LEXIS 25417, at *21-23, 36-37 (D. Or.

Feb. 28, 2012) (granting remand for failure to articulate reasons

for rejecting lay witness statements made by a friend of claimant);

see also Petite v. Astrue, No. ED CV 09-1347-PLA, 2010 U.S. Dist.

LEXIS 54009, at *21-27 (C.D. Cal. June 1, 2010) (remanding for

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failure to provide reasons for discounting testimony of claimant's

wife); Bojarski, 2010 U.S. Dist. LEXIS 24081, at *33-34.

D. Credibility Determination

Finally, Plaintiff argues that the ALJ's finding that Overs

was not credible is not supported by clear and convincing evidence. 

(Mot. Summ. J. Attach. #1 Mem. P. & A. 11, ECF No. 8.) Overs

contends that the ALJ failed to provide specific reasons for

finding that Plaintiff was not credible. (Id.) Further, she

argues that Judge Trembly was "obsessed" with her failure to follow

the treatment regimine prescribed by her physicians, but Overs was

in continuous treatment from January 2007 to April 2009. (Id.) 

The Defendant does not address this issue in his Motion for Remand. 

(See generally Mot. Remand Attach. #1 Mem. P. & A. 1-4, ECF No. 9.)

"In order for the ALJ to find [claimant's] testimony

unreliable, the ALJ must make 'a credibility determination with

findings sufficiently specific to permit the court to conclude that

the ALJ did not arbitrarily discredit claimant's testimony.'"

Turner v. Comm'r of Soc. Sec. Admin., 613 F.3d 1217, 1224 (9th Cir.

2010) (quoting Thomas, 278 F.3d at 958). In evaluating the

credibility of a plaintiff's testimony regarding subjective pain,

the adjudicator must engage in a two-step analysis. Vasquez v.

Astrue, 572 F.3d 586, 591 (9th Cir. 2009) (citing Lingenfelter, 504

F.3d at 1035-36); see Batson, 359 F.3d at 1196. "'First, the ALJ

must determine whether the claimant has presented objective medical

evidence of an underlying impairment which could reasonably be

expected to produce the pain or other symptoms alleged.'" Vasquez,

572 F.3d at 591 (quoting Lingenfelter, 504 F.3d at 1036). Second,

if the claimant satisfies the first step and there is no evidence

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of malingering, the ALJ may reject the claimant's testimony about

the severity of the symptoms if he gives "'specific, clear and

convincing reasons'" for doing so. Id. (quoting Lingenfelter, 504

F.3d at 1036); Smolen, 80 F.3d at 1283-84.

Here, Judge Trembly initially determined that Overs's

impairments "could reasonably be expected to cause the alleged

symptoms . . . ." (Admin. R. Attach. #2, 21, ECF No. 6.) Neither

the Plaintiff nor the Defendant challenges this conclusion. The

first prong of the ALJ's inquiry regarding Plaintiff's credibility

is therefore satisfied. See Vasquez, 572 F.3d at 591. The issue,

then, is whether Judge Trembly provided clear reasons for the

adverse credibility finding that are supported by the evidence in

the record.

The Commissioner's reasons for rejecting a claimant's

testimony must be "clear and convincing." Reddick v. Charter, 157

F.3d 715, 722 (9th Cir. 1998) (quoting Lester, 81 F.3d at 834). To

support a finding that the plaintiff was not credible, the ALJ must

"'point to specific facts in the record that demonstrate that [the

plaintiff] is in less pain than she claims.'" Vasquez, 572 F.3d at

592 (quoting Dodrill, 12 F.3d at 918). The ALJ must make specific

findings "stat[ing] which pain testimony is not credible and what

evidence suggests the complaints are not credible." Dodrill, 12

F.3d at 918. A reviewing court should not be forced to speculate

as to the grounds for an administrative law judge's rejection of a

plaintiff's allegations of disabling pain. Bunnell v. Sullivan,

947 F.2d 341, 346 (9th Cir. 1991) (citing Murray v. Heckler, 722

F.2d 499, 502 (9th Cir. 1983)); see also Steele v. Barnhart, 290

F.3d 936, 941 (7th Cir. 2002) (explaining that the ALJ must build

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an accurate and logical connection between the evidence and the

decision).

In general, questions of credibility are for the ALJ to

resolve. Sample v. Schweiker, 694 F.2d 639, 642 (9th Cir. 1982). 

Courts should not "second-guess" an ALJ's credibility

determinations. Allen v. Heckler, 749 F.2d 577, 580 (9th Cir.

1984). If the evidence is conflicting and could be rationally

interpreted more than one way, the court must uphold the ALJ's

decision. Id. at 579. 

Social Security Ruling 96-7p provides the relevant standard: 

4. In determining the credibility of the individual's

statements, the adjudicator must consider the entire case

record, including the objective medical evidence, the

individual's own statements about symptoms, statements and

other information provided by treating or examining physicians

or psychologists and other persons about the symptoms and how

they affect the individual, and any other relevant evidence in

the case record. An individual's statements about the

intensity and persistence of pain or other symptoms or about

the effect the symptoms have on his or her ability to work may

not be disregarded solely because they are not substantiated

by objective medical evidence.

5. It is not sufficient for the adjudicator to make a

single, conclusory statement that 'the individual's

allegations have been considered' or that 'the

allegations are (or are not) credible.' It is also not

enough for the adjudicator simply to recite the factors

that are described in the regulations for evaluating

symptoms. The determination or decision must contain

specific reasons for the finding on credibility,

supported by the evidence in the case record, and must be

sufficiently specific to make clear to the individual and

to any subsequent reviewers the weight the adjudicator

gave to the individual's statements and the reasons for

that weight.

Soc. Sec. Ruling 96-7p, 1996 SSR LEXIS 4, at *2-4. 

The Ninth Circuit has articulated the grounds on which an ALJ

may properly decide to discredit a claimant's testimony: 

In weighing a claimant's credibility, the ALJ may

consider [claimant's] reputation for truthfulness,

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inconsistencies either in his testimony or between his

testimony and his conduct, his daily activities, his work

record, and testimony from physicians and third parties

concerning the nature, severity, and effect of the

symptoms of which he complains.

Light v. Comm'r of Soc. Sec. Admin., 119 F.3d 789, 792 (9th Cir.

1997) (citations omitted). Where the ALJ's credibility assessment

is supported by substantial evidence, it will not be disturbed even

where some of the reasons for discrediting a claimant's testimony

were improper. Tonapetyan, 242 F.3d at 1148; see Carmickle v.

Comm'r of Soc. Sec. Admin., 533 F.3d 1155, 1163 (9th Cir. 2008). 

Here, Judge Trembly listed ten reasons for finding that

Plaintiff was not fully credible: 

However, to the extent that it is alleged that the

claimant cannot perform work at the residual functional

capacity as recited above, the Administrative Law Judge

finds those allegations are not totally credible for the

following clear and convincing reasons.

First, the claimant's activities of daily living include;

independently caring for her own personal hygiene;

cooking; cleaning; shopping; and driving a vehicle

(Exhibit 8F). These activities did not indicate a

disabling level of impairment of the claimant's residual

functional capacity.

Second, during the January 25, 2007, psychiatric

evaluation at the San Diego County Psychiatric Hospital

emergency department, by Dr. Kang, it was noted that the

claimant was not currently taking any prescription

medication for any impairment. This is not consistent

with a disabling level of impairment. Third, it was also

noted during the January 25, 2007, evaluation, by Dr.

Kang, that the claimant was referred for outpatient

psychiatric treatment; however, based on her subsequent

psychiatric assessment at the San Diego County Mental

Health Services on March 14, 2007, she never pursued

outpatient treatment and she just took the prescribed

medication for four weeks and then discontinued it. The

Regulations state, "in order to get benefits you must

follow the prescribed treatment, if you do not follow the

prescribed treatment without a good reason, we will not

find you disabled" (20 CFR 404.1530 and 416.930). Since

there were no allowable reasons offered for discontinuing

the prescribed medication and for not following up with

the outpatient mental health treatment, the claimant

cannot be denied benefits based on this regulation.

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Fourth, during the March 14, 2007, evaluation at the San

Diego County Psychiatric Center, the claimant reported

that she never had any formal psychiatric treatment,

never been psychiatrically hospitalized, and she denied

suicide attempts. Fifth, it was also noted during the

March 14, 2007, mental status evaluation that the

claimant displayed no significant psychomotor agitation

or retardation; she was calm and cooperative in the

interview; her thought process was linear, logical and

goal-directed; and she denied any hallucinations,

suicidal ideation, or homicidal ideation. 

Sixth, at the June 29, 2007, consultative internist

examination by Dr. Eriks, the claimant reported that she

has been on Darvocet in the past for pain, but was not

currently on any medications.

Seventh, Dr. Eriks reported after the June 29, 2007

evaluation, that other than the mild tenderness and

slight paraspinous muscle spasm in the lower thoracic

spine and mild kyphoscoliosis in the lower thoracic spine

and mild kyphoscoliosis in the lower thoracic spine, the

remainder of claimant's examination was grossly normal. 

Eighth, when the claimant was seen at the Sharp Grossmont

Hospital Emergency room on August, 24, 2007, she reported

that her prescribed medications included Prozac,

Trazadone, Klonopin, and Carbamazepine; however, she had

never started taking the Carbamazepine and had not taken

the Klonopin or Trazedone for awhile. Again, the

claimant can be found "not disabled" for not following

prescribed treatment (20 CFR 404.1530 and 416.930).

Ninth, when discussing the claimant[']s impairments, no

physician, neither any of the claimant[']s treating

physicians or a State Agency ever opined that listing

level limitations were ever met or equaled. Tenth, the

objective evidence of the claimant's medical record does

not establish impairments likely to produce disabling

pain or other limitations as alleged for any period of 12

or more continuous months.

After careful consideration of the evidence, the

undersigned finds that the claimant's medically

determinable impairments could reasonably be expected to

cause the alleged symptoms; however, the claimant's

statements concerning the intensity, persistence and

limiting effects of these symptoms are not credible to

the extent they are inconsistent with the above residual

functional capacity assessment. 

(Admin. R. Attach. #2, 20-21, ECF No. 6.) (emphasis in

original)

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Judge Trembly identified numerous instances in which

Plaintiff failed to take medications as prescribed or follow a

physician-recommended course of treatment. The ALJ noted that

at her January 25, 2007 psychiatric evaluation by Dr. Kang,

Overs was not taking any prescription medication, which was

inconsistent with her alleged disabling pain. (Id. at 20.) 

Likewise, Plaintiff stated during her June 29, 2007

appointment with Dr. Eriks that she was not on any medication. 

(Id.) Overs also failed to pursue recommended outpatient

psychiatric treatment and take her prescribed Carbamezepine

medication. (Id. at 20-21.) 

An ALJ may rely on evidence of a claimant's failure to

take medication when questioning the claimant's credibility. 

Esquivel v. Astrue, No. 5:11-CV-00905 PSG, 2012 U.S. Dist.

LEXIS 50481, at *17-18 (N.D. Cal. Apr. 10, 2012) (citing

Moncada v. Chate, 60 F.3d 521, 524 (9th Cir. 1995)). 

"[N]oncompliance with treatment may be a clear and convincing

reason for an adverse credibility determination." Kral v.

Astrue, No. 1:10-cv-01483 JLT, 2011 U.S. Dist. LEXIS 106642,

at *18 (E.D. Cal. Sept. 20, 2011) (citing Fair, 885 F.2d at

603); Pharris v. Astrue, No. 1:10-cv-01323 JLT, 2011 U.S.

Dist. LEXIS 99485, at *25, (E.D. Cal. Sept. 2, 2011) (same).

Judge Trembly properly considered these factors when finding

that Overs was not fully credible. The record supports his

conclusion. 

Moreover, the ALJ cited numerous inconsistencies between

the Plaintiff's testimony and the evidence in the record. For

example, the judge recognized instances where Overs conceded

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that she was not taking any prescribed medications, which

conflicted with her alleged disabling impairments. (Admin. R.

Attach. #2, 20, ECF No. 6.) The ALJ also considered that

Plaintiff's thought process was "linear, logical and goaldirected" during her March 14, 2007 evaluation. (Id.) 

Similarly, Overs's June 29, 2007 examination was "grossly

normal," which was inconsistent with her complaints. (Id.) 

"[T]he adjudicator may not discredit a claimant's

testimony of pain and deny disability benefits solely because

the degree of pain alleged by the claimant is not supported by

objective medical evidence." Bunnell, 947 F.2d at 346-47

(emphasis added). Nonetheless, "[w]hile subjective pain

testimony cannot be rejected on the sole ground that it is not

fully corroborated by objective medical evidence, the medical

evidence is still a relevant factor in determining the

severity of the claimant's pain and its disabling effects." 

Rollins v. Massanari, 261 F.3d 853, 857 (9th Cir. 2001). As

discussed, Judge Trembly properly provided other specific,

convincing reasons for discrediting Overs's testimony, such as

her failure to take prescribed medications, that are supported

by the evidence in the record. His credibility determination

was therefore not based solely on inconsistencies between

Overs's testimony and objective medical evidence. 

The ALJ also referred to Plaintiff's activities of daily

living to illustrate inconsistencies between her testimony --

that she is in pain, is fearful of venturing in public, and

cannot sit or stand for extended periods of time — and her

conduct -- cooking, cleaning, shopping, ane driving. (Admin.

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R. Attach. #2, 20, ECF No. 6.) An ALJ may consider the

claimant's daily activities and may reject excess pain

allegations where the activities contradict the claimant's

other testimony. Orn v. Astrue, 495 F.3d 625, 639 (9th Cir.

2007). Judge Trembly properly referred to Overs's activities

of daily living to illustrate that they were not consistent

with Plaintiff's testimony regarding her disabling level of

impairment. See id. The record also supports this

determination.

Nonetheless, Judge Trembly provided multiple specific,

detailed bases for his credibility assessment, which are

supported by the evidence in the record. Turner, 613 F. 3d at

1224.

V. CONCLUSION AND RECOMMENDATION

Plaintiff's Motion for Summary Judgment [ECF No. 8]

should be GRANTED in part and DENIED in part. Overs's request

to remand the matter for further administrative proceedings

should be GRANTED, but her request for an order reversing the

ruling should be DENIED. The Defendant's Motion to Remand

[ECF No. 9] should be GRANTED. 

This Report and Recommendation will be submitted to the

United States District Court Judge assigned to this case,

pursuant to the provisions of 28 U.S.C. § 636(b)(1). Any

party may file written objections with the Court and serve a

copy on all parties on or before July 31, 2012. The document

should be captioned "Objections to Report and Recommendation." 

Any reply to the objections shall be served and filed on or

before August 14, 2012. The parties are advised that failure

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to file objections within the specified time may waive the

right to appeal the district court's order. Martinez v. Ylst,

951 F.2d 1153 (9th Cir. 1991).

Dated: July 16, 2012 

RUBEN B. BROOKS

United States Magistrate Judge

cc: Judge Hayes

 All Parties of Record

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