Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_08-cv-01022/USCOURTS-casd-3_08-cv-01022-1/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:402 Social Security Benefits

---

1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

1 08cv1022 

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

 

Teodoso Serrano Moreno,

Plaintiff,

v.

Michael Astrue, Commissioner of Social

Security Administration,

Defendant. 

 _____________________

)

)

)

)

)

)

)

)

)

)

)

)

Civil No. 08cv1022 WQH (PCL)

REPORT AND RECOMMENDATION OF

U.S. MAGISTRATE JUDGE RE: 

DENYING PLAINTIFF’S MOTION FOR

SUMMARY JUDGMENT [Doc. 12]; 

and

GRANTING DEFENDANT’S MOTION

FOR SUMMARY JUDGMENT [Doc. 15].

Plaintiff Teodoso Serrano Moreno seeks judicial review of Defendant Social Security

Commissioner Michael J. Astrue’s determination that he is not entitled to Supplemental Security

Income disability benefits under Title XVI of the Social Security Act. Plaintiff has filed a Motion

for Summary Judgment [doc. 12] and Defendant has filed a Cross-Motion for Summary Judgment

[doc. 15]. Responses have also been filed. [Docs. 18 and 19.] For the reasons set forth below, the

Court recommends that Plaintiff’s motion be DENIED, that Defendant’s motion be GRANTED,

and that the ALJ’s decision be affirmed. 

///

///

///

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 1 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

2 08cv1022 

I. PROCEDURAL HISTORY 

Plaintiff applied for Title XVI Supplemental Security Income benefits on November 28,

2005, alleging an onset date of disability of October 1, 2005 due to mental illness. (A.R. 13.) The

claim was denied initially on March 28, 2006 and, upon reconsideration, on December 4, 2006. 

(A.R. 13.) Thereafter, Plaintiff filed a timely written request for hearing on December 28, 2006. 

(A.R. 13.) Plaintiff appeared and testified at a hearing held on April 24, 2007 in San Diego,

California before Administrative Law Judge (ALJ) Eve Godfrey. (A.R. 13.) Also appearing and

testifying were Sidney Bolter, M.D., an impartial medical expert; Mark Remas, an impartial

vocational expert; and Flerida Hernandez, the sister of the Plaintiff. 

After considering the evidence, Judge Godfrey concluded the following: 1) that there

was no evidence that Plaintiff has engaged in substantial gainful activity since November 28,

2005; 2) that Plaintiff had a severe impairment, psychosis; 3) that Plaintiff does not have an

impairment or combination of impairments that meets or medically equals one of the listed

impairments in 20 CFR Part 404, Subpart P, Appendix 1; 4) that Plaintiff has the residual

functional capacity to perform a full range of work at all exertional levels but is limited to simple

repetitive tasks involving minimum contact with others and public contact; 5) that Plaintiff is

unable to perform any past relevant work; 6) that Plaintiff was a younger individual age 18-49

under the rules; 7) that Plaintiff had a marginal education and is able to communicate in English;

8) that transferability of skills is not material to his case; 9) that there were jobs that existed in

significant numbers in the national economy that Plaintiff could perform; 10) that Plaintiff was not

living in the United States on the alleged onset date; and 11) that Plaintiff was not disabled within

the meaning of the Social Security Act during the petitioned period. (A.R. 13-23.) 

Plaintiff requested a review of the ALJ’s decision; the Appeals Counsel for the Social

Security Administration denied Plaintiff’s request for review on April 7, 2008. (A.R. 4-7.) 

Plaintiff reapplied for Social Security Income benefits on October 30, 2007, and his application

was approved on April 2, 2008. (Doc. 12-2, at 6-7.) Plaintiff commenced this action pursuant to

42 U.S.C. § 405(g) for a closed period of benefits not received between November 28, 2005 and

October 30, 2007. 

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 2 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

3 08cv1022 

II. ADMINISTRATIVE RECORD

A. Medical Evidence

1. Treating Physicians

The record indicates that Plaintiff sought medication and financial help at the South

Bay Guidance Center in November 2005. (A.R. 187-193.) The mental status exam showed that

Plaintiff was alert, clean, well-nourished, coherent but had pressured and slowed speech, agitated

behavior, flat affect, poor vocabulary, poor abstraction, poor recent memory, poor remote

memory, uncertain judgment, repetitive motions, and poor insight. (A.R. 191.) He also had

abused alcohol and cocaine recently. (A.R. 191.) He was diagnosed with a severe impairment of

psychosis, not otherwise specified, and alcohol dependence in sustained full remission. (A.R.

192.) He was referred to Dr. Bucardo for treatment. (A.R. 192.) 

On January 5, 2006, Dr. Bucardo, a psychiatrist, examined Plaintiff, noting that he was

attentive; spoke clearly; had good insight with a linear thought process; was intact with reality;

and had no hallucinations or delusions. (A.R. 186.) Plaintiff complained of agitation, insomnia,

palpitations, aggressive impulses, and depression. (A.R. 186.) Plaintiff had a global functioning

scale score of 55. (A.R. 186.) He was prescribed Haldol, Akineton, and Risperdal. (A.R. 187.) 

He was again seen by Dr. Bucardo on February 2, 2006. (A.R. 183.) Dr. Bucardo noted that

Plaintiff recently had visited a local hospital where a physician discontinued Plaintiff’s use of

Risperdal and gave him Ativan for anxiety. (A.R. 183; see A.R. 130-31.) Dr. Bucardo described

Plaintiff as follows: he was cooperative, in good spirits, and nervous; he had good eye contact and

speech; his thought process was linear; and he had no hallucinations or delusions. (A.R. 183.) Dr.

Bucardo ordered that Plaintiff discontinue using Risperdal; start using Seroquel; continue using

Haldol; start using Vistaril; increase the dosage of Akineton; and not use Ativan. (A.R. 183.) Dr.

Bucardo recommended against employment during the time of his medication switch to an

atypical antipsychotic. (A.R. 182.) Two days later, Plaintiff’s family brought him to the

Emergency Psychiatric Unit, where staff psychiatrist Mary Ann Renzi examined him. (A.R. 133-

135.) She noted that Plaintiff’s chief complaint was abdominal pain and that he sought Ativan, an

addictive substance that had been previously prescribed to him two weeks ago for a trial run but

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 3 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

4 08cv1022 

that Dr. Bucardo would not re-prescribe. (A.R. 133.) At one point, Dr. Renzi observed him

rolling on the floor demanding more Ativan, but could not give a psychiatric reason why he

should be given it. (A.R. 133.) Dr. Renzi also noted that although Plaintiff complained of

abdominal pain, he did not exhibit any actionable signs of pain when pressure was applied to his

abdomen. (A.R. 133.) Describing him as drug seeking, Dr. Renzi told Plaintiff that any changes

to his medical treatment would need to be through his outpatient psychiatrist. (A.R. 135.) 

On March 10, 2006, Dr. Bucardo again examined Plaintiff and noted that he did not

tolerate Seroquel and only occasionally took Vistaril and not at the prescribed dosage. (A.R. 181.) 

Plaintiff was prescribed Haldol, Akineton, and Vistaril to be taken in regular daily dosages. (A.R.

181.) Plaintiff was again seen for a scheduled follow-up on May 5, 2006. (A.R. 178.) Dr.

Bucardo noted that Plaintiff became depressed and distraught over the news that he was denied

Social Security Income benefits and that he sought crisis intervention by phone twice and during a

walk-in session once in April 2006. (A.R. 178.) Dr. Bucardo noted that Plaintiff had several

episodes with severe psychosis and social withdrawal. (A.R. 178.) Dr. Bucardo noted one

occasion where Plaintiff fled to the mountains of Mexico and his family had to search for him to

bring him back to civilization. (A.R. 178.) Dr. Bucardo altered Plaintiff’s prescription as follows:

he added Lexapro for Plaintiff’s depression, substituted the medication Artane for the Akineton,

and maintained the dosages of Haldol and Vistaril. (A.R. 178-79.) At a June 2006 checkup, Dr.

Bucardo noted that Plaintiff remained depressed and reclusive, and he increased the dosage of

Haldol and maintained the dosages of the other medications. (A.R. 175.) 

At the next scheduled follow-up on August 18, 2006, Plaintiff reported improvement in

mood and thought, was not reclusive or isolating, and denied paranoia or flashbacks. (A.R. 171.) 

His sister also reported noticeable improvement, but explained that he ate sparingly and has not

tended to his hygiene in the past two weeks. (A.R. 171.) Dr. Bucardo noted that Plaintiff was less

guarded but had poor eye contact, and his speech was soft with increased latency but clear and

coherent. (A.R. 171.) Dr. Bucardo increased the dosage of Haldol and maintained the dosages of

the other medications. (A.R. 171.) 

On December 4, 2006, Plaintiff sought treatment at the San Diego County Psychiatric

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 4 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

5 08cv1022 

Hospital for hearing voices. (A.R. 204.) The examining physician Dr. Conte noted found no

functional limitations from a psychiatric standpoint. (A.R. 204.) On December 8, 2006, Plaintiff

appeared for a checkup with Dr. Bucardo, who noted that Plaintiff had another exacerbation of

psychotic symptoms while on a trip to Sinaloa. (A.R. 212.) Plaintiff’s sister explained to Dr.

Bucardo that he was partially compliant with his medications, experienced anxiety, and was

unable to obtain/maintain employment. (A.R. 212.) Dr. Bucardo noted that Plaintiff was clear

and coherent, was less guarded, but said he suffered paranoid ideation and voices. (A.R. 212.) 

His prescription stayed the same. (A.R. 212.) At a follow-up in February 2007, Plaintiff’s sister

explained that he remained depressed and observed partial compliance with his medications. 

(A.R. 211.) Plaintiff tried to minimize his sister’s claims, stating that he feels normal but

admitting that he has good and bad days. (A.R. 211.) 

In March 2007, Dr. Bucardo examined Plaintiff for the purpose of filing out an INS

form and for welfare. (A.R. 208-10.) Dr. Bucardo noted that Plaintiff was unable to work, that

his disability was not permanent if Plaintiff followed the prescribed treatment, that Plaintiff was

able to care for himself and was cooperating with the medical treatment. (A.R. 210.) Several

weeks later, Dr. Bucardo gave Plaintiff the Folstein mini-mental status exam for INS reporting

purposes. (A.R. 208.) Dr. Bucardo concluded that Plaintiff’s symptoms (i.e. depression,

paranoia, and agitation), previous medical records, and the exam results showed that Plaintiff’s

impairment rendered him unable to learn in Spanish or in English. (A.R. 208.) Furthermore, on a

document titled “Psychiatric Review Form,” which appears to be signed by Dr. Bucardo on April

12, 2007 but has several indications of being a forged document fraudulently submitted as part of

the administrative record, Plaintiff’s diagnosis was listed as schizophrenia, paranoid type, his

highest global assessment of functioning was 37, and he would experience four or more repeated

episodes of decompensation, each of extended duration. (A.R. 215-18.) 

2. Evaluating Physicians for Benefits Purposes

a. Dr. Rodriguez’s Psychiatric Consultative Evaluation

Dr. Romualdo Rodriguez performed a complete psychiatric evaluation of Plaintiff on

March 12, 2006 at the request of the Department of Social Security. (A.R. 146.) Dr. Rodriguez

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 5 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

6 08cv1022 

noted that Plaintiff “was probably using” Haldol and Vistaril regularly but not Ativan. (A.R. 147.) 

Plaintiff reported that he has been having a problem with hearing voices since the age of 26, but

he “constantly stayed vague and nonspecific and was noncommittal.” (A.R. 146-48.) Dr.

Rodriguez noted that Plaintiff made good eye contact and had “good interpersonal contact.” (A.R.

149.) Plaintiff explained that he last worked four years ago as a dishwasher and stopped working

because “I felt bad.” (A.R. 151.) Since then, Plaintiff helped his sister in the kitchen, ran errands,

and helped with the gardening. (A.R. 151.) Dr. Rodriguez found “no impressive abnormalities on

mental status examination.” (A.R. 151.) Dr. Rodriguez determined that Plaintiff was basically

stable, had no functional limitations from a psychiatric standpoint, and was “probably capable of

independently managing funds in an appropriate manner.” (A.R. 152.) 

b. Non-examining Consultants for Social Security

Non-examining Social Security Administration consultants Dr. Robert Paxton concluded that Plaintiff had no medically determinable impairment. (A.R. 153-168.) The opinion

was based on one-time consultative examination of non-treating physician Dr. Romualdo

Rodriguez. 

3. Function Reports

A. Reports by Plaintiff’s Sister

Flerida Hernandez, Plaintiff’s sister, provided written statements set forth in three thirdparty function reports solicited by the Social Security Administration. (A.R. 71-91.) On

December 19, 2005, she wrote that Plaintiff used to be an active person a year ago but he now 

slept during the day, avoided social contact with others, and had no desire to work or care for his

family. (A.R. 71-78.) On June 6, 2006, she noted that Plaintiff felt like dying. (A.R. 85.)

B. Plaintiff’s Report

On December 19, 2005, Plaintiff submitted a form describing his day-to-day habits and

feelings. (A.R. 87-94.) He wrote that he sits and watches television most of the day, that he is

depressed, and that he sleeps over 14 hours. (A.R. 87-94.) 

B. Administrative Hearing

1. Plaintiff’s Testimony

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 6 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

7 08cv1022 

 Before Judge Godfrey, Plaintiff testified regarding his medical condition and

consequent limitations. (A.R. 229-237; 243-47; 249.) Plaintiff testified that he was unable to

work because he hears voices and was paranoid. (A.R. 229-30.) He explained that the voices

would tell him to kill himself and that he was worthless. (A.R. 230.) He also testified, “[W]hen I

go on the street, I feel everybody’s looking at me, that somebody, that everybody wants to harm

me.” (A.R. 229.) Plaintiff testified that he spends the majority of his time inside. (A.R. 229.) He

testified that he separated from his wife and kids, who are living in Mexico, because of his illness. 

(A.R. 231-32.) He was attempting to obtain U.S. citizenship for himself and his wife and

children, and he hired an attorney to do so. (A.R. 236-39.) Plaintiff spent most of time period

under his sister’s care; she would apportion out his medication daily and feed him once a day. 

(A.R. 245.) He testified that he would kill himself if he had to live on his own and care for

himself. (A.R. 244.) 

2. Plaintiff’s Sister’s Testimony

Flerida Hernandez, sister and cohabitant of Plaintiff, also testified at the April 2007

hearing. (A.R. 237-243.) Ms. Hernandez testified that Plaintiff sometimes would lock himself in

his room, would be afraid to come out, would sleep during the day, would barely eat, would have

to be told to clean himself or do his chores, and was only partially compliant with his doctor’s

prescriptions. (A.R. 242-43.) Ms. Hernandez also explained that Plaintiff went over to Mexico by

himself back in 2006. (A.R. 240.) When he was there, he overdosed on his medication and went

to an emergency room to see his physician in Mexico. (A.R. 240.) The Mexican doctor told him

he had to take the medication that was prescribed to him in Mexico and not the ones he was

prescribed in the United States. (A.R. 240.) Plaintiff’s sister explained that when he returned to

the United States, she took him to the psychiatrist, who advised Plaintiff not to go to Mexico in

the future and revised the prescription for his psychosis. (A.R. 240.) She also testified that she

tried to assist her brother’s wife and kids to come to the United States to care for Plaintiff, to no

avail. (A.R. 238-39.)

3. Medical Expert’s Testimony

 At the hearing, medical expert Sidney Bolter, M.D., noted the inconsistencies present in

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 7 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

8 08cv1022 

the psychiatric review form signed by Dr. Bucardo and speculated that at least some parts of the

document were forged. (A.R. 250-51.) Dr. Bolter pointed out many of the symptoms noted on the

form, including a diagnosis of schizophrenia, did not match up with Plaintiff’s symptoms as

described in previous medical records. (A.R. 252.) He noted that on February 9, 2007, Plaintiff

said he felt normal, had no symptoms of paranoia, and minimized his sister’s claims, but later said

that he had good and bad days, with occasional auditory hallucinations and paranoid ideation. 

(A.R. 252-53.) He pointed out the partial compliance with the treatment medication as well as his

drug seeking behavior, particularly with the addictive drug Ativan. (A.R. 255-57, 263-65.) Dr.

Bolter acknowledged that Plaintiff has some psychotic symptoms, but believed that he would be

considerably better if he fully complied with his medications. (A.R. 257-59.) Although Dr.

Bolter said that his social functioning was markedly impaired, he concluded that he could work

with minimal contact with peers and supervisors. (A.R. 259-60.) He testified, “I don’t think that

he just always locks himself in his room. There’s something wrong with that whole story. The

concentration, persistence, and pace would be mild for very simple, repetitive tasks.” (A.R. 260.) 

He speculated that he would have minimal (one to two) episodes of decompensation. (A.R. 262.) 

4. Vocational Expert’s Testimony

Mark Remas appeared and testified as a vocational expert (VE) at the hearing. (A.R.

273-77.) He responded to four hypothetical questions. First, the VE testified that an individual

limited to non-public simple, repetitive, unskilled tasks would be able to do work as a hand

packager, laundry folder, or harvest worker, but not a gardener. (A.R. 274.) Second, the VE

testified that Plaintiff would not be able to sustain work if he were to miss more than three days

per month. (A.R. 276.) Third, the VE testified that if Plaintiff had to lay down for five hours

during the day, he could not sustain work. (A.R. 276.) Fourth, he opined that if Plaintiff were to

miss one, two-week, unscheduled period of work without notice, he would most likely be

terminated. (A.R. 277.) 

III. THE ALJ DECISION 

 A hearing before ALJ Godfrey was conducted on April 24, 2007. (A.R. 13.) Plaintiff,

his sister Flerida Hernandez, medical expert Dr. Sidney Bolter, and vocational expert Mark Remas

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 8 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

9 08cv1022 

each made an appearance and testified. (A.R. 13-23.) After considering the record, the ALJ

found that Plaintiff had the severe impairment of psychosis, not otherwise specified, but that it did

not meet or equal the severity of any impairment listed at 20 CFR Part 404, Subpart P, Appendix 1

(20 CFR 416.920(d), 416.925, 416.926). (A.R. 15-16.) The ALJ found that in activities of daily

living Plaintiff had moderate restriction; in social functioning Plaintiff had marked difficulties;

with regard to concentration, persistence, or pace, the claimant had mild difficulties; and as for

episodes of decompensation, Plaintiff had experienced one or two episodes of decompensation

and not repeated episodes as defined in the Social Security regulations. (A.R. 15-16.) 

The ALJ noted Plaintiff’s sister testimony that Plaintiff was only partially compliant

with his medication, was isolating himself, had been unable to obtain a job, and was paranoid. 

(A.R. 21.) The ALJ found that Plaintiff’s beliefs regarding his limitations were not totally

credible because of his drug-seeking behavior, noncompliance with medication and treatment

regimens, conflicting and inconsistent testimonies, inconsistent presentations on psychiatric

examinations, and motivation to obtain United States citizenship for himself and his wife and

children. (A.R. 17-22.) For these same reasons, the ALJ disregarded results from a mini-mental

status exam performed on March 22, 2007 as well as a psychiatric review form dated April 12,

2007, which showed that Plaintiff had schizophrenia, had a global functioning score of 37, and

would experience four or more episodes of decompensation, each of extended duration. (A.R.

21.) Additionally, the ALJ noted that at least a portion of the psychiatric review form was forged. 

(A.R. 21.)

Based on the testimony of the medical expert Dr. Bolter and the vocational expert Mark

Remas, the ALJ concluded that Plaintiff had the residual functional capacity to perform a full

range of work at all exertional levels but would be limited to simple repetitive tasks involving

minimum contact with others and no public contact. (A.R. 16.) Considering the claimant’s age,

education, work experience, and residual functional capacity, the ALJ determined that there were

jobs that existed in significant numbers in the national economy that Plaintiff could perform. 

(A.R. 22-23.) Thus, Plaintiff had not been under a disability, as defined in the Social Security

Act, between November 28, 2005 and October 30, 2007. (A.R. 23.) 

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 9 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

10 08cv1022 

///

IV. STANDARD OF REVIEW

To qualify for disability benefits under the Social Security Act, an applicant must show

that: (1) He suffers from a medically determinable impairment that can be expected to result in

death or that has lasted or can be expected to last for a continuous period of twelve months or

more, 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 2004). An applicant must meet both

requirements to be “disabled.” Id.

A. Sequential Evaluation of Impairments

The Social Security Regulations outline a five-step process to determine whether an

applicant is “disabled.” The five steps are as follows: (1) Whether the claimant is presently

working in any substantial gainful activity. If so, the claimant is not disabled. If not, the

evaluation proceeds to step two. (2) Whether the claimant’s impairment is severe. If not, the

claimant is not disabled. If so, the evaluation proceeds to step three. (3) Whether the impairment

meets or equals a specific impairment listed in the Listing of Impairments. If so, the claimant is

disabled. If not, the evaluation proceeds to step four. (4) Whether the claimant is able to do any

work she has done in the past. If so, the claimant is not disabled. If not, the evaluation proceeds

to step five. (5) Whether the claimant is able to do any other work. If not, the claimant is

disabled. Conversely, if the Commissioner can establish there are significant number of jobs in

the national economy that the claimant can do, the claimant is not disabled. 20 CFR § 404.1520;

see also Tackett v. Apfel, 180 F.3d 1094, 1098-99 (9th Cir. 1999). 

B. Judicial Review

Sections 206(g) and 1631(c)(3) of the Social Security Act allow unsuccessful applicants

to seek judicial review of the Commissioner’s final agency decision. 42 U.S.C.A. §§ 405(g),

1383(c)(3). The scope of judicial review is limited. The Commissioner’s final decision should

not be disturbed unless: (1) the ALJ’s findings are based on legal error or (2) are not supported by

substantial evidence in the record as a whole. Schneider v. Comm’r of Soc. Sec. Admin., 223

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 10 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

11 08cv1022 

F.3d 968, 973 (9th Cir. 2000). Substantial evidence means “more than a mere scintilla but less

than a preponderance; it is such relevant evidence as a reasonable mind might accept as adequate

to support a conclusion.” Andrews v. Shalala, 53 F.3d 1035, 1039 (9th Cir. 1995). The Court

must consider the record as a whole, weighing both the evidence that supports and detracts from

the ALJ’s conclusion. See Mayes v. Massanari, 276 F.3d 453, 459 (9th Cir. 2001); Desrosiers v.

Sec’y of Health & Human Servs., 846 F.2d 573, 576 (9th Cir. 1988). “The ALJ is responsible for

determining credibility, resolving conflicts in medical testimony, and for resolving ambiguities.” 

Vasquez v. Astrue, 547 F.3d 1101, 1104 (9th Cir. 2008) (quoting Andrews, 53 F.3d at 1039). 

Where the evidence is susceptible to more than one rational interpretation, the ALJ’s decision

must be affirmed. Id. (citation and quotations omitted). 

Section 405(g) permits this Court to enter a judgment affirming, modifying, or

reversing the Commissioner’s decision. 42 U.S.C.A. § 405(g). This matter may also be remanded

to the Social Security Administration for further proceedings. Id. Furthermore, “[a] decision of

the ALJ will not be reversed for errors that are harmless.” Burch v. Barnhart, 400 F.3d 676, 679

(9th Cir. 2005). 

V. DISCUSSION

A. The ALJ Sufficiently Considered the Testimony of Plaintiff’s Sister

Plaintiff first contends that the ALJ committed legal error by not considering Flerida

Hernandez’s testimony concerning Plaintiff’s ability to work. (Doc. 12-2, at 15.) Ms. Hernandez

provided live testimony at the April 24, 2007 hearing and written statements set forth in two thirdparty function reports solicited by the Social Security Administration. (A.R. 71-91, 237-243.) 

Defendant argues that the ALJ did not ignore Ms. Hernandez’s testimony and written statements

but considered them for the limited probative value and addressed them adequately in her written

opinion. (Doc. 15-2, at 4.) 

“In determining whether a claimant is disabled, an ALJ must consider lay witness

testimony concerning a claimant’s ability to work.” Stout v. Comm’r of Soc. Sec. Admin., 454

F.3d 1050, 1053 (9th Cir. 2006). An ALJ must give reasons for discounting this type of evidence

and cannot disregard it without comment. Nguyen v. Chater, 100 F.3d 1462, 1467 (9th Cir. 1996). 

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 11 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

1 The Plaintiff argues in his response to the Motion for Summary Judgment (Doc. 19, at 2) that the ALJ should

 have recited specific reasons for finding this witness credible or not credible, but he fails to cite to a specific

 case where this can be construed as a legal error. Even if it were legal error to not make specific findings

 on credibility, the error would be harmless as the ALJ did accept at face value this witness’s testimony. 

12 08cv1022 

If the ALJ intends to disregard such testimony, then he must give reasons germane to each witness

for doing so. Lewis v. Apfel, 236 F.3d 503, 511 (9th Cir. 2001). “However, in interpreting the

evidence and developing the record, the ALJ does not need to “discuss every piece of evidence,”

only that which is significant and probative. Howard ex rel. Wolff v. Barnhart, 341 F.3d 1006,

1012 (9th Cir. 2003); see also Vincent v. Heckler, 739 F.2d 1393, 1394-95 (9th Cir. 1984). 

Here, Plaintiff’s sister, Ms. Hernandez, testified that Plaintiff would lock himself in his

room, was occasionally paranoid, would sleep during the day, would barely eat, would clean

himself or do his chores only when told, would overdose on certain medications, and was not fully

compliant in taking all of the medication prescribed. In her opinion, the ALJ did not refer to all of

the statements made by Ms. Hernandez but did consider those significant and probative: that

Plaintiff was only partially compliant with medication; that he isolated himself; that he was unable

to obtain a job; and that he was paranoid. (A.R. 21.) Although the ALJ did not question the

credibility of Ms. Hernandez’s statements,1 she did use evidence provided by Ms. Hernandez –

namely Plaintiff’s paranoia, his noncompliance with medication and treatment regimens, and his

inability to obtain a job – to bolster her finding that Plaintiff was not disabled because he could

have had the ability to work had he properly and consistently taken his medications. See Warre v.

Comm’r of Soc. Sec. Admin., 439 F.3d 1001, 1006 (9th Cir. 2006) (finding that impairments that

can be effectively controlled with medication are not disabling for purposes of determining

eligibility for Social Security benefits). Thus, the ALJ did not commit legal error as she properly

considered those statements made by Ms. Hernandez that were significant and probative to

deciding Plaintiff’s case. 

 B. The ALJ Sufficiently Considered the Medical and Vocational Experts’ Testimonies

Plaintiff next contends that the ALJ did not consider testimonies given by the vocational expert and the medical expert allegedly showing that Plaintiff is disabled because he is

unable to work on a sustained basis due to future episodes of decompensation lasting two weeks

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 12 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

2 The Social Security regulations define “episodes of decompensation” as follows: 

exacerbations or temporary increases in symptoms or signs accompanied by a loss of adaptive

functioning, as manifested by difficulties in performing activities of daily living, maintaining social

relationships, or maintaining concentration, persistence, or pace. Episodes of decompensation may

be demonstrated by an exacerbation in symptoms or signs that would ordinarily require increased

treatment or a less stressful situation (or a combination of the two). 

20 CFR 404, Subpt. P, App. 1.

13 08cv1022 

or more. (Doc. 12-2, at 18.) Defendants argue that the ALJ did not find that Plaintiff was likely

to experience episodes of decompensation in the future and did not have to accept the vocational

expert’s hypothetical testimony. (Doc. 15-2, at 5.)

To make his argument that he is disabled, Plaintiff relies on the testimony of the

medical expert Dr. Bolter, who testified that Plaintiff would experience one or two episodes of

decompensation (Doc. 12-2, at 18-19; see A.R. 262.) Plaintiff also relies on the testimony of the

vocational expert Mark Remas, who hypothesized that Plaintiff would be unable to retain a job if

he were to miss one two-week unscheduled period of work. (Doc. 12-2, at 18-19; see A.R. 277.) 

Plaintiff completes his argument that he is unable to work for a sustained period of time by

defining “episodes of decompensation” as lasting for “at least two weeks.” (Doc. 12-2, at 18.) 

However, according to the regulations, the time period of an episode of decompensation2 is not

defined; more specifically, they are of “temporary” duration that would require “increased

treatment or a less stressful situation (or a combination of the two).” 20 CFR 404, Subpt. P, App.

1. The regulations do define “repeated episodes of decompensation” as “three episodes within 1

year . . . each [episode] lasting for at least 2 weeks.” Id. But Plaintiff is not correct in saying that

Dr. Bolter testified that Plaintiff would experience one to two episodes of decompensation, each

lasting two weeks or more. The record shows that Dr. Bolter said that Plaintiff would experience

minimal decompensation, one to two episodes, but did not specify the length of time for each

episode. (A.R. 262.) Moreover, the record shows that the vocational expert only hypothesized

that if Plaintiff were absent from a job without notice for two weeks, he would most likely be

terminated for cause for failing to give notice. (A.R. 277.) Nowhere in the record does the

vocational expert testify that Plaintiff would experience repeated episodes of decompensation

lasting two weeks or more and thus would be unable to sustain a job. Thus, the Court finds that

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 13 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

14 08cv1022 

the ALJ was justified in concluding that Plaintiff would not suffer repeated episodes of

decompensation, properly considered the vocational and medical experts’ testimony, and did not

commit reversible legal error as Plaintiff alleges. 

C. The ALJ Provided Valid Reasons for Rejecting Treating Physician’s Opinion

Plaintiff next claims that the ALJ failed to provide specific and legitimate reasons based

on substantial evidence in the record for rejecting Dr. Bucardo’s opinions set forth on a minimental status exam performed on March 22, 2007 as well as a psychiatric review form dated April

12, 2007, which showed that Plaintiff had schizophrenia, a global functioning score of 37, and

would experience four or more repeated episodes of decompensation, each of extended duration. 

(Doc. 12-2, at 19-21.) Defendants contend that the ALJ properly rejected information contained

in forms signed by Dr. Bucardo because they were inconsistent with his treatment notes and other

medical evidence of record. (Doc. 18, at 6.) 

“Because treating physicians are employed to cure and thus have a greater opportunity

to know and observe the patient as an individual, their opinions are given greater weight than the

opinions of other physicians.” Smolen v. Chater, 80 F.3d 1273, 1285 (9th Cir. 1996). To reject a

treating physician’s opinion, an ALJ must make “‘specific, legitimate reasons for doing so that are

based on substantial evidence in the record.’” Id. (quoting Winans v. Bowen, 853 F.2d 643, 647

(9th Cir. 1987)). For example, an ALJ can disregard a treating physician’s diagnosis as untrustworthy when it was obtained for advocative purposes, when it varies from the treating physician’s

previous treatment notes, or when it is worded ambiguously in an apparent attempt to assist the

claimant in obtaining Social Security benefits. Saelee v. Chater, 94 F3.d 520, 522 (9th

Cir. 1996). 

Here, the ALJ did not outright reject the opinions of the treating physician Dr. Bucardo;

rather, the ALJ provided specific and legitimate reasons for disregarding opinions contained in

two forms supposedly filled out by Dr. Bucardo: the psychiatric review form dated April 12, 2007

and the results of the mental status examination dated March 22, 2007. (See A.R. 19-21.) 

First, the ALJ noted that pertinent progress notes dated March 22, 2007 reflected that

Plaintiff was given the mental status examination for the purpose of supportive documentation for

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 14 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

15 08cv1022 

immigration reporting and for applying for citizenship. (A.R. 21; see A.R. 208-10.) The ALJ was

justified in concluding that the results of the exam were untrustworthy because it was obtained for

advocative purposes. See Saelee, 94 F.3d at 522. 

Second, the ALJ noted that Dr. Bucardo’s treatment notes from January 5, 2006 through

March 15, 2007 provided little or no support for the opinions expressed in either the mental status

examination dated March 22, 2007 or the psychiatric review form dated April 12, 2007, which

concluded that Plaintiff had schizophrenia and had a global functioning score of 37. (A.R. 21.) 

For example, in January 2006 according to Dr. Bucardo, Plaintiff was intact with reality, had no

hallucinations or delusions, had a global functioning score of 55, and was given medication for a

psychosis not otherwise specified. (A.R. 186.) In February 2006, Plaintiff exhibited drug-seeking

behavior according to psychiatrist Dr. Renzi. (A.R. 135.) In August 2006, Plaintiff reported to

Dr. Bucardo improvement in mood and thought, was not reclusive or isolating, and denied

paranoia or flashbacks. (A.R. 171.) Dr. Bucardo noted that Plaintiff was less guarded but had

poor eye contact, and his speech was soft with increased latency but clear and coherent. (A.R.

171.) In December 2006, after taking a trip to Sinaloa where his medications were altered by a

Mexican doctor, Plaintiff started hearing voices; however, Dr. Conte, the examining physician at

the psychiatric hospital in San Diego, found no functional limitations from a psychiatric standpoint. (A.R. 204.) That same month, Dr. Bucardo noted that Plaintiff was not fully complying

with the treatment prescribed by him and told him to take the medications prescribed by him

regularly. (A.R. 212.) At a follow-up in February 2007, Plaintiff’s sister explained that he

remained depressed and observed partial compliance with his medications. (A.R. 211.) Plaintiff

tried to minimize his sister’s claims, stating that he feels normal but admitting that he has good

and bad days. (A.R. 211.) On March 15, 2007, Dr. Bucardo wrote that Plaintiff’s disability was

not permanent and that he may recover his ability to participate in vocational rehabilitation. (A.R.

210.) As concluded by the ALJ, all these statements did not comport with the diagnosis of

schizophrenia and the low global functioning score that appeared for the first time in the psychiatric review form and the mini-mental status examination results in the spring of 2007. 

Third, the ALJ noted that it was questionable whether the psychiatric review form was

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 15 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28 3 Upon reviewing the form, the undersigned believes that the psychiatric review form is a fraudulent 

 document. It does not appear to be signed and dated by Dr. Bucardo, and there are multiple different 

 handwritings on the document.

16 08cv1022 

actually signed by Dr. Bucardo and that few of the comments on the form were made by him.3

(A.R. 21.) The ambiguity and indications of fraud evidenced in the document were another

legitimate reason for the ALJ to reject it outright. 

In sum, the ALJ properly rejected a portion of Dr. Bucardo’s opinion with specific and

legitimate reasons for doing so based on substantial evidence in the record. 

D. The ALJ’s Decision Is Supported by Substantial Evidence

Plaintiff finally argues that the ALJ’s decision is not supported by substantial evidence

because it ignores the treating physician’s opinion, competent lay testimony, and probative

vocational expert testimony. (Doc. 12-2, at 23.) Plaintiff contends that the ALJ instead adopted

the opinion of the medical expert Dr. Bolter without considering pertinent evidence in the record. 

(Id.) Defendant argues that the ALJ properly adopted the opinion of Dr. Bolter and made her

conclusions based on substantial evidence in the record. (Doc. 18, at 7.)

The Court finds that the ALJ properly relied on the testimony of Dr. Bolter, who

testified that Plaintiff was mentally capable of performing simple repetitive tasks with no public

contact and minimal contact with other workers and could function even better than that if he

properly took his medications. (A.R. 18, 260.) As shown above, the Court finds that the ALJ

properly considered and used the testimony of Plaintiff’s sister Flerida Hernandez; sufficiently

considered the testimonies of the medical and vocational experts; provided valid reasons for

rejecting a portion of Dr. Bucardo’s opinions; and made her ultimate conclusion that Plaintiff was

not disabled under the Social Security Act based on substantial evidence in the record. 

VI. CONCLUSION

For the reasons set forth above, Plaintiff’s Motion for Summary Judgment should be

DENIED, Defendant’s Cross-Motion for Summary Judgment should be GRANTED, and the

decision of the ALJ should be affirmed. 

This report and recommendation is submitted to the Honorable William Q. Hayes, the

United States District Judge assigned to the case, pursuant to 28 U.S.C. § 636(b)(1). Any party

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 16 of 17
 1

 2

 3

 4

 5

 6

 7

 8

 9

 10

 11

 12

 13

 14

 15

 16

 17

18

19

20

21

22

23

24

25

26

27

28

17 08cv1022 

may file written objections with the Court and serve a copy on all parties on or before April 17,

2009. The document should be captioned “Objections to Report and Recommendation.” Any

reply to the Objections shall be served and filed on or before April 27, 2009. The parties are

advised that failure to file objections within the specific time may waive the right to appeal the

district court’s order. Martinez v. Ylst, 951 F.2d 1153 (9th Cir. 1991).

IT IS SO ORDERED.

DATED: March 26, 2009

Peter C. Lewis

U.S. Magistrate Judge

United States District Court

cc: District Judge Hayes; all parties and counsel of record

Case 3:08-cv-01022-WQH-PCL Document 21 Filed 03/26/09 Page 17 of 17