Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-01048/USCOURTS-casd-3_16-cv-01048-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:0405id Review of HHS Decision (SSID)

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

INDIA VIOLA BAKER,

Plaintiff,

v.

CAROLYN W. COLVIN, Acting 

Commissioner Of Social Security,

Defendant.

Case No.: 16-cv-01048-CAB (JMA)

REPORT AND 

RECOMMENDATION OF 

UNITED STATES MAGISTRATE 

JUDGE

Plaintiff India Viola Baker (“Plaintiff”) seeks judicial review of Defendant 

Social Security Acting Commissioner Carolyn W. Colvin’s (“Defendant”) 

determination that she is not entitled to supplemental security income (“SSI”) 

benefits. The parties have filed cross-motions for summary judgment. For the 

reasons set forth below, the Court recommends Plaintiff’s motion for summary 

judgment be DENIED and Defendant’s cross-motion for summary judgment be 

GRANTED.

I. BACKGROUND

Plaintiff, who was born on August 21, 1990, was twenty-one years old

when she filed her applications for benefits. (Admin. R. at 211.) She did not 

complete high school, but obtained a General Educational Development (“GED”) 

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degree. (Id. at 83.) She has held a few part-time jobs, each lasting for only a 

short period of time. (Id. at 80-82.) In an application for SSI protectively filed on 

May 25, 2012, Plaintiff alleged a disability onset date of May 25, 2012. (Id. at 

211.) Plaintiff’s application was denied initially on September 6, 2012, and upon 

reconsideration on December 6, 2012. (Id. at 113-123, 124-134.) On December 

30, 2012, Plaintiff requested an administrative hearing. (Id. at 148-150.) A 

hearing was conducted on July 8, 2014 by Administrative Law Judge (“ALJ”) 

Robert Iafe, who determined on September 26, 2014 that Plaintiff was not 

disabled. (Id. at 37-44.) Plaintiff requested a review of the ALJ’s decision (Id. at 

26). The Appeals Council for the Social Security Administration (“SSA”) denied 

Plaintiff’s request for review on March 1, 2016. (Id. at 1-4.) Plaintiff then 

commenced this action pursuant to 42 U.S.C. § 405(g). 

II. MEDICAL EVIDENCE

A. Seagate Medical Group (2011)

On November 15, 2011, Dr. Gregory Nicholson performed a 

Comprehensive Psychiatric Evaluation of Plaintiff at the request of the 

Department of Social Security. (Id. at 330.) Dr. Nicholson reviewed Social 

Security Disability Report Form SSA-3368 and conducted a mental status 

examination. (Id.) Plaintiff reported she was bothered by hearing voices 

speaking when there was no one there, although she could not remember what 

the voices said. (Id. at 330-31.) She also reported feeling paranoid and fearful

that someone would harm her. (Id. at 331.) Plaintiff informed Dr. Nicholson that 

she experienced insomnia, decreased appetite, trouble concentrating, and 

decreased interest in normal activities. (Id.) She told him she stopped working 

as a cashier due to shortness of breath. (Id. at 331-32.) Plaintiff also reported 

feeling suicidal in the past and said she had attempted suicide multiple times. 

(Id. at 331.) Plaintiff denied any history or symptoms related to mania or anxiety 

disorders, or any history of psychiatric hospitalizations. (Id.) Plaintiff was not 

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seeing a psychiatrist at the time of the evaluation. (Id.)

Plaintiff reported she dropped out of school in the 12th grade. (Id.) She 

denied any history of street drug use, problems related to drinking, or legal 

history. (Id. at 331-32.) Plaintiff also stated she did not have her own place to 

live and “stay[s] with anybody who will let [her].” (Id. at 332.) She indicated she 

did not cook and other people gave her food, but stated she did her own laundry, 

and had no difficulty with dressing, bathing, or hygiene. (Id.) She also indicated 

she did not drive because she did not have a license. (Id.) She stated she could

handle cash and get out on her own. (Id.) 

Dr. Nicholson’s mental status examination consisted of observations in 

several different categories. Dr. Nicholson first reported on Plaintiff’s 

appearance, attitude and behavior, noting Plaintiff arrived neatly and casually 

groomed. (Id.) Plaintiff made good eye contact and good interpersonal contact 

and was generally cooperative. (Id.) Plaintiff volunteered information 

spontaneously with no psychomotor agitation or retardation. (Id.) Plaintiff 

appeared to be genuine and truthful and there was no evidence of exaggeration 

or manipulation. (Id.) Dr. Nicholson also noted that Plaintiff did not appear to be 

under the influence of drugs or alcohol. (Id.)

Dr. Nicholson found Plaintiff’s thought processes to be coherent and 

organized. (Id.) He remarked there was no tangentially or loosening of 

associations. (Id.) Plaintiff reported hallucinations and paranoia related to her

thought content. (Id.) She denied plans to harm herself or others and did not 

appear to be responding to internal stimuli. (Id. at 332-33.) Plaintiff’s mood was 

depressed and her affect was dysphoric, which Dr. Nicholson noted was 

appropriate and congruent with her thought content. (Id. at 333.) Plaintiff was 

not tearful. (Id.)

Dr. Nicholson found Plaintiff’s speech to be normal and clearly articulated. 

(Id.) He did not observe stammering, dysarthria, neologisms, tangentiality, 

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circumstantiality, or loosened, unusual or blocked associations. (Id.)

Dr. Nicholson reported Plaintiff’s intellectual functioning was alert and 

oriented to time, place, person, and purpose. (Id.) Plaintiff appeared to Dr. 

Nicholson to be of average intelligence. (Id.)

Dr. Nicholson tested Plaintiff’s memory and reported she was able to recall 

three items immediately, two out of three items after five minutes, and three out 

of three items with hints. (Id.) He administered a digit span test of six forward 

and three backward. (Id.) Dr. Nicholson noted Plaintiff’s fund of knowledge was 

grossly intact and her insight and judgment appeared to be grossly intact. (Id.) 

Plaintiff was also asked to spell “world” to which she responded she had trouble 

with spelling. (Id.) She was able to perform a serial threes test and correctly 

stated 80 cents would be received from a dollar if two oranges were bought at 10 

cents each. (Id.)

Dr. Nicholson’s diagnostic impression consisted of the following:

AXIS I: 1. Psychotic Disorder, not otherwise specified.

2. Depressive Disorder, not otherwise specified.

AXIS II: No diagnosis

AXIS III: Deferred to the appropriate specialist.

AXIS IV: Psychosocial stressors during the past year: Financial stress.

AXIS V: Current GAF: 551

(Id. at 334.)

 

1 The Global Assessment of Functioning scale, or GAF scale, is a numeric scale (0 through 

100) used by mental health practitioners to rate social, occupational, and psychological 

functioning, with lower numbers representing more severe symptoms, difficulties, or 

impairments. The scale is presented in the Diagnostic and Statistical Manual of Mental 

Disorders. A GAF score between 51 and 60 suggests moderate symptoms (e.g., flat affect 

and circumlocutory speech, occasional panic attacks) or moderate difficulty in social, 

occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). 

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth 

Edition Text Revision (2013).

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Dr. Nicholson reported his diagnosis of psychotic disorder was based on 

Plaintiff’s history of hallucinations and paranoia. (Id.) The depressive disorder 

diagnosis was based on Plaintiff’s history of depressed mood, dysphoric affect 

and neurovegetative symptoms of depression. (Id.) Dr. Nicholson opined 

Plaintiff’s condition was expected to improve in the next twelve months with 

active treatment. (Id.) 

Dr. Nicholson’s functional assessment of Plaintiff included the following:

1. Plaintiff is able to understand, remember, and carry out simple one or 

two-step job instructions.

2. Plaintiff is able to do detailed and complex instructions.

3. Plaintiff’s ability to relate and interact with coworkers and the public is 

mildly limited.

4. Plaintiff’s ability to maintain concentration and attention, persistence 

and pace is mildly limited.

5. Plaintiff’s ability to accept instructions from supervisors is not limited.

6. Plaintiff’s ability to maintain regular attendance in the work place and 

perform work activities on a consistent basis is mildly limited.

7. Plaintiff’s ability to perform work activities without special or additional 

supervision is not limited.

(Id. at 334-335.) Dr. Nicholson also reported Plaintiff was capable of handling 

funds. (Id. at 335.)

B. Seagate Medical Group (2012)

On June 29, 2012, Plaintiff met with Dr. Douglas R. Dolnak, who performed 

a Comprehensive Psychiatric Evaluation at the request of the Department of 

Social Security. (Id. at 363-368.) Dr. Dolnak also reviewed Social Security 

Disability Report Form SSA-3368. (Id. at 363.) 

/ /

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Dr. Dolnak reported Plaintiff appeared to be a reliable historian. (Id.) 

Plaintiff informed him she applied for disability because of her chronic worry and 

anxiety about finances, health, future and being homeless. (Id.) Plaintiff also 

reported daily worry and frustration about her health and a history of irregular 

heavy vaginal bleeding. (Id.) Plaintiff indicated she experienced daytime fatigue, 

low energy, occasional insomnia and restless sleep. (Id.) 

Dr. Dolnak’s mental examination consisted of his observations in several 

different categories. He first reported on Plaintiff’s appearance, attitude and 

behavior, noting Plaintiff arrived on time, casually dressed and in no acute 

distress. (Id. at 365.) She ambulated well, sat in the chair comfortably, and was 

pleasant, cooperative, and not agitated. (Id.) Dr. Dolnak noted her mood was 

dysphoric with mild anxiety. (Id.) Her affect was constricted, not labile. (Id.)

Dr. Dolnak also reported Plaintiff’s thought content and processes were 

clear and goal directed. (Id.) Dr. Dolnak reported feelings of helplessness and 

frustration colored the interview. (Id.) Plaintiff reported nightmares and 

occasional flashbacks related to prior trauma with occasional anticipatory 

anxiety. (Id.) Plaintiff also reported she was easily startled. (Id.) Plaintiff denied 

suicidal ideation with plan or intent, but did report homicidal ideation with plan or 

intent. (Id.) Plaintiff reported occasional difficulties with attention and 

concentration: she stated she gets distracted, forgets things around the house, 

and misplaces objects. (Id.) Plaintiff reported her difficulties affected her two to 

three days out of the week. (Id.) Plaintiff denied other severe symptoms for 

mania, bipolar disorder or psychosis. (Id.) Dr. Dolnak reported Plaintiff did not 

seem to be internally preoccupied. (Id.)

Dr. Dolnak reported Plaintiff was alert and oriented to person, place, and 

time; she did not know the date, but knew the month and year. (Id. at 366.) Dr. 

Dolnak performed memory and cognition tests. (Id.) Plaintiff could recall three 

items immediately, and two out of three items after five minutes. (Id.) Plaintiff 

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was able to perform serial sevens and serial twos from twenty to ten. (Id.) 

Plaintiff could spell “world” forward but not backward. (Id.) Plaintiff could do 

three digits backward and three digits forwards. (Id.) Dr. Dolnak reported

Plaintiff demonstrated mild difficulty with attention and concentration during the 

interview. (Id.) 

Plaintiff was able to state similarities between an apple and an orange and 

between a coat and a shirt. (Id.) Plaintiff was not able to interpret the proverb, 

“as plain as the nose on your face”. (Id.) Dr. Dolnak reported Plaintiff’s insight 

and judgment appeared fair regarding the current situation. (Id.)

Dr. Dolnak’s diagnostic impression consisted of the following:

AXIS I: 1. Depressive Disorder, not otherwise specified.

2. Post-Traumatic Stress Disorder.

AXIS II: None.

AXIS III: History of dysfunction vaginal bleeding.

AXIS IV: Psychosocial stressors during the past year: Mild (chronic 

enduring circumstances), limited psychosocial support system 

and financial difficulty.

AXIS V: Current GAF: 60

(Id. at 366.)

Dr. Dolnak opined Plaintiff’s prognosis was treatable and the likelihood of 

recovery was fair. (Id. at 367.) He further opined Plaintiff’s condition could

improve over the next twelve to twenty-four months with adequate medical care 

and follow-up, enhanced psychosocial support and entrance into vocational 

rehabilitation programs. (Id.)

Dr. Dolnak’s functional assessment of Plaintiff included the following:

1. Plaintiff was able to understand, remember, and carry out simple one 

or two-step job instructions.

2. Plaintiff would have mild difficulty with detailed and complex 

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instructions secondary to mild difficulty with attention and 

concentration related to depression and anxiety.

3. Plaintiff was able to relate and interact with coworkers and the public.

4. Plaintiff would have some mild difficulty in her ability to maintain 

concentration and attention, persistence and pace.

5. Plaintiff was able to associate with day-to-day work activity, including 

attendance and safety.

6. Plaintiff was able to accept instructions from supervisors.

7. Plaintiff would have some difficulty in being able to perform work 

activities without special or additional supervision regarding 

occasional anxiety and depression related to prior history of trauma 

and difficulties with attention and concentration related to anxiety that 

would affect her ability to perform work activities on a very consistent 

basis.

8. Plaintiff was able to maintain regular attendance in the work place 

and complete a normal work day routine without any interruptions 

from any major psychiatric disorder at this time.

(Id. at 367.) Dr. Dolnak also reported Plaintiff was capable of handling funds. 

(Id.)

C. UCSD Health System (2013)

On May 25, 2013 Plaintiff presented to UC San Diego Health System, 

Hillcrest Emergency for back pain after being hit in the back with a door at work. 

(Id. at 413, 419.) Dr. Lucia Modesti noted Plaintiff was dramatic during the 

interview, “often deranging from the answer,” and made angry statements. (Id. at 

421.) Dr. Modesti also noted Plaintiff could be redirected, but acted annoyed and 

had a demanding attitude. (Id.) Dr. Modesti further noted Plaintiff refused to see 

her after the initial evaluation and exam. (Id. at 422.)

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D. Areta Crowell BPSR Center (2013)

On November 21, 2013, Plaintiff was assessed and admitted to the Areta 

Crowell BPSR Center. (Id. at 438.) At the time Plaintiff was admitted she was

diagnosed with Major Depressive Disorder, Recurrent, Severe without Psychotic 

Features and Posttraumatic Stress Disorder. (Id.) Plaintiff was prescribed

Remeron and Vistaril and was referred to community mental health outpatient 

services for follow-up. (Id. at 441.)

a. December 2013

On December 3, 2013, Plaintiff presented to Dr. John Sullivan for

medication management. (Id. at 457.) Plaintiff arrived in a good mood and was 

cooperative. (Id.) Dr. Sullivan reported Plaintiff described a history of sexual, 

physical, and emotional abuse and trauma which had affected her negatively in 

several aspects of her life, including her memory, mood, concentration, and 

sleep. (Id. at 455.)

Dr. Sullivan also reported Plaintiff described a history of substance abuse, 

but that she had been sober for the past year. (Id.) She denied a past history of 

mania or hypomania, and psychiatric admissions. (Id.) Plaintiff described one 

suicidal overdose on Vicodin in September 2013, but denied suicidal ideation 

since. (Id.) Plaintiff described a history of hearing voices when depressed or 

stressed, which had caused her to instigate fights when the voices told her to 

protect herself. (Id.) She reported the voices had not commanded her to harm 

herself. (Id.)

Dr. Sullivan’s mental status exam noted Plaintiff was irritable and guarded, 

had an “irritated” mood, constricted affect, and linear thoughts, with denials of 

suicidal or homicidal ideation, or auditory or visual hallucinations. (Id.) Dr. 

Sullivan noted risk of suicide was low as Plaintiff was future-oriented and

motivated to improve her mental health. Dr. Sullivan advised Plaintiff to continue 

Remeron and Vistarol and also prescribed Abilify. (Id. at 456.)

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b. March 2014

On March 3, 2014, Plaintiff returned to Dr. Sullivan for medication 

management. (Id. at 466.) Dr. Sullivan reported Plaintiff discussed spending

more time thinking about her trauma, which became worse with triggers. (Id. at 

464.) Plaintiff also described poor concentration, sad mood, feelings of being 

watched, and visual hallucinations of shadows in her room. (Id.)

Dr. Sullivan’s report regarding Plaintiff’s history mirrors his December 2013 

report summarized above. Dr. Sullivan’s mental status exam observations were

similar to the December report and indicated Plaintiff was guarded and anxious

with a constricted affect and linear thoughts, and she denied any suicidal or 

homicidal ideations or auditory and visual hallucinations. (Id.) Dr. Sullivan also 

noted paranoia. (Id.) Dr. Sullivan advised Plaintiff to continue taking Abilify, 

Remeron and Vistaril and prescribed Zoloft. (Id. at 465.)

The same day, and at Dr. Sullivan’s request, Plaintiff was also seen by

therapist Matthew Holley. (Id. at 467.) Mr. Holley observed Plaintiff to be

somewhat disheveled, slumped in the chair, and at times was minimally verbal 

with little eye contact. (Id.) He reported the therapeutic intervention consisted of 

empathetic and reflective listening, assessment for safety, and assistance with 

identifying steps to reduce stressors. (Id.) Plaintiff informed Mr. Holley she was

feeling stressed about housing and not being able to find a job, and said she

wanted to find both a job and apartment. (Id.) She said she had experienced

suicidal ideation, but denied plan or intent. (Id.) She stated she spent a lot of 

time in bed, had low motivation, and was worried about her future, but was taking 

her medications. (Id.) 

On March 5, 2014, Plaintiff returned to Mr. Holley for follow-up. (Id. at 469.) 

Mr. Holley reported Plaintiff was well-groomed and had a depressed mood and 

blunted affect. (Id.) Plaintiff reported she had been up since five o’clock in the 

morning and was “done with sleep” because she had slept a lot over the past few 

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days. (Id.) Mr. Holley also reported Plaintiff seemed suddenly motivated to apply 

to several jobs. (Id.) Plaintiff was focused on problem-solving her upcoming 

need for housing and verbalized many ideas. (Id.) Mr. Holley’s therapeutic 

intervention consisted of exploring Plaintiff’s previous homicidal ideations and 

assessed current risk. (Id.) Mr. Holley also assisted Plaintiff with identifying next 

steps towards finding a job and re-framing stressors as goals, and gave her 

positive feedback regarding her focus on problem-solving. (Id.) 

c. April 2014

On April 1, 2014, Plaintiff returned to Dr. Sullivan for medication 

management. (Id. at 473-475.) Dr. Sullivan reported Plaintiff had a history of 

bipolar with psychotic features and post-traumatic stress disorder. (Id. at 473.) 

Plaintiff described experiencing: oversleeping, social isolation, nightmares, poor 

concentration, periods of mania with increased energy, decreased need for 

sleep, racing thoughts, impulsivity, and going many days without sleeping. (Id.) 

Dr. Sullivan’s report also included the same history notes as the December and 

March reports described above. (Id.)

Dr. Sullivan indicated Plaintiff had a guarded “up and down” mood, 

constricted affect and linear thoughts. (Id.) She denied having suicidal or 

homicidal ideations or auditory or visual hallucinations. (Id.) Plaintiff was again 

prescribed Abilify, Remeron, Vistaril, and Zoloft. (Id. at 475.)

On the same day Dr. Sullivan completed a Mental Impairment Residual 

Function Capacity Questionnaire at the request of Plaintiff’s representative. (Id. 

at 472, 445-49.) Dr. Sullivan reported Plaintiff’s bipolar mood fluctuation 

impaired her focusing, concentration, and organization and that Plaintiff was

unable to maintain minimum concentration to complete tasks. (Id. at 447.) Dr. 

Sullivan opined Plaintiff had “no useful ability to function” with respect to the 

following: to understand and remember short and simple instructions; carry out 

short and simple instructions; complete a normal workday and workweek without 

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interruptions from psychologically based symptoms; perform at a consistent pace 

without an unreasonable number and length of rest periods; respond 

appropriately to changes in a routine work setting; deal with normal work stress; 

understand and remember detailed instructions; carry out detailed instructions; 

and deal with stress of semiskilled and skilled work. (Id. at 447-48.) Additionally, 

Dr. Sullivan opined Plaintiff was “unable to meet competitive standards” with 

respect to the following: maintaining regular attendance and being punctual 

within customary, usual strict tolerances; maintaining attention for two hour 

segments; making simple work-related decisions; accepting instructions and 

responding appropriately to criticism from supervisors; getting along with coworkers or peers without causing them undue distraction or exhibiting behavioral 

extremes; and using public transportation because her PTSD is triggered in this 

setting. (Id.) Dr. Sullivan concluded Plaintiff’s impairments or treatment would 

cause her to miss more than four days of work per month, with impairments 

expected to last at least twelve months. (Id. at 449.)

III. THE ADMINISTRATIVE HEARING

The ALJ conducted an administrative hearing on July 8, 2014. (Id. at 68.)

A. Plaintiff’s Testimony

Plaintiff’s attorney suggested Plaintiff met Section 12.04 of the disability 

listings2

. (Id. at 70.) The ALJ began by questioning Plaintiff’s work experience. 

(Id.) Plaintiff testified she presently worked for In-Home Support Services

(“IHSS”) through San Diego State University. (Id.) In the course of this 

employment, Plaintiff went to an autistic female adult’s house to sweep, prepare 

meals, and write in a journal documenting the client’s behavior. (Id. at 71, 72). At 

the time of the hearing Plaintiff had been employed for three months, receiving 

 

2 Section 12.04 of the Social Security disability listings pertains to Depressive, Bipolar, and 

related disorders.

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$10.00 an hour and working twenty hours per week. (Id. at 71). Plaintiff 

indicated she had asked to work more, but her boss would not give her more 

hours. (Id. at 78.) Plaintiff also testified her schedule did not change week to 

week, but she had stayed for one overnight shift. (Id. at 73, 76.) Plaintiff testified

she obtained the job after talking with someone about her problems and the 

person thought the job would help with her depression. (Id. at 72.) Plaintiff 

testified her training for the job consisted of visiting the house with another 

person to observe how to keep a journal and talk with the client, and watching a 

video about the program. (Id. at 73, 91). 

Plaintiff testified she slept most of the time during her shift. (Id. at 73.) 

Plaintiff indicated she used to drive the client around to shop, but her shift was 

changed so she did not have to drive. (Id. at 74.) Plaintiff speculated this was 

due to her poor driving record. (Id.) Plaintiff also indicated she attended the fair 

with the client and the client’s father to help the client with the restroom, but any 

outing required supervision because she would likely not be able to handle the 

client alone. (Id. at 75.) Plaintiff indicated she completed a journal entry once 

per day at the end of her shift which consisted of answering specific questions 

about the client’s diet, interactions, verbal arguments, and any time the client 

spent alone. (Id. at 78-79.) Plaintiff indicated at times she became annoyed or 

mad and had to walk away for a few minutes. (Id. at 79).

Plaintiff testified her boss recently visited during a shift and asked the client 

about Plaintiff’s behavior and whether Plaintiff was capable of working. (Id. at 

77.) Plaintiff stated the client told her boss Plaintiff needed more patience and 

Plaintiff slept a lot. (Id.) 

Prior to Plaintiff’s current employment, Plaintiff worked at Jack in the Box 

for one month in the year 2013, but sustained a back injury, resulting in a 

$5,000.00 worker’s compensation claim. (Id. at 80-82.) The ALJ noted two 

reported jobs: Jamba Juice and Sutherland Management. (Id. at 81). Plaintiff 

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testified the longest she had held a job was three months before getting fired. 

(Id. at 80.) Plaintiff also testified when she had a job she always had problems: 

that she does not know how to feel, “freaks out”, cries, becomes emotional if 

someone says something nice, and wants to sleep and do nothing. (Id. at 86).

Plaintiff testified she received her GED in the year 2008. (Id. at 83.) She 

indicated she spent her time partying and couch surfing around San Diego 

County the next four years and did not live at home. (Id.) Plaintiff thought she 

might have applied for work during that time, but her “mind wasn’t really there 

much.” (Id.)

Plaintiff testified she took three medications to help with sleep, anxiety and 

depression. (Id. at 84.) The medications helped, but she said she still 

experienced symptoms. (Id.) 

Plaintiff testified during a typical bad day she does not want to do anything 

and her mood is mad and sad. (Id. at 84.) She indicated she has more bad days 

than good days and has difficulty being around people. (Id.) She also indicated

she has been told that her mood can change quickly. (Id.) Plaintiff testified she 

spent her time sleeping, reading, and going to the doctor once a month. (Id. at 

85.) Plaintiff further testified she had pain everywhere, specifically in her legs, 

feet, and back. (Id.) Plaintiff also indicated she has been sober for eighteen 

months. (Id.) At the time of the hearing, Plaintiff lived with her grandparents, and 

indicated there were some scary nights. (Id. at 85, 86.) Prior to living with her 

grandparents, Plaintiff lived at a center that helps the homeless. (Id. at 87.)

The ALJ determined Plaintiff did not have any documented past work 

experience based on Plaintiff’s limited past part-time work. (Id. at 91)

/ /

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/ /

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IV. THE ALJ’S DECISION

After considering the record, ALJ Iafe made the following findings:

. . . .

2. The claimant has the following severe impairments: 

depressive disorder NOS and post-traumatic stress 

disorder [citation omitted].

3. The claimant does not have an impairment or 

combination of impairments that meets or medically equals 

the severity of one of the listed impairments in [the Social 

Security regulations].

4. After careful consideration of the entire record, the 

undersigned finds that the claimant has the residual 

functional capacity to perform a full range of work at all 

exertional levels but with the following nonexertional 

limitations: the claimant is able to understand, remember, 

and carry out simple instructions for simple and repetitive 

tasks.

5. The claimant has no past relevant work [citation 

omitted]. 

....

8. The claimant has no transferable job because she 

has no past relevant work [citation omitted].

9. Considering the claimant’s age, education, work 

experience, and residual function capacity, there are jobs 

that exist in significant numbers in the national economy 

that the claimant can perform [citation omitted].

9. The claimant has not been under a disability, as defined in 

the Social Security Act, since May 25, 2012, the date the 

application was filed [citation omitted].

(Id. at 39-44.)

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V. STANDARD OF REVIEW

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

must show: (1) He or she 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. ' 423(d)(1)(A), (2)(A). An applicant must meet 

both requirements to be Adisabled.@ Id. Further, the applicant bears the burden of 

proving he or she was either permanently disabled or subject to a condition 

which became so severe as to disable the applicant prior to the date upon which 

his or her disability insured status expired. Johnson v. Shalala, 60 F.3d 1428, 

1432 (9th Cir. 1995).

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 (s)he has done in the past. If so, the claimant is not 

disabled. If not, the evaluation continues 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 a significant number of jobs in the national 

economy the claimant can do, the claimant is not disabled. 20 C.F.R. '

404.1520; see also Tackett v. Apfel, 180 F.3d 1094, 1098-99 (9th Cir. 1999).

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B. Judicial Review

Sections 205(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 Soc. Sec. 

Admin., 223 F.3d 968, 973 (9th Cir. 2000); Garrison v. Colvin, 759 F.3d 995, 

1009 (9th Cir. 2014). 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 Commissioner’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, 572 F.3d 

586, 591 (9th Cir. 2009) (citing 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. at 591 (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). The matter may 

also be remanded to the SSA for further proceedings. Id.

VI. DISCUSSION

Plaintiff argues the ALJ erred in granting little weight to the mental function 

opinions of Dr. Sullivan, her treating psychiatrist. (Pl.’s Mot. at 7-13.) 

“In disability benefits cases . . . physicians may render medical, clinical 

opinions, or they may render opinions on the ultimate issue of disability–the 

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claimant’s ability to perform work.” Reddick v. Chater, 157 F.3d 715, 725 (9th 

Cir. 1998). There are three types of physicians in such cases: “(1) those who 

treat the claimant (treating physicians); (2) those who examine but do not treat 

the claimant (examining physicians); and (3) those who neither examine nor treat 

the claimant (nonexamining physicians).” Lester v. Chater, 81 F.3d 821, 830 (9th 

Cir. 1995). When considering a disability claim, an ALJ evaluates the medical 

opinions in light of the evidentiary record as a whole. See 20 C.F.R. § 

416.927(b). Generally, a treating physician’s opinion is given more weight by the 

SSA than a nontreating physician’s opinion. Lester, 81 F.3d at 830; see also 20 

C.F.R. § 404.1527(c)(2). 

When the treating physician’s opinion is contradicted by another doctor, as 

is the case here, the ALJ may reject the opinion only by giving “specific and 

legitimate” reasons for doing so that are based on substantial evidence in the 

record. Lester, 81 F.3d at 830 (citing Murray v. Heckler, 722 F.2d 499, 502 (9th 

Cir. 1983)). This is the case because a treating physician’s opinion is still owed 

deference and will often be “entitled to the greatest weight . . . even if it does not 

meet the test for controlling weight.” Garrison, 759 F.3d at 1012 (citing Orn v. 

Astrue, 495 F.3d 625, 633 (9th Cir. 2007)). “An ALJ can satisfy the ‘substantial 

evidence’ requirement by setting out a detailed and thorough summary of the 

facts and conflicting clinical evidence, stating his interpretation thereof, and 

making findings.” Garrison, 759 F.3d at 1012 (quotations and citation omitted). 

An ALJ commits error if he does not explicitly reject a medical opinion or set forth 

specific and legitimate reasons for crediting one medical opinion over another. 

Nguyen v. Chater, 100 F.3d 1462, 1464 (9th Cir. 1996).

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Here, the ALJ noted Dr. Sullivan diagnosed Plaintiff with bipolar disorder 

with psychotic features and assigned a GAF score of 33.3

 (Id. at 42, 445.) He 

considered Dr. Sullivan’s opinions that Plaintiff had “no useful ability to function” 

with respect to the aforementioned mental abilities and aptitudes; was “unable to 

meet competitive standards” with respect to the aforementioned mental abilities 

and aptitudes; and would be absent from work more than four days per month. 

(Id. at 42, 447-49.) The ALJ observed that Dr. Sullivan’s conclusions regarding 

Plaintiff’s limitations were based on the diagnosis of bipolar disorder with 

psychotic features, which “impair[s] her focusing, concentration, and 

organization,” accompanied by racing thoughts, impulsivity, and concentration 

difficulties. (Id. at 42, 447-48.) The ALJ also noted Dr. Sullivan completed the 

mental impairment residual functional capacity form at the request of the 

Plaintiff’s representative. (Id. at 42.)

The medical opinions of Dr. Sullivan were contradicted by examining 

psychiatrist, Dr. Dolnak, who determined Plaintiff had no more than a mild limit in 

any major mental functional domain. (Id. at 42-43, 334-35,367.) In resolving Dr. 

Sullivan’s and Dr. Dolnak’s conflicting medical opinions, the ALJ summarized 

both professionals’ observations, diagnosis, and assessment of Plaintiff’s 

functional limitations, and determined the weight of the evidentiary record best 

comported with Dr. Dolnak’s functional assessment. (Id. at 55-58.) The ALJ 

explained he gave Dr. Dolnak’s opinions greater weight than those of Dr. Sullivan

because Dr. Sullivan’s assessment of Plaintiff’s functional limitations: 1) is not 

supported by objective medical evidence; 2) is inconsistent with the opinions of 

Dr. Dolnak; and 3) is inconsistent with Plaintiff’s daily activities and testimony.

 

3 A GAF score between 31 and 40 suggests some impairment in reality testing or 

communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in 

several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., 

depressed adult avoids friends, neglects family, and is unable to work; child frequently beats 

up younger children, is defiant at home, and is failing at school).

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Plaintiff contends the reasons proffered are neither specific nor legitimate, and 

are not supported by substantial evidence in the record. The Court will address 

the ALJ’s reasons for discounting Dr. Sullivan’s opinions in turn.

A. The ALJ Did Not Err In Concluding Dr. Sullivan’s Functional

 Assessment Was Not Supported By Objective Clinical Findings

The ALJ stated he gave “little weight” to the medical opinions of Dr. 

Sullivan in part because the functional limits described by Dr. Sullivan were not 

supported by objective findings from mental health treating sources. (Id. at 42.) 

See 20 C.F.R. § 416.927(c)(3) (“The more a medical source presents relevant 

evidence to support an opinion, particularly medical signs and laboratory 

findings, the more weight [the state agency or Social Security Administration] will 

give that opinion.) See also Thomas v. Barnhart, 278 F.3d 947, 957 (9th Cir. 

2002). (“The ALJ need not accept the opinion of any physician, including a 

treating physician, if that opinion is brief, conclusory, and inadequately supported 

by clinical findings.”)

Dr. Sullivan’s opinions regarding Plaintiff’s functional limits were set forth 

on a questionnaire form that largely consists of check-the-box style responses. 

(Admin R. at 445-449.) See Crane v. Shalala, 76 F.3d 251, 253 (9th Cir. 1996) 

(ALJ permissibly rejected psychological evaluations as they were check-off 

reports that did not contain any explanation of the bases of their conclusions.) 

Dr. Sullivan opined his assessment of Plaintiff’s functional limitation is due to 

bipolar disorder. (Admin. R. at 447.) His assessment, however, is inconsistent 

with his treatment notes and other records from Areta Crowell BPSR Center, 

which the ALJ observed did not indicate clinical signs and symptoms of a bipolar 

disorder. (Id. at 42.) These records, as the ALJ properly describes, notate 

Plaintiff’s variable mood and constricted affect, but mostly contain reports of

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Plaintiff’s subjective complaints, a source the ALJ determined not to be credible.4 

(Id. at 41-42, 455, 464, 473.) 

Plaintiff takes issue with the ALJ’s determination, pointing to records of a 

visit she made to Areta Crowell BPSR Center on December 3, 2013, as evidence 

of a bipolar disorder. (Pl. Mot. at 9.) On that date, Dr. Sullivan observed Plaintiff’s 

mood to be irritable, guarded and constricted, whereas Licensed Vocation Nurse 

Julie Allen observed Plaintiff to be “in a good mood and cooperative.” (Admin. R. 

at 455 and 457.) The weight of the medical evidence, however, does not support 

Dr. Sullivan’s diagnosis of bipolar disorder with psychotic features or his 

assessment of Plaintiff’s functional limitations. When Plaintiff was first assessed 

and admitted to the Areta Crowell BPSR Center, her diagnosis was Recurrent 

Severe Major Depressive Disorder, without Psychotic Features and 

Posttraumatic Stress Disorder. (Id. at 438.) Thereafter, Dr. Sullivan twice 

reported that Plaintiff denied having a history of mania or hypomania5 (Id. at 455 

& 464) and for all three examinations, he reported Plaintiff had linear thinking 

without auditory or visual hallucinations (Id. at 42, 455, 464, 473-474.). See

Bayliss v. Barnhart, 427 F.3d 1211, 1216 (finding that the discrepancy between 

the treating physician’s recorded observations and statement was a clear and 

convincing reason for not relying on an uncontradicted opinion.) As the ALJ 

noted, the treating records did not contain evidence of psychotic features such as 

abnormalities of thought content and processes, and Dr. Sullivan’s mental status 

examinations were unremarkable other than irritable mood, variable mood, and 

 

4 Plaintiff does not challenge the ALJ’s finding that she was not a reliable source for 

information. 

5 Plaintiff also denied experiencing severe symptoms for mania, bipolar disorder or psychosis 

when examined by Dr. Dolnak. (Admin. R. 365.)

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constricted affect.6 (Id. at 42, 455, 473.) In sum, Dr. Sullivan’s narrow clinical 

findings of variable mood and constricted affect, coupled with the lack of 

psychotic evidence and inconsistencies between his treating records and 

opinions, do not support a determination of the severe functional limitations

indicated on the questionnaire form. 

B. The ALJ Did Not Err In Giving Less Weight To Dr. Sullivan’s

 Functional Assessment Because It Was Inconsistent With Dr.

 Dolnak’s Clinical Findings

The ALJ also rejected Dr. Sullivan’s opinion regarding Plaintiff’s functional 

limits because it was inconsistent with the clinical findings reported by examining

psychiatrist Dr. Dolnak, who found no significant cognitive defects. (Admin R. at 

42, 366). Plaintiff argues Dr. Dolnak’s assessment does not constitute 

substantial evidence because he only reviewed SSA form 3368 and his 

assessment was made without the benefit of Dr. Sullivan’s records and opinion

and, thus, was not based on a complete medical assumption.7 8 (Pl’s Mot. at 10.) 

In addition to reviewing SSA form 3368, however, Dr. Dolnak performed a 

comprehensive psychiatric evaluation of Plaintiff and, thus, is an “examining 

physician” whose opinion constitutes substantial evidence when it rests on the 

his own independent examination of the claimant. See Tonapetyan v. Halter, 

242 F.3d 1144, 1149 (9th Cir. 2001). Here, Dr. Dolnak based his opinion on 

 

6 Although, as Plaintiff points out, the ALJ did not address Dr. Sullivan’s observation of 

paranoia made during one of Plaintiff’s mental status examinations (Admin R. at 464), this 

notation of paranoia does not alone justify the severe functional limitations assigned by Dr. 

Sullivan, and which Dr. Sullivan attributed to a bipolar disorder diagnosis.

 

7 Dr. Dolnak’s assessment was made more than one year prior to Plaintiff’s visits with Dr. 

Sullivan so records of Dr. Sullivan’s observations, opinions and treatment did not yet exist at 

the time Dr. Dolnak’s report was made. (Admin. R. at 363, 455.)

8 Plaintiff also contends the ALJ failed to discuss “obvious inconsistencies” between Dr. 

Dolnak’s mental examination and his assessed limitations, but does not identify any such 

inconsistencies. (Pl’s Mot. at 11.) 

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observations and responses by Plaintiff to various clinical tests such as serial 

sevens and twos, and spelling and digit span testing and, as the ALJ correctly 

noted, found no significant cognitive deficits. (Admin R. at 42, 366.) 

Furthermore, as the ALJ also observed, Dr. Dolnak’s findings of only mild 

limitations is consistent with his own mental status examination, the clinical 

findings of Dr. Nicholson, who also examined Plaintiff, as well as the treatment 

notes of Dr. Sullivan and the Areta Crowell BPSR Center. (Id. at 43, 365-67, 

455, 464, 473.)

C. The ALJ Did Not Err In Concluding Dr. Sullivan’s Functional

 Assessment Was Not Supported By Plaintiff’s Testimony And 

 Daily Activities

Lastly, Plaintiff contends the ALJ erred in discounting Dr. Sullivan’s opinion 

on the basis his findings are undermined by Plaintiff’s daily activities, problem 

solving skills, and testimony regarding her employment. (Pl. Mot. at 11-12.) In 

analyzing an individual’s overall well-being, the ALJ may consider Plaintiff’s daily 

activities, treating therapist notes, and evidence suggesting she has responded 

well to treatment. Crane, 76 F.3d at 254. Here, the ALJ explained he also 

rejected Dr. Sullivan’s opinion based on Plaintiff’s active search for employment, 

her ability to engage in problem solving and coping skills, and her testimony 

about her ability to perform the IHSS duties for an autistic client, which she had 

been doing for about 20 hours per week for three months. (Admin R. at 42.) 

First, Plaintiff argues the ALJ erroneously relied on Plaintiff’s statement

“she would like to find a job” as evidence that Plaintiff was actively searching for 

employment. (Pl’s Mot. at 11, citing to Admin. R. at 467.) Plaintiff incorrectly 

contends “(t)he ALJ’s citation to the record does not demonstrate active search 

for employment” and that Plaintiff simply reported to her therapist that she would 

like to find a job, not that she had been actively searching for one. (Id.) In fact, 

the record indicates on March 3, 2014, Plaintiff reported “she had not been able 

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to find a job despite applying for several” and two days later she stated there 

were three jobs she would apply for that day and she would also inquire about 

getting her previous job back. (Admin. R. at 467 and 469.)

Plaintiff also takes issue with the ALJ’s consideration of Plaintiff’s use of 

problem solving skills she learned through treatment at the Areta Crowell BPSR 

Center. (Pl. Mot. at 12.) Records of her therapy show Plaintiff’s psychotherapist, 

Matthew Holley, worked with Plaintiff to develop problem solving and coping 

skills as a means of managing her stressors. (Admin. R. at 467-470.) On March 

5, 2014, he evaluated her progress and reported Plaintiff was “engaging her 

problems to solve them and keep them from becoming bigger stressors for her.” 

(Id. at 469.) He further reported she was “engaging in mental health treatment to 

assist her in navigating stressors and using coping skills” and that Plaintiff 

“agreed that her current problems are able to be solved, she just needs to remain 

focused and motivated.” (Id.) These observations are at odds with Dr. Sullivan’s 

opinion regarding Plaintiff’s functional limitations and it was not error for the ALJ 

to consider them. See Crane, 76 F.3d at 254.

Lastly, Plaintiff contends the ALJ erred in considering Plaintiff’s testimony 

about her IHSS employment as a basis for discounting Dr. Sullivan’s opinions. 

The ALJ considered Plaintiff’s ability to perform IHSS duties for an autistic client 

20 hours per week for three months. (Admin. R. at 42.) As part of her duties, 

Plaintiff cleaned, prepared meals, and maintained a journal documenting the 

client’s conduct and demeanor. (Id. at 70-73.) Plaintiff wrote in the journal daily, 

at the end of each shift, and answered questions such as what the client ate, any 

interactions with others, any verbal arguments, or any time the client spent alone. 

(Id. at 78-80.) The ALJ’s determination that Plaintiff’s self-reported duties are 

inconsistent with Dr. Sullivan’s assessment of “no useful ability to function” in 

being able to understand, remember, and carry out short and simple instructions

is, thus, supported by substantial evidence. (Id. at 447.)

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VII. CONCLUSION

For the reasons set forth above, the Court concludes, after a thorough 

review of the record as a whole, the ALJ’s evaluation of the medical evidence 

and finding that Plaintiff is not disabled is not based on legal error and is 

supported by substantial evidence. The Court recommends Plaintiff’s motion for 

summary judgment be DENIED and Defendant’s cross-motion for summary 

judgment is GRANTED.

This report and recommendation will be submitted to the Honorable Cathy 

A. Bencivengo, United States District 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 24, 2017. The 

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

Any reply to the Objections shall be served and filed on or before July 31, 2017. 

The parties are advised that failure 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 7, 2017

IT IS SO ORDERED. 

Dated: July 7, 2017

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