Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_06-cv-00078/USCOURTS-caed-1_06-cv-00078-0/pdf.json

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

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The parties consented to the jurisdiction of the United States Magistrate Judge. On June 5, 2006, the 1

Honorable Oliver W. Wanger reassigned the case to the Honorable Sandra M. Snyder for all purposes. On February

5, 2008, the case was reassigned to the undersigned for all purposes. 

1

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

MARK GALLEGOS, )

)

)

)

Plaintiff, )

)

v. )

)

MICHAEL J. ASTRUE, Commissioner )

of Social Security, )

)

)

)

Defendant. )

 )

1:06-cv-00078 GSA

ORDER REGARDING PLAINTIFF’S

SOCIAL SECURITY COMPLAINT

(Document 16)

BACKGROUND

Plaintiff Mark Gallegos (“Plaintiff”) seeks judicial review of a final decision of the

Commissioner of Social Security (“Commissioner”) denying his application for supplemental

security income (“SSI”) pursuant to Title XVI of the Social Security Act. The matter is currently

before the Court on the parties’ briefs, which were submitted, without oral argument, to the

Honorable Gary S. Austin, United States Magistrate Judge. 

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28 References to the Administrative Record will be designated as “AR,” followed by the appropriate page 2

number.

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FACTS AND PRIOR PROCEEDINGS2

On May 7, 1999, Plaintiff filed an application for SSI benefits. AR 77-79. He alleged

disability since November 17, 1978, due to brain injuries. AR 77-79, 91. After being denied

both initially and on reconsideration, Plaintiff requested a hearing before an Administrative Law

Judge (“ALJ”). AR 58-61, 65-68, 69. On January 31, 2002, ALJ Richard A. Urbin held a

hearing. AR 29-50. ALJ Urbin denied benefits on February 25, 2002. AR 11-23. On April 15,

2002, the Appeals Council denied Plaintiff’s request for review. AR 8-9. 

In December 2002, the parties stipulated to a remand by the district court for further

administrative proceedings, including a new hearing and decision. AR 399-401. Based on the

parties stipulation, the court remanded the case for further proceedings. AR 397-398. On June 7,

2003, the Appeals Council vacated the final decision of the Commissioner and remanded the

case to an ALJ for further proceedings consistent with the order of the court. AR 395-396. 

On May 18, 2005, Patricia Flierl held a hearing. AR 517-552. ALJ Flierl denied benefits

on September 21, 2005. AR 357-367. 

On January 19, 2006, Plaintiff filed the instant action for court review. 

 Hearing Testimony

On May 18, 2005, ALJ Flierl held a telephonic hearing in Fresno, California. AR 517-

552. Plaintiff appeared by telephone from an area conservation center. AR 520. Plaintiff’s

attorney, Lawrence Rohlfing, appeared by telephone from his office. AR 520. Vocational expert

(“VE”) Tom Dachelet also appeared and testified. AR 519, 548-551. At the outset of the

hearing, the ALJ indicated that it had been two years since the last hearing and the present

hearing should include Plaintiff’s physical and mental limitations. AR 520. 

In response to questions from the ALJ, Plaintiff testified that he has not worked since the

last hearing. AR 521. The last time he worked was in 1997 or in 1998. AR 521. He was

released from prison in November 1994. AR 521. He was re-incarcerated on June 24, 2003, for

a new charge. AR 521. He was caught with a gun and trafficking marijuana. AR 522. He is

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“getting out” in March 2008. AR 522. Plaintiff also testified that he has been exposed to TB and

is taking medication for it. AR 522.

In response to questions from his attorney, Plaintiff testified that he had been trafficking

marijuana for a couple years before he was incarcerated. AR 522. He was making enough

money to pay his rent and to feed himself. AR 522. He probably made about $700-800 per

month for two or three years. AR 523. When he appeared at the prior hearing he was selling

marijuana. AR 523. Between 2002 and the day he was incarcerated, he did not go to school or

try to attend any vocational training. AR 523. While he was “out,” he received treatment at

Pacific Clinic, a mental health facility. AR 523. He would talk to the psychiatrist. AR 523. He

was on Zyprexa, which helped. AR 524. The Zyprexa was treating his symptoms of hearing

voices and schizophrenia. AR 524. While on Zyprexa, he did not hear voices. AR 524. They

were “completely under control.” AR 524. 

Plaintiff testified that during the period between April 28, 1999, and June 2003, his

ability to get along with other people was good. AR 524. He was taking Zyprexa. AR 525. He

stayed away from people, but when he had to deal with them, he dealt with them “pretty good.” 

AR 525. He got into some physical fights with other men about once every five or six months. 

AR 525-526. He got into physical fights with women about once every couple of years. AR 526. 

He did not get into fights with people that he came in contact with on the street, but with peopled

from past relationships. AR 526. Between 1999 and 2003, he got into verbal yelling matches

with other people a couple times a month. AR 526. 

Plaintiff testified that he was a bully. AR 527. If someone stood up to him, he would end

up either fighting or having a yelling match. AR 527. That has been the pattern throughout

much of his adult life and even when he was a teenager. AR 527. Plaintiff testified that how he

got along with people is not what “you call normal or what would be normal.” AR 527. 

Between 1999 and 2003, while taking his medication, Plaintiff had problems being

suspicious. AR 528. Sometimes he used drugs or alcohol in addition to taking the medication. 

AR 528. He would drink once or twice a week at night. AR 528. He would consume about a 40

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ounce malt liquor. AR 528. He did not get into fights or altercations when he was drinking. AR

529. He drank at home by himself most of the time. AR 529.

Plaintiff testified that he had a head injury after a motorcycle accident in 1978. AR 529. 

After the head injury, he was a little slower to react. AR 529. People would have to repeat

things and he was kind of slow. AR 529. It caused him to want to medicate himself, “do alcohol

and drugs,” be suspicious and not be trusting. AR 530. He did not have feelings of people

talking about him or not trusting people when he was taking his medication. AR 530. The

symptoms got better with medication. AR 530. He found himself more trusting, easygoing, and

a lot calmer. AR 530. By a lot calmer, he was talking about where he is getting into physical

fights twice a year or so, yelling matches a couple times a month and still bullying people. AR

530. His demeanor was a lot more relaxed. AR 530. 

Plaintiff testified that he is not receiving any kind of psychiatric care while incarcerated. 

AR 530. His psychotic symptoms have returned. AR 530. He has been dealing with it and

keeping it to himself. AR 530. He isolates himself and does his own program. AR 530. 

Plaintiff testified that he suffers from hepatitis C. AR 531. He feels “real tired,” fatigued 

most of the day, but tries to be active. AR 531-532. He sleeps when he has the opportunity. AR

532. It “helps a lot.” AR 532. When he is feeling fatigued, he cannot walk at all. AR 532. 

When he is feeling fatigued, he can walk from his cell to the mess hall. AR 532. It is about a

“couple blocks.” AR 532. When he gets to the mess hall, he is able to stand in line and get his

food. AR 532. When he is feeling fatigued, he is able to get back to the table and sit down to

eat. AR 533. If he wanted, he could walk to the mess hall and back without stopping. AR 533. 

He did not know if he could walk to the mess hall and back twice without stopping when he is

feeling fatigued. AR 533. He could walk four blocks. AR 533. When he is feeling fatigued, he

generally can stand not more than 10 minutes before he must sit down. AR 533. He has

difficulty sitting in one place. AR 533. He can sit for five minutes and then will get up and

stretch. AR 534. He can sit for at least 15 or 20 minutes. AR 534. He could endure sitting

about 20 minutes when he is feeling fatigued. AR 534. 

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Plaintiff testified that he can lift and carry about 50 pounds for an hour. AR 534-535. He

could lift 25 pounds more frequently than 50 pounds. AR 535. He did not think he could remain

productive for an eight-hour day. AR 536. He thought he could string together an hour and a

half. AR 536. When he was selling marijuana, he worked a couple hours a day. AR 536. He

would do that whenever he had an opportunity. AR 536. 

Plaintiff testified that between 1999 and 2003, he could not have handled a very easy,

sedentary job, which required sitting down most of the day and never lifting more than 10

pounds, because of his fatigue. AR 536-537. During that same period, he could maintain

attention and concentration about 50 percent of the time. AR 537. 

Plaintiff testified that he is not taking any medication for his Hepatitis C and he was not

taking any before 2003. AR 537. He has not received “interferon” or any other kind of

chemotherapy treatment. AR 537. 

Plaintiff testified that he was living alone between 1999 and 2003. AR 538. He rented a

room. AR 538. He had to keep his own room clean. AR 538. He kept it neat. AR 538. He had

a bed in the room. AR 538. He did not wash his own sheets. AR 538. His sister used to do

laundry. AR 538. He sometimes did his own grocery shopping. AR 538. He would go grocery

shopping once every couple months, but his sister usually would help him. AR 538. She would

take him to the store. AR 538. 

Plaintiff testified that he was unrelated to the people renting him a room. AR 539. He

sometimes got along with the people renting rooms. AR 539. Between 1999 and 2003, he lived

in about five different places. AR 540. He moved because they would raise the rent or he would

not get along with the people there. AR 540. 

In response to questions from the ALJ, Plaintiff testified that he found out he had

Hepatitis C in 2000. AR 540. Between 2000 and 2003, he did not have any medical insurance. 

AR 540. He tried to get MediCal, but they “wouldn’t give it to [him].” AR 540. He currently

takes TB medication. AR 541. He is not taking any other medications and they are not giving

him anything for mental and emotional problems. AR 541. He does not see a psychiatrist. AR

541. He could see one if he wanted. AR 541. He is “kind of doing all right” and trying “to do

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[his] time and get out.” AR 541. He does not want to see a psychiatrist who could put him back

on Zyprexa. AR 541. He could see him, but with the hepatitis C, the mediation “messes with”

his liver. AR 541. The doctor told him that. AR 541. He quit taking it just before he left the

street because it was “messing” with his liver. AR 541. He has not tried other medications. AR

542. 

Plaintiff testified that he has a job while in prison. AR 542. He works on the kitchen line

five days a week. AR 542-543. He worked a split shift from 6:00 to 7:30 in the morning and

then from 5:00 to 7:30 in the evening. AR 543. He works about four hours a day. AR 543. He

passes trays while standing. AR 543-544. The standing causes a “little bit” of a problem. AR

544. After he finishes his morning shift, he goes back to his cell to sleep. He goes back to work

about 4:30. AR 544. When he is finished at 7:30, he takes a shower, goes to get his TB

medication and returns to his cell. AR 544. When he returns to his cell, he reads a book, listens

to the radio, gets his rest, kicks back and relaxes. AR 545. He walks laps in the yard three times

a week. AR 545. He walks about six laps. AR 545. Three laps are a mile. AR 545. He goes to

sleep after the lights go out at about 11:00. AR 545. 

Plaintiff testified that he is right-handed. AR 545. His ring finger does not “fully

extend.” AR 545-546. It gets in the way sometimes. AR 546. It turns toward the palm of his

hand a little bit. AR 546. Gripping is okay because it closes. AR 546. It “doesn’t open.” AR

546. He uses his right hand for writing. AR 546. It is not a problem. AR 546. He can write. 

AR 546. 

Plaintiff testified that he has something wrong with one leg, when he sustained a head

injury in 1978. AR 546. He was in a coma. AR 547. One leg is shorter and he walks with a

limp. AR 547. It hurts when “it gets real cold and stuff.” AR 547. It acts “funny,” like

paralysis. AR 547. He has to walk on it a little. AR 547. It goes to sleep when it is cold or

walks on it. AR 547. He has never taken pain pills for it. AR 547. He tries to limit any type of

medication because of his hepatitis. AR 547. 

Plaintiff testified that he goes to the mess hall to eat twice a day. AR 547. They give him

a bag lunch. AR 548. After he finishes his duty in the evening, his leg feels tired. AR 548. He

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has “to go and get some rest, get off of it.” AR 548. He experiences pain in his knee and his

ankle. AR 548. He does not have any back pain. AR 548. 

VE Thomas Dachelet also testified. AR 548. The VE reviewed the work history report. 

AR 549. There were three jobs that are light physical demand, unskilled. AR 549. 

Plaintiff again testified in response to questions from the ALJ. Plaintiff was born on May

5, 1960, and was 45 years old at the time of the hearing. AR 550. He completed the tenth grade. 

AR 550. 

The ALJ asked the VE to assume a hypothetical individual between he ages of 38-39 to

age 45 with a residual functional capacity for light work with no repetitive fine manipulation

with the dominant right hand. AR 550. The VE testified that such an individual could not

perform Plaintiff’s past relevant work. AR 550-551. There were no other jobs for such an

individual in the national economy. AR 551.

For the next hypothetical, the ALJ asked the VE to assume an individual with a residual

functional capacity for medium work with no repetitive fine manipulation with the right

dominant hand. AR 551. The VE testified there would be no past relevant work and no other

work as would normally be found in the national economy. AR 550.

For the next hypothetical, the ALJ asked the VE to assume a person with a residual

functional capacity for sedentary work. AR 550. The VE testified he would have the same

response. AR 551. An individual with frequent change of position and no repetitive fine

manipulation with the right dominant hand also would have the same response. AR 551. 

Medical Evidence

Plaintiff was admitted to Los Angeles County-USC Medical Center on November 17,

1978, following a motorcycle accident. AR 238. Plaintiff lost consciousness, sustained multiple

abrasions and complained of right thigh pain. AR 238. A neurosurgery consult indicated that

Plaintiff “was essentially without any neurological sequella.” AR 238. Plaintiff had a right distal

third femur fracture, right 5 metacarpal fracture and concussion. AR 170, 238. He received a th

tibial pin and was placed in balanced suspension for six weeks. AR 238. During his hospital

stay, ortho PA progress notes from January 8, 1979, indicated that Plaintiff appeared to be “high”

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after spending time on the outside patio with a female friend. AR 174. Plaintiff was discharged

from the hospital on January 9, 1979. AR 173, 238. He was given three months disability. AR

238. 

Between January 22, 1979, and November 19, 1979, Plaintiff received follow-up

treatment at Los Angeles County-USC Medical Center Ortho Trauma Clinic for his right femur. 

AR 164-169, 171, 172, In January 1979, the provider indicated that Plaintiff was doing well and

noted disability for 3 months. AR 172. In November 19, 1979, the provider opined that Plaintiff

was “[d]oing well” and should continue range of motion work. AR 164. 

In May 1982, Plaintiff sought treatment at USC Medical Center due to an alleged assault. 

AR 161. Plaintiff reported being struck in the right jaw. AR 161. He was diagnosed with a

mandibular fracture. AR 247. He was to have his jaw wired. AR 162.

On March 21, 1988, Plaintiff sought emergency treatment for a swollen right hand. AR

251. Plaintiff reported being beaten with a stick 2 days prior to seeking treatment. AR 251. 

Progress notes dated March 14, 2999, from Watts Health Foundation, Inc., Care Programs

GREEP, indicated that Plaintiff last worked on July 19, 1999, because of migraines, high blood

pressure, allergies, and “neck and back leg arthritis.” AR 255. Plaintiff had problems with

sitting, standing, balance, carrying, lifting and hearing. AR 255. 

On June 17, 1999, Sarah L. Maze, M.D., a Diplomate of the National Board of Medical

Examiners, completed a consultative neurological evaluation of Plaintiff. AR 260-264. Plaintiff

chiefly complained of a head injury. AR 260. He also reported problems with pain in the back

of the neck and intermittent back pain. AR 260. He denied difficulty with memory and

coordination, but reported being tired all of the time and sad. AR 260. He was not taking any

medications, but admitted taking a friend’s Valium and Darvon for pain. AR 260-261. Plaintiff

indicated that he recently was released from prison. AR 261. He was separated from his wife

and had two children ages 14 and 7 years. AR 261. 

On mental status examination, Plaintiff was alert with a good general fund of knowledge. 

AR 261. Dr. Maze opined that Plaintiff’s intellectual functioning appeared to be in the normal to

dull normal range. AR 261. He comprehended and followed one, two and three part

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instructions. AR 261. His immediate recall, remote and recent memory were not reduced. AR

261. His speech was coherent and logical, and his concentration was not impaired. AR 261. 

 On physical examination, Plaintiff walked without a limp. AR 262. He was able to

stand and walk on heels and toes. AR 262. His strength and coordination testing were normal

and his reflexes were symmetrical. AR 263. 

Dr. Maze opined that Plaintiff presented with a normal neurological examination. AR

263. He remained able to lift 50 pounds occasionally and 25-30 pounds frequently. AR 263. He

could stand, sit and walk for six hours out of an 8-hour day. AR 263. Dr. Maze further opined

that Plaintiff may “function better in an environment with minimal contact with others.” AR

263. Her report was based on formal physical examination, formal testing, and observation of

Plaintiff’s spontaneous actions. AR 263.

On June 18, 1999, Albert Shnaider, M.D., a Diplomate of the American Board of

Psychiatry and Neurology, conducted a complete consultative psychiatric evaluation of Plaintiff. 

AR 265-270. Dr. Shnaider observed Plaintiff to be limping slightly on his right leg. AR 265. 

Plaintiff complained of lower back pain, neck pain, chronic right leg pain and daily headaches. 

AR 265. Plaintiff reported feeling depressed, hopeless and moderately worthless. AR 266. He

also indicated difficulty with memory and concentration. AR 266. 

Plaintiff admitted drinking at least four 40-ounce bottles of beer per day. AR 266. He

reported using PCP, LSD and heroin on a regular basis until 1989. AR 266. He indicated being

arrested in 1996 for marihuana possession. AR 266. He informed Dr. Shnaider that he borrows

Valium from friends 2 to 3 times per month for his headaches. AR 266. 

Dr. Shnaider reported Plaintiff’s current level of functioning to include self-dressing, selfbathing and personal hygiene. AR 267. Plaintiff performed household chores, errands and

shopping. AR 267. He reported that his hobby is collecting cans. AR 267. His sister pays bills

and handles money. AR 267. He does not get along with family members and does not like

people. AR 267. His general daily activities to consisted of watching TV, light reading, playing

chess or checkers and visiting with relatives. AR 267. 

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On mental status examination, Plaintiff’s mood was described a depressed. AR 268. He

had no paranoid ideations, delusions or hallucinations. AR 268. His mini mental status

examination score was 30 out of 30. AR 269. 

Dr. Shnaider diagnosed Plaintiff with depression secondary to poly substance abuse,

alcohol abuse and poly substance drug abuse. AR 269. He assigned Plaintiff a 65 on the Global

Assessment of Functioning (‘GAF”) scale. AR 269. Dr. Shnaider opined that Plaintiff presented

with a life long history of depression, but “the true etiology of his depression [was] entirely

obscured by his history of ongoing drug and alcohol abuse.” AR 269. He further opined that the

drug and alcohol abuse was “most likely responsible” for Plaintiff’s depressive symptoms. AR

269. Dr. Shnaider also suspected ongoing, undisclosed drug abuse. AR 269. 

Dr. Shnaider indicated that Plaintiff had no difficulty interacting with Dr. Shnaider or

clinic staff. AR 269. He demonstrated no significant memory or concentration deficits. AR

269. Based on the objective symptoms presented, Dr. Shnaider opined that Plaintiff should be

able to interact with customers, co-workers and supervisors. AR 269. He should be able to adapt

to the stresses common to a normal work environment and adequately follow at least moderately

complex written and oral instructions. AR 269. 

Dr. Shnaider further indicated that he was unable to diagnose Plaintiff with antisocial

personality disorder, despite a significant criminal history, because much of his criminality was

“likely to be related to ongoing drug and alcohol abuse, rather than psychopathy.” AR 270. Dr.

Shnaider indicated that Plaintiff’s prognosis was guarded due to ongoing drug and alcohol abuse. 

AR 270. 

On June 23, 1999, H. Harlan Bleecker, M.D., F.A.C.S., a Diplomate of the American

Board of Orthopaedic Surgeons, conducted a complete consultative orthopaedic evaluation of

Plaintiff. AR 271-274. Plaintiff complained of pain in his neck, a throbbing sensation in his left

shoulder with certain movement, constant burning sensation in his low back and swelling of the

right ankle. AR 271. He reported smoking half a pack of cigarettes a day and drinking three or

four 32-ounce bottles of beer a day. AR 272.

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On physical examination, Plaintiff’s gait was normal and he walked on tiptoes and heels

satisfactorily. AR 272. He had full range of motion of the neck. AR 272. Range of motion in

his back, shoulders, elbows, wrists and hips was within normal limits. AR 272. His range of

motion of the fingers also was within normal limits, except for his right ring finger. AR 272. 

Range of motion of the left knee was within normal limits, and his right knee extended to 0 and

flexed to 90 degrees. AR 273. He had 0 dorsiflexion of the right ankle and 3/8-inch shortening

of the right lower extremity. AR 273. His lower extremity strength was 5/5 and symmetrical. 

AR 273. 

Dr. Bleecker diagnosed plaintiff with (1) fracture, right femur, healed; and (2) fracture,

right fifth metacarpal, healed. AR 274. Dr. Bleecker opined that Plaintiff demonstrated only

3/8-inch shortening of his right lower extremity and 90-degree flexion deformity of the right ring

finger. AR 274. Dr. Bleecker further opined that “it is felt that there are no orthopaedic

impairments.” AR 274. 

On June 25, 1999, Brian S. Taylor, M.D., a state agency psychiatric consultant, completed

a Psychiatric Review Technique form. AR 275-276. Dr. Taylor opined that Plaintiff’s

impairment(s) were not severe. AR 276.

On July 15, 1999, a state agency medical consultant completed a Physical Residual

Functional Capacity Assessment form. AR 278-285. The state agency physician opined that

Plaintiff could lift and/or carry 50 pounds occasionally, 25 pounds frequently, could stand and/or

walk about 6 hours in an 8-hour workday, could sit about 6 hours in an 8-hour workday and

could push and/or pull without limitation (other than as shown for lift and/or carry). AR 279. He

frequently could climb a ramp/stairs/ladder, balance, stoop, kneel, crouch and crawl. AR 280. 

He occasionally could climb a rope or scaffolds. AR 280. He had unlimited reaching, handling

and feeling. AR 281. He had limited fingering and the state agency physician noted no constant

repetition on his right hand. AR 281. He had no visual, communicative or environmental

limitations. AR 281-282. 

On January 21, 2000, Plaintiff tested positive for Hepatitis C. AR 286. 

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On January 28, 2000, a GR Assessment form noted that Plaintiff’s right leg was shorter. 

AR 252. Progress notes from Watts Health Foundation, Inc., Care Programs GREEP, indicated

that Plaintiff had problems with sitting, standing, turning, balance, bending, writing, pushing,

pulling, reaching, carrying and lifting. AR 253. 

On March 8, 2000, a state agency physician completed a Physical Residual Functional

Capacity Assessment form. AR 293-300. The physician opined that Plaintiff could lift and/or

carry 50 pounds occasionally, 25 pounds frequently, could stand and/or walk about 6 hours in an

8-hour workday, could sit about 6 hours in an 8-hour workday and push and/or pull without

limitation (other than as shown for lift and/or carry). AR 294. Plaintiff had no postural,

manipulative, visual, communicative or environmental limitations. AR 295-297. 

On April 10, 2000, Alan R. Schrift, M.D., a state agency psychiatrist, completed a

Psychiatric Review Technique form. AR 277. Dr. Schrift opined that Plaintiff’s impairments

were not severe. AR 277. He also affirmed the assessment of June 25, 1999. AR 277. 

On July 6, 2000, a Ph.D. at Pacific Clinics of the Los Angeles County-Department of

Mental Health completed an adult initial assessment of Plaintiff for mental health treatment. AR

306-310. Plaintiff reported depressed mood, tearfulness, social withdrawal, memory problems,

poor concentration, insomnia, impulse control difficulties, fatigue and apparent visual

hallucinations (space ships). AR 306. He described his past drug use to include PCP, alcohol,

marijuana, acid and mushrooms. AR 307. He indicated that his current use included marijuana

and alcohol. AR 307. 

On mental status evaluation, Plaintiff was dysphoric, tearful, irritable and hopeless. AR

309. His intellectual functioning was impaired and was estimated to be in the slightly below

average range. AR 309. Plaintiff was diagnosed with a mood disorder not otherwise specified,

rule out social phobia, polysubstance dependence (sustained full remission), alcohol dependence

(sustained partial remission), cannabis dependence (sustained partial remission) and antisocial

personality disorder. AR 310. 

On August 22, 2000, Plaintiff underwent a psychiatric evaluation at Pacific Clinics. AR

316-317. He reported his belief that he was being followed and studied by the government, that

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he gets subliminal messages from the TV to control his mind, that Cal Tech has devices to

control the weather, that he saw a space ship and that he sees ghosts. AR 316. The evaluator

diagnosed paranoid schizophrenia, R/O social anxiety, antisocial personality disorder and

hypertension. AR 315. He was prescribed a trial of Zyprexa. AR 315. 

On September 5, 2000, Plaintiff sought follow-up treatment at Pacific Clinics. AR 314. 

Plaintiff reported that he still believed the government was after him, that he was being student

and that he was getting messages from TV. AR 314. The provider increased Plaintiff’s Zyprexa. 

AR 314.

On September 20, 2000, Plaintiff sought treatment at Pacific Clinics. AR 314. He

reported that he was still feeling that he is being studied by the government and that he has the

power to read minds. AR 314. The provider increased Plaintiff’s Zyprexa. AR 314.

Between October 17, 2000, and February 7, 2001, Plaintiff received follow-up treatment

at Pacific Clinics on six occasions. AR 311-312. Plaintiff continued on Zyprexa, which he

reported working “good” on December 14, 2000. AR 312. 

On March 7, 2001, Plaintiff saw Dr. El-Gabalawy at Pacific Clinics for mental health

medication support due to paranoid schizophrenia. AR 348. Dr. El-Gabalawy reported that

Plaintiff continued to do well. AR 348. Plaintiff denied hallucinations or paranoia. AR 348. He

was to continue Zyprexa. AR 348. 

On April 11, 2001, Plaintiff sought treatment from Dr. El-Gabalawy. AR 347. Plaintiff

reported doing well and that he was staying with his sister. AR 347. He was to continue taking

Zyprexa. AR 347. 

On May 9, 2001, Dr. El-Gabalawy prepared a letter regarding treatment of Plaintiff. AR

343. Dr. El-Gabalawy reported that Plaintiff had been under psychiatric care at Pacific Clinics

since August 2000. AR 343. He was on antipsychotic medications for paranoid schizophrenia. 

AR 343. Dr. El-Gabalawy also indicated that Plaintiff had a history of polydrug dependence in

remission, along with a medical history of head injury, hypertension and Hepatitis C. AR 343. 

Dr. El-Gabalawy opined that Plaintiff had been compliant with medication and appointments, as

well as being sober and drug free. AR 343.

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Plaintiff also saw Dr. El-Gabalawy for treatment on May 9, 2001. AR 346. Dr. ElGabalawy opined that Plaintiff continued to do well with no paranoia or hallucinations. AR 346. 

Plaintiff was compliant with his medications and was to continue Zyprexa. AR 346. 

On June 13, 2001, Plaintiff saw Dr. El-Gabalawy for medication support. AR 345. Dr.

El-Gabalawy opined that Plaintiff was doing well. AR 345. Plaintiff reported working “under

the table for his uncle (gardening).” AR 345. Plaintiff was to continue with Zyprexa. AR 345. 

On August 15, 2001, Plaintiff saw Dr. El-Gabalawy for treatment. AR 344. Dr. ElGabalawy opined that Plaintiff continued to do well. AR 344. Plaintiff reported that he avoided

people and stayed to himself “in order not to get in trouble.” AR 344. Dr. El-Gabalawy

indicated that Plaintiff was compliant with his medications and was to continue with Zyprexa. 

AR 344. 

On October 3, 2001, Stuart Shipko, M.D., a Diplomate of the American Board of

Psychiatry and Neurology, completed a consultative comprehensive psychiatric examination of

Plaintiff. AR 349. Dr. Shipko opined that Plaintiff was “a vague and evasive historian.” AR

349. Plaintiff stated that he has “heard voices” since he was a teen. AR 349. Dr. Shipko opined

that Plaintiff did not perceive the voices as external and knew that they were his own thoughts. 

AR 349. The voices/thoughts most often focused on danger to or hurting himself or others. AR

349. Plaintiff also reported that he had not used any drugs for years. AR 350. He denied current

medical problems. AR 350.

On mental status examination, Plaintiff was alert and oriented to time, place, person and

reason for the interview. AR 350. His gait and motor activity were normal. AR 350. His mood

was neutral and his affect was appropriate to the content of speech. AR 350. Dr. Shipko opined

that Plaintiff had no delusions of persecution, grandeur or reference. AR 350. Dr. Shipko did

not observe any suicidal, homicidal or paranoid ideation or hallucinations. AR 350. Plaintiff’s

cognition was appropriate to his level of education. AR 350. His abstract reasoning was intact

and his insight and judgment were good. AR 351.

Dr. Shipko diagnosed Plaintiff with polysubstance abuse, sociopathic personality disorder

and malingering. AR 351. Dr. Shipko reported that although Plaintiff hears voices, Plaintiff is

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“quite clear that these are internal thoughts and he does not give the history of a hallucination. 

AR 351. Dr. Shipko opined that the history seemed “to be fabricated since his last social security

evaluation.” AR 351. Plaintiff had no objective findings of schizophrenia such as

suspiciousness, preoccupation with internal stimuli, blunting of affect or loosening of

associations. AR 351. Dr. Shipko further opined that Plaintiff was careful to conceal

information regarding his criminal history and his drug history. AR 351. Dr. Shipko did not feel

that Plaintiff’s records or his examination supported a diagnosis of mental illnesses other than his

history of drug abuse and his sociopathic personality traits. AR 351. Dr. Shipko indicated that

Plaintiff was not competent to manage funds on his own behalf. AR 352. Dr. Shipko opined that

a meaningful functional assessment could not be made due to malingering. AR 352. 

On October 11, 2001, Dr. Shipko also completed a Medical Source Statement of Ability

to Do Work-Related Activities (Mental) form. AR 353-354. Dr. Shipko opined that Plaintiff’s

ability to understand, remember and carry out instructions and his ability to respond appropriately

to supervision, co-workers, and work pressure in a work setting were not affected by his

impairment. AR 353-354. 

On October 15, 2001, Plaintiff saw Dr. El-Gabalawy for medication support. AR 356. 

Dr. El-Gabalawy indicated that Plaintiff continued to do well and was still looking for a job. AR

356. Plaintiff denied using drugs. AR 356. Plaintiff was to continue with Zyprexa. AR 356. 

On December 10, 2001, Plaintiff received medication support from Dr. El-Gabalawy. 

AR 355. Dr. El-Gabalawy opined that Plaintiff was responding well and staying out of trouble. 

AR 355. Plaintiff admitted to occasionally drinking beer and smoking THC. AR 355. Dr. ElGabalawy educated Plaintiff about the risks of alcohol and THC and indicated that Plaintiff

needed to stop completely. AR 355. Plaintiff was to continue Zyprexa. AR 355.

On February 5, 2004, Plaintiff was seen in the California Department of Corrections Hep

C Clinic. AR 504. Plaintiff did not want a prescription. AR 504. 

On November 10, 2004, Plaintiff saw Mike Witwer, MD, FACP, a physician and surgeon

at Sierra Conservation Center. AR 501. Plaintiff indicated that he wanted prophylactic TB

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treatment. AR 501. Chest x-rays were normal. AR 511. He had no active disease and no

evidence of active tuberculosis. AR 512. 

On December 2, 2004, Plaintiff received counseling in prison regarding TB infection and

disease. AR 500. 

ALJ’s Findings

The ALJ determined that Plaintiff had not engaged in substantial gainful activity since the

alleged onset of disability. AR 366. The ALJ found that Plaintiff had the severe impairments of

Hepatitis C, history of polysubstance abuse, sociopathic personality disorder, and healed right

femur fracture and healed right 5 metacarpal. AR 366. The ALJ concluded that Plaintiff did th

not have an impairment or combination of impairments that met or medically equaled one of the

listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1. AR 366. The ALJ further

found that Plaintiff had the residual functional capacity to lift and carry 50 pounds occasionally

and 25 pounds frequently. AR 366. He could sit, stand, and walk about 6 hours in an 8-hour

day. AR 366. He also could perform simple repetitive tasks. AR 366. Therefore, the ALJ

concluded that Plaintiff’s impairments did not prevent him from performing his past relevant

work as a telephone operator, a customer service representative and a driver. AR 366. The ALJ

also used Rule 203.25 of the Medical-Vocational Guidelines as a framework to determine that

Plaintiff was not disabled based on his residual functional capacity for medium work, his age as a

younger individual and his limited education. AR 366. Therefore, the ALJ concluded that

Plaintiff was not under a “disability.” AR 366. 

SCOPE OF REVIEW

Congress has provided a limited scope of judicial review of the Commissioner’s decision

to deny benefits under the Act. In reviewing findings of fact with respect to such determinations,

the Court must determine whether the decision of the Commissioner is supported by substantial

evidence. 42 U.S.C. § 405(g). Substantial evidence means more than a mere scintilla,

Richardson v. Perales, 402 U.S. 389, 401 (1971), but less than a preponderance. Sorenson v.

Weinberger, 514 F.2d 1112, 1119, n. 10 (9th Cir. 1975). It is “such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.” Richardson, 402 U.S. at 401

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(internal quotation marks and citation omitted). The record as a whole must be considered,

weighing both the evidence that supports and the evidence that detracts from the Commissioner’s

conclusion. Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). In weighing the evidence and

making findings, the Commissioner must apply the proper legal standards. E.g., Burkhart v.

Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988). This Court must uphold the Commissioner’s

determination that the claimant is not disabled if the Commissioner applied the correct legal

standards, and if the Commissioner’s findings are supported by substantial evidence. See

Sanchez v. Sec’y of Health and Human Serv., 812 F.2d 509, 510 (9th Cir. 1987). 

 REVIEW

In order to qualify for benefits, a claimant must establish that he is unable to engage in

substantial gainful activity due to a medically determinable physical or mental impairment which

has lasted or can be expected to last for a continuous period of not less than 12 months. 42

U.S.C. § 1382c (a)(3)(A). A claimant must show that he has a physical or mental impairment of

such severity that he is not only unable to do his previous work, but cannot, considering his age,

education, and work experience, engage in any other kind of substantial gainful work which

exists in the national economy. Quang Van Han v. Bowen, 882 F.2d 1453, 1456 (9th Cir. 1989). 

The burden is on the claimant to establish disability. Terry v. Sullivan, 903 F.2d 1273, 1275 (9th

Cir. 1990).

In an effort to achieve uniformity of decisions, the Commissioner has promulgated

regulations which contain, inter alia, a five-step sequential disability evaluation process. 20

C.F.R. §§ 404.1520 (a)-(g), 416.920 (a)-(g) (2006). Applying the evaluation process in this case,

the ALJ found that Plaintiff (1) has not engaged in substantial gainful activity since the alleged

onset of disability; (2) has an impairment or a combination of impairments that is considered

“severe” (Hepatitis C, history of polysubstance abuse, sociopathic personality disorder, healed

right femur fracture and healed right 5 metacarpal) based on the requirements in the th Regulations

(20 C.F.R. § 416.920(c) (2006)); (3) does not have an impairment or combination of impairments

that meets or equals one of the impairments set forth in Appendix 1 to Subpart P of Part 404; and

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(4) is able to perform his past relevant work as a telephone operator, a customer service

representative and a driver. AR 366. 

In this case, Plaintiff argues that the ALJ erred by: (1) rejecting the prior residual

functional capacity assessment on remand; and (2) rejecting the presence of a severe mental

impairment. 

DISCUSSION 

A. Residual Functional Capacity Following Remand

1. Rule of Mandate

Plaintiff argues that the ALJ erred by rejecting the prior residual functional capacity

assessment and changing the finding of the manipulative impairment on remand. Plaintiff’s

Opening Brief, at p. 8. To support his argument, Plaintiff alleges that the ALJ’s change did not

fall within the scope of the stipulated remand and violated the mandate of the case, which directs

consideration of the manipulative limitations framed in the first ALJ decision. Plaintiff further

contends that the letter and spirit of the stipulation, order and judgment demand that Plaintiff

“has a manipulative impairment against repetitive fine fingering.” Plaintiff’s Opening Brief, at p.

9. Plaintiff’s argument and contentions are without merit.

Here, the parties stipulated to a remand by the district court in December 2002. AR 399-

401. The stipulation signed by counsel for the parties provides, in relevant part, as follows:

that this action be remanded to the Commissioner of Social Security for further

administrative proceedings, including a new hearing and decision. Upon remand

the Administrative Law Judge (“ALJ”) will ... 3) re-assess plaintiff’s residual

functional capacity, both physical and mental, in light of all record medical

evidence....

AR 399-400, 401 (emphasis added). The plain language of the stipulation identifies the parties’

agreement to the reassessment of Plaintiff’s physical residual functional capacity. There is no

indication that the ALJ was prohibited from re-evaluating Plaintiff’s physical limitations

(including manipulative limitations) on remand. Plaintiff’s contention that he stipulated to a

remand only “for reconsideration of the mental impairments afflicting him” is contradicted by the

express language of the stipulation. 

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Further, Plaintiff’s citations to “rule of mandate” cases for the proposition that the ALJ

could not revisit its already final determinations are not instructive. The parties expressly

stipulated to reassessment of Plaintiff’s residual functional capacity on remand and the district

court ordered remand of the matter “pursuant to the Stipulation for Remand and Order of

Remand” filed by the parties. AR 397-397. 

2. Inquisitorial Nature of Proceedings

Plaintiff next argues that the ALJ’s finding violates the inquisitorial nature of the

proceedings. Plaintiff’s Opening Brief, at p. 9. Plaintiff contends that the ALJ erred by failing

“to raise the intent to change/eliminate the limitation with respect to the ability to engage in fine

manipulation at or before the conclusion of the hearing.” Plaintiff’s Opening Brief, at p. 9-10. 

Plaintiff cites case law regarding the inquisitorial nature of social security hearings before an

ALJ. See, e.g., Sims v. Apfel, 530 U.S. 103, 120 S.Ct. 2080 (2000). 

Although Plaintiff correctly contends that social security hearings are not adversarial

proceedings, Plaintiff himself bears the burden of proving that he is disabled. Meanel v. Apfel,

172 F.3d 1111, 1113-1114 (9th Cir. 1999) (claimants represented by counsel must raise all issues

and evidence at their administrative hearings). When the evidence is ambiguous or “the record is

inadequate” to allow for proper evaluation of the evidence, however, the ALJ has a duty to

develop the record. Tonapetyan v. Halter, 242 F.3d 1144, 1150 (9th Cir.2001). Here, there is no

indication that the evidence was ambiguous or the record inadequate to allow for proper

evaluation of any manipulative limitations. The ALJ determined that Dr. Bleecker, who

conducted a consultative orthopaedic evaluation of Plaintiff, “did not identify any limitations that

would cause any limitations.” AR 365. The record demonstrates that Plaintiff did not complain

to Dr. Bleecker about his right hand. AR 271-274. Dr. Bleecker noted that Plaintiff’s range of

motion was not within normal limits in the right ring finger and that Plaintiff had a 90-degree

flexion deformity of the right ring finger. AR 272, 274. Dr. Bleecker concluded, however, that

Plaintiff had a healed fracture of the right fifth metacarpal and that Plaintiff had “no orthopaedic

impairments.” AR 274. 

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3. Opinion of State Agency Physician

 Plaintiff contends that the ALJ erred by failing to articulate the weight given to state

agency and medical expert opinions. While the ALJ did not expressly state the weight afforded

to the opinions of state agency and medical expert opinions, the ALJ accepted the opinion of the

examining physician, Dr. Bleecker, who did not identify any orthopaedic limitations. AR 365. 

Failure by the ALJ to articulate or explain the weight given to the reports of the examining or

consultative physicians can be harmless error. See Curry v. Sullivan, 925 F.2d 1127, 1129 (9th

Cir.1991). 

To support his argument for a manipulative limitation, Plaintiff relies on the opinion of a

non-examining state agency physician, who opined in July 1999 that Plaintiff had a limitation in

the right hand for repetitive fingering. AR 361. Plaintiff’s reliance is misplaced. The opinion of

a nonexamining physician cannot, by itself, constitute substantial evidence that justifies the

rejection of the opinion of either an examining physician or a treating physician. Pitzer v.

Sullivan, 908 F.2d 502, 506 n. 4 (9th Cir. 1990). Here, the examining physician did not find any

manipulative limitations. Further, a state agency physician issued a contradictory opinion in

March 2000 that Plaintiff had no manipulative or other limitations. AR 295-297. 

B. Severe Mental Impairment

Plaintiff contends that ALJ erred in rejecting the presence of a severe mental impairment

and that Plaintiff’s mental impairment is inconsistent with work activity at any level of exertion.

Opening Brief, at p. 12. To support his argument, Plaintiff does not cite any evidence of

functional limitations imposed by Plaintiff’s treating or examining physicians, but identifies the

diagnoses of Drs. El-Gabalawy and Shipko. The mere diagnosis of a mental impairment is not

sufficient to sustain a finding of disability. See, e.g., Key v. Heckler, 754 F.2d 1545, 1549 (9th

Cir. 1985). 

Further, the determination of an impairment’s severity is distinct from the determination

of residual functional capacity. At the second step of the sequential evaluation of disability, the

ALJ determines whether a claimant has a severe impairment or combination of impairments. A

severe impairment is one that significantly limits the claimant’s physical or mental ability to do

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basic work activities. 20 C.F.R. § 416.920(c). An impairment or combination of impairments is

found “not severe” and a finding of “not disabled” is made at this step “when medical evidence

establishes only a slight abnormality or a combination of slight abnormalities which would have

no more than a minimal effect on an individual’s ability to work even if the individual’s age,

education, or work experience were specifically considered (i.e., the person’s impairment(s) has

no more than a minimal effect on his or her physical or mental ability(ies) to perform basic work

activities).” Social Security Ruling (“SSR”) 85-28.

In contrast, at step four, further evaluation of the claimant’s inability to work is made

based on an analysis of the claimant’s residual functional capacity and an assessment of other

vocational factors. 20 C.F.R. § 416.920(a). Accordingly, at the fourth step of the sequential

evaluation process, a claimant’s capacity to perform relevant work performed in the past is

evaluated on the basis of a medical assessment of the claimant’s residual functional capacity and

a vocational assessment of the physical and mental demands of the work. 20 C.F.R. §

416.920(e). A claimant who has the capacity to perform past relevant work will be found not

disabled. Id.

Here, at step two, the ALJ determined that plaintiff suffered from a “severe” medically

determinable mental impairment or combination of impairments which were more than slight

abnormalities and had more than a minimal effect on his ability to work. The ALJ described

these mental impairments as “history of polysubstance abuse, sociopathic personality disorder.”

AR 366. He then went on to step three and determined that Plaintiff’s impairments did not meet

or equal a listing.

At step four of the sequential evaluation, the ALJ stated, “A determination must be made

whether the claimant retains the residual functional capacity to perform the requirements of his

past relevant work or other work existing in significant numbers in the national economy.” AR

363. The ALJ then reviewed and discussed the medical record, Plaintiff’s testimony, third party

questionnaires and medical opinions, and concluded that Plaintiff retained the residual functional

capacity to lift and carry 50 pounds occasionally and 25 pounds frequently, to sit, stand, and walk

about 6 hours in an 8-hour day and to perform simple repetitive tasks. AR 365. The ALJ

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determined that Plaintiff retained the exertional capacity for medium work and was therefore

capable of performing his past relevant light unskilled work. AR 365. 

The ALJ’s finding at step two that Plaintiff suffered from a “severe” impairment, did not

preclude his finding at step four that Plaintiff could perform work at the medium exertion level. 

As noted, the analysis at each step is separate and distinct and one finding does not dictate any

particular outcome. A person found to have a severe impairment at step two may still be found at

step four to be capable of medium work. A “severe” impairment at step two is merely an

impairment or combination of impairments that has more than a minimal effect on the claimant’s

abilities to perform basic work activities. See 85-28. The step two analysis is a threshold one

which enables the ALJ to deny benefits based on medical considerations alone to those

applicants with impairments of such minimal nature that they could never prevent a person from

working. Id. The ALJ’s findings that plaintiff’s history of polysubstance abuse and sociopathic

personality disorder passed this minimal threshold did not dictate any particular outcome, but

rather allowed the ALJ to go further with the sequential evaluation where he could consider both

medical and vocational evidence. 

CONCLUSION 

Based on the foregoing, the Court finds that the ALJ’s decision is supported by

substantial evidence in the record as a whole and is based on proper legal standards. 

Accordingly, this Court DENIES Plaintiff’s appeal from the administrative decision of the

Commissioner of Social Security. The clerk of this Court is DIRECTED to enter judgment in

favor of Defendant Michael J. Astrue, Commissioner of Social Security, and against Plaintiff

Mark Gallegos.

IT IS SO ORDERED. 

Dated: April 10, 2008 /s/ Gary S. Austin 

60kij UNI 8 TED STATES MAGISTRATE JUDGE

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