Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_19-cv-00086/USCOURTS-caed-2_19-cv-00086-0/pdf.json

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

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UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

ARLENE MARIE ALVA,

Plaintiff,

v.

ANDREW SAUL, Commissioner of Social 

Security,

Defendant.

No. 2:19-cv-00086 CKD

ORDER &

FINDINGS AND RECOMMENDATIONS

Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security 

(“Commissioner”) denying an application for disability benefits under Title II of the Social 

Security Act (“Act”). For the reasons discussed below, the undersigned will recommend that 

plaintiff’s motion for summary judgment be denied and the Commissioner’s cross-motion for 

summary judgment be granted.

BACKGROUND

Plaintiff, born in 1974, filed a Title II application on December 1, 2015 for disability and 

disability insurance benefits, alleging disability beginning December 15, 2010. Administrative 

Transcript (“AT”) 15, 23. Plaintiff alleged she was unable to work due to depression, anxiety, 

numbness, tingling pain from knuckles to elbows, loss of strength in hands and arms, limited 

range of motion, inability to write or open or close hand fully. AT 84-85. In a decision dated 

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April 4, 2018, the ALJ determined that plaintiff was not disabled.1 AT 15-24. The ALJ made 

the following findings (citations to 20 C.F.R. omitted):

1. The claimant last met the insured status requirements of the Social 

Security Act on March 31, 2016.

2. The claimant has not engaged in substantial gainful activity during 

the period from her alleged onset date of December 15, 2010 through 

her date last insured of March 31, 2016.

3. Through the date last insured, had the following severe 

impairments: history of left finger fusion, history of right elbow 

surgery, carpal tunnel syndrome, epicondylitis, and obesity.

4. Though the claimant does not have an impairment or combination 

of impairments that meets or medically equals one of the listed 

impairments in 20 CFR Part 404, Subpart P, Appendix 1.

 

1 Disability Insurance Benefits are paid to disabled persons who have contributed to the 

Social Security program, 42 U.S.C. § 401 et seq. Supplemental Security Income is paid to 

disabled persons with low income. 42 U.S.C. § 1382 et seq. Both provisions define disability, in 

part, as an “inability to engage in any substantial gainful activity” due to “a medically 

determinable physical or mental impairment. . . .” 42 U.S.C. §§ 423(d)(1)(a) & 1382c(a)(3)(A). 

A parallel five-step sequential evaluation governs eligibility for benefits under both programs. 

See 20 C.F.R. §§ 404.1520, 404.1571-76, 416.920 & 416.971-76; Bowen v. Yuckert, 482 U.S. 

137, 140-142, 107 S. Ct. 2287 (1987). The following summarizes the sequential evaluation: 

Step one: Is the claimant engaging in substantial gainful 

activity? If so, the claimant is found not disabled. If not, proceed to 

step two. 

Step two: Does the claimant have a “severe” impairment? If 

so, proceed to step three. If not, then a finding of not disabled is 

appropriate. 

Step three: Does the claimant’s impairment or combination 

of impairments meet or equal an impairment listed in 20 C.F.R., Pt. 

404, Subpt. P, App.1? If so, the claimant is automatically determined 

disabled. If not, proceed to step four. 

Step four: Is the claimant capable of performing his past 

work? If so, the claimant is not disabled. If not, proceed to step five. 

Step five: Does the claimant have the residual functional 

capacity to perform any other work? If so, the claimant is not 

disabled. If not, the claimant is disabled.

 

Lester v. Chater, 81 F.3d 821, 828 n.5 (9th Cir. 1995). 

The claimant bears the burden of proof in the first four steps of the sequential evaluation 

process. Bowen, 482 U.S. at 146 n.5, 107 S. Ct. at 2294 n.5. The Commissioner bears the 

burden if the sequential evaluation process proceeds to step five. Id.

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5. Through the date last insured, the claimant had the residual 

functional capacity to perform light work except: she could have 

frequently fingered and felt with the bilateral upper extremities; and 

she could have occasionally handled, grasped, and twisted with the 

dominant right upper extremity.

6. The claimant was unable to perform her past relevant work.

7. Jobs existed in significant numbers that the claimant could have 

performed.

8. The claimant was not under a disability, as defined in the Social 

Security Act, at any time from December 15, 2010, the alleged onset 

date, through March 31, 2016, the date last insured.

AT 17-24.

ISSUES PRESENTED

Plaintiff argues that the ALJ committed the following errors in finding plaintiff not 

disabled: (1) the ALJ erred in finding that plaintiff did not have severe mental impairment; and 

(2) the ALJ erred in rejecting the opinion of a treating physician.

LEGAL STANDARDS

The court reviews the Commissioner’s decision to determine whether (1) it is based on 

proper legal standards pursuant to 42 U.S.C. § 405(g), and (2) substantial evidence in the record 

as a whole supports it. Tackett v. Apfel, 180 F.3d 1094, 1097 (9th Cir. 1999). Substantial 

evidence is more than a mere scintilla, but less than a preponderance. Connett v. Barnhart, 340 

F.3d 871, 873 (9th Cir. 2003) (citation omitted). It means “such relevant evidence as a reasonable 

mind might accept as adequate to support a conclusion.” Orn v. Astrue, 495 F.3d 625, 630 (9th 

Cir. 2007), quoting Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005). “The ALJ is 

responsible for determining credibility, resolving conflicts in medical testimony, and resolving 

ambiguities.” Edlund v. Massanari, 253 F.3d 1152, 1156 (9th Cir. 2001) (citations omitted). 

“The court will uphold the ALJ’s conclusion when the evidence is susceptible to more than one 

rational interpretation.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 2008).

The record as a whole must be considered, Howard v. Heckler, 782 F.2d 1484, 1487 (9th 

Cir. 1986), and both the evidence that supports and the evidence that detracts from the ALJ’s 

conclusion weighed. See Jones v. Heckler, 760 F.2d 993, 995 (9th Cir. 1985). The court may not 

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affirm the ALJ’s decision simply by isolating a specific quantum of supporting evidence. Id.; see 

also Hammock v. Bowen, 879 F.2d 498, 501 (9th Cir. 1989). If substantial evidence supports the 

administrative findings, or if there is conflicting evidence supporting a finding of either disability 

or nondisability, the finding of the ALJ is conclusive, see Sprague v. Bowen, 812 F.2d 1226, 

1229-30 (9th Cir. 1987), and may be set aside only if an improper legal standard was applied in

weighing the evidence. See Burkhart v. Bowen, 856 F.2d 1335, 1338 (9th Cir. 1988).

ANALYSIS

A. Medical Opinions

Plaintiff asserts that the ALJ erred in rejecting the opinion of physician Dr. Vinay Reddy, 

who completed an Upper Extremity Assessment in September 2017.2 See AT 914-918 (Dr. 

Reddy’s September 21, 2017 report). At the October 2017 hearing on her disability claim, 

plaintiff testified that she had “constant pain in my arms and hands” that was not relieved by 

medication or 2012 surgery on her right elbow, and that limited her ability to use her hands and 

fingers for activities like zipping, buttoning, tying, and twisting the lids off containers. AT 43-49; 

see AT 19 (ALJ’s summary of plaintiff’s testimony).

The ALJ”s decision addressed Dr. Reddy’s report as follows: 

Vinay Reddy, M.D., the claimant’s provider at Spine and Nerve 

Diagnostic Center, completed an opinion dated September 21, 2017 

and stated that the claimant could never/rarely engage in fine 

manipulations, gross manipulations, reaching, or pushing/pulling; 

she could rarely lift/carry 10 pounds; her symptoms would likely 

increase if she were to work; her symptoms would frequently to 

constantly interfere with her attention and concentration; she would 

need unscheduled 10- to 15-minute breaks every 15 to 30 minutes; 

and she would be absent from work more than 3 times per month.3

Although Dr. Reddy has treated the claimant, I give her opinion little 

weight. At the outset, Dr. Reddy’s opinion is speculative, as she only 

began to treat the claimant as of July 18, 20134, yet she opined upon 

 

2 As noted above, the relevant period of alleged disability is from December 15, 2010 to March 

31, 2016. AT 17.

3 Citing AT 914-918.

4 Citing AT 740-742 (July 18, 2013 new patient consultation with Dr. Reddy where plaintiff 

presented with right elbow, forearm, and hand pain). 

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the claimant’s condition two years and seven months before she 

began to treat the claimant.

Furthermore, Dr. Reddy’s opinion has issues with supportability and 

consistency with the record. While Dr. Reddy cited to her clinical 

findings, she also cited to positive “NCS bilaterally” findings and 

positive “Xrays.”5 However, prior to the date that the claimant was 

last insured, Dr. Reddy’s progress notes describe the claimant’s 

electrodiagnostic studies as being ‘normal.’6 Furthermore, the wrist 

x-rays documented prior to the date that the claimant was last insured 

showed normal findings.7

Dr. Reddy’s opinion also is inconsistent with material evidence. 

Stephen Hankins, M.D., the claimant’s provider at Sutter Health who 

recommended her elbow lateral release procedure8noted that the 

claimant had postoperative symptoms, yet she did well following 

surgery9, she achieved nearly full range of motion with no 

neurological deficits10, and her bilateral forearm pain was of an 

‘uncertain etiology.’11 In fact, Dr. Reddy’s opinion is not entirely 

consistent with and neglects to mention the claimant’s hand 

therapist’s November 25, 2013 statement that the claimant was not 

‘faithfully’ attending hand therapy.12

Accordingly, I give little weight to Dr. Reddy’s opinion.

AT 22. 

 

5 Citing AT 914.

6 Citing AT 740 (noting that June 2013 electrodiagnostic studies of upper extremities performed 

by Dr. Reddy showed normal results). 

7 Citing AT 733-734 (January 2011 diagnostic imaging report showing “unremarkable” results for 

plaintiff’s right wrist).

8 Citing AT 375 (Dr. Hankins’ July 2012 recommendation of elbow surgery).

9 Citing AT 376 (Dr. Hankins’ October 2012 note that plaintiff was “doing reasonably well” after 

surgery and had “nearly full digital flexion and extension”).

10 Citing AT 376, 394 (Dr. Hankins’ November 2012 note that plaintiff “does not feel any 

significant improvement compared with her symptoms prior to surgery. On examination she has 

nearly full range of motion, no neurological deficits.”). 

11 Citing AT 506 (Dr. Hankins’ April 2014 note that plaintiff continued to present with bilateral 

forearm pain, claimed surgery had not provided “any benefit whatsoever,” and on exam had full 

range of motion and positive radial tunnel tenderness. Dr. Hankins noted “bilateral forearm pain 

of uncertain etiology”).

12 Citing AT 501 (November 2013 medical note).

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In contrast, the ALJ credited the opinion of State agency reviewing physician Dr. Nancy 

Armstrong, who concluded in a March 2016 assessment that plaintiff “could perform light 

exertional work; she could frequently handle and finger on the right; she is unable to forcefully 

grip on the right; and she could frequently feel with the bilateral upper extremities.” AT 21, 

citing AT 78-81 (opining that plaintiff “had complaints of hand/arm pain, with minimal findings. 

The marked alleged functional limitations are not supported by her impairment and are only 

partially credible at most.”). 

The ALJ similarly credited the opinion of State agency reviewing physician Dr. H. 

Bronstein, who concluded in a June 2016 assessment that plaintiff “could perform light exertional 

work; she could frequently handle and finger on the right; she could occasionally engage in strong 

gripping on the right; she could frequently feel bilaterally; and she must avoid all exposure to 

hazards, including unprotected heights.” AT 21, citing AT 88-91.

The ALJ found Dr. Armstrong’s and Dr. Bronstein’s opinions “consistent with the 

discussed treatment evidence that reflects normal EMG testing and normal radiographic studies of 

the wrists, in addition to providing reasonable restrictions when considering the claimant’s 

surgery for epicondylitis.”13 AT 21. The ALJ found that these opinions also provided reasonable 

restrictions based on plaintiff’s obesity and treatment history. AT 21. 

The weight given to medical opinions depends in part on whether they are proffered by 

treating, examining, or non-examining professionals. Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 

1995). Ordinarily, more weight is given to the opinion of a treating professional, who has a 

greater opportunity to know and observe the patient as an individual. Id.; Smolen v. Chater, 80 

F.3d 1273, 1285 (9th Cir. 1996). 

To evaluate whether an ALJ properly rejected a medical opinion, in addition to 

 

13 “Lateral epicondylitis, commonly known as ‘tennis elbow,’ is a painful condition involving the 

tendons that attach to the bone on the outside (lateral) part of the elbow. . . . This can lead to pain 

associated with activities in which this muscle is active, such as lifting, gripping and/or grasping. 

Sports such as tennis are commonly associated with this, but the problem can occur with many 

different activities.” American Society for Surgery of the Hand, 

https://handcare.assh.org/Anatomy /Details-Page/ArticleID/27941/Tennis-Elbow-LateralEpicondylitis (last accessed January 16, 2020). 

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considering its source, the court considers whether (1) contradictory opinions are in the record, 

and (2) clinical findings support the opinions. An ALJ may reject an uncontradicted opinion of a 

treating or examining medical professional only for “clear and convincing” reasons. Lester, 81 

F.3d at 831. In contrast, a contradicted opinion of a treating or examining professional may be 

rejected for “specific and legitimate” reasons, that are supported by substantial evidence. Id. at 

830. While a treating professional’s opinion generally is accorded superior weight, if it is 

contradicted by a supported examining professional’s opinion (e.g., supported by different 

independent clinical findings), the ALJ may resolve the conflict. Andrews v. Shalala , 53 F.3d 

1035, 1041 (9th Cir. 1995) (citing Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989)). In 

any event, the ALJ need not give weight to conclusory opinions supported by minimal clinical 

findings. Meanel v. Apfel, 172 F.3d 1111, 1113 (9th Cir. 1999) (treating physician’s conclusory, 

minimally supported opinion rejected); see also Magallanes , 881 F.2d at 751. The opinion of a 

non-examining professional, without other evidence, is insufficient to reject the opinion of a 

treating or examining professional. Lester, 81 F.3d at 831.

Plaintiff asserts that the ALJ did not provide legitimate reasons, supported by the record, 

to discount Dr. Reddy’s 2017 opinion. She argues that, contrary to the ALJ’s analysis, Dr. 

Reddy’s report was consistent with treatment notes indicating tenderness in plaintiff’s right 

forearm and elbow, and pain on internal rotation of her right arm and wrist. See e.g., AT 744, 

746, 749-750, 752-753, 756-757, 760, 763. However, insofar as these treatment notes were based 

on plaintiff’s subjective symptoms, the ALJ found these not fully credible in an unchallenged 

finding. AT 21; see AT 19-20 (discussing medical evidence of hand and arm issues). 

Moreover, Dr. Reddy’s work status designation of plaintiff as “temporarily totally 

disabled” for part of 2013 and most of 2014, in part due to a diagnosis of depression14, are 

inconsistent with multiple normal exam findings during the alleged period of disability and 

evidence of improvement, as noted by the ALJ.

For example, progress notes often show physical examination 

findings including full upper extremity range of motion with no 

 

14 AT 742, 750, 755, 768, 771.

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edema or atrophy, 4/5 to 5/5 strength, and intact sensation despite 

forearm tenderness and mixed findings of positive and negative 

Tinel’s and Phalen’s signs. . . . By July 10, 2013, progress notes state 

that the claimant was using a TENS unit with ‘good benefit.’15 In 

fact, the claimant’s progress notes repeatedly state that the claimant 

was released to ‘[r]egular duty’ and ‘[f]ull duty’ work.16

AT 20; see generally AT 315-512. 

Plaintiff cites post-surgical treatment notes showing that she continued to report disabling 

pain and impaired function in her arms and hands. See, e.g., AT 795 (“The patient continues to 

feel that [their] hand [sic] are tired. She reports that she can not peel an orange. She can not do 

any gripping due to her pain. . . . [S]he continues to have difficulty using her arms.”). However, 

these subjective complaints implicate the ALJ”s unchallenged negative credibility finding. See

Gertsch v. Colvin, 589 Fed. App’x 381 (9th Cir. 2015) (unpublished) (“The ALJ rejected 

[claimant’s] subjective complaints as not credible, a finding that [claimant] does not challenge on 

appeal and has therefore waived.”), citing Avenetti v. Barnhart, 456 F.3d 1122, 1125 (9th Cir.

2006).

Finally, the ALJ properly discounted Dr. Reddy’s opinion as to plaintiff’s condition in the 

years prior to July 2013, when Dr. Reddy began treating her. See Meanel v. Apfel, 172 F.3d at

1113 (treating physician’s conclusory, minimally supported opinion rejected). The undersigned 

concludes that the ALJ supplied specific and legitimate reasons, supported by substantial 

evidence, for discounting the opinion of treating physician Dr. Reddy. 

B. Severe Mental Impairment

Plaintiff asserts that the ALJ erred by not finding her depression a severe impairment 

at step two of the sequential evaluation. 

At step two, ALJ found plaintiff to have multiple severe physical impairments. AT 17. 

Though the ALJ discussed plaintiff’s diagnoses and complaints of depression (AT 17), he found 

her mental impairments to be non-severe for the following reasons: 

 

15 AT 337. 

16 AT 318, 321, 323, 326, 328, 332, 334.

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When considering the factors in Social Security Ruling 16-3p, the 

claimant’s allegations are not entirely consistent with the evidence. 

For example, progress notes . . . often show generally normal mental 

status findings[.]17 While the claimant’s providers have described 

her reported symptoms as being moderate to severe, progress notes 

show that the claimant reported improvement with her anxiety [on 

medication] by August 5, 2015.18 By December 4, 2015, . . . her 

provider stated that her anxiety ‘has been appropriately managed.’19

. . . 

The claimant completed a Function Report; however, she largely 

attributed her limitations to her physical condition rather than to any 

psychiatric symptoms.20 . . . Furthermore, when the claimant [was] 

treated at Mercy Medical Group, her mental status examination 

findings have been normal with the exception that she has presented 

with the anxious affect.21

AT 18. 

The ALJ also gave “great weight” to the opinion of State agency reviewing psychiatrist 

Dr. L. Colsky, who opined in March 2016 that plaintiff did not have a severe mental impairment. 

AT 18; see AT 72-82. Dr. Colsky concluded that plaintiff’s alleged mental limitations were not 

“substantiated by the objective medical evidence” and were only partially consistent with the total 

medical evidence. AT 78. The ALJ concluded that plaintiff had mild limitations in 

understanding, remembering, or applying information; interacting with others; concentrating, 

persisting, or maintaining pace; and adapting or managing herself. AT 18. 

An impairment or combination of impairments is deemed to be severe at step two if it 

“significantly limits [plaintiff’s] physical or mental ability to do basic work activities.” 20 C.F.R. 

§§ 404.1520(c), 404.1521(a). Basic work activities encompass “the abilities and aptitudes 

necessary to do most jobs,” including “(1) physical functions such as walking, standing, sitting, 

lifting and carrying, (2) capacities such as seeing, hearing, and speaking, (3) understanding, 

 

17 Citing AT 846-912.

18 Citing AT 883.

19 Citing AT 882.

20 Citing AT 212-225 (February 2016 report).

21 Citing AT 846-912.

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carrying out, and remembering simple instructions, (4) use of judgment, (5) responding 

appropriately to supervision, co-workers, and usual work situations, and (6) dealing with changes 

in a routine work setting.” 20 C.F.R. § 404.1521(b). An impairment is “not severe” only if it 

“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.” SSR 85-28. The 

purpose of step two is to identify claimants whose medical impairment is so slight that it is 

unlikely they would be disabled even if age, education, and experience were taken into account. 

Bowen v. Yuckert, 482 U.S. 137, 107 S. Ct. 2287 (1987). “The step-two inquiry is a de minimis 

screening device to dispose of groundless claims. An impairment or combination of impairments 

can be found not severe only if the evidence establishes a slight abnormality that has no more 

than a minimal effect on an individual’s ability to work.” Smolen v. Chater 80 F.3d 1273, 1290 

(9th Cir. 1996); see also Edlund v. Massanari, 253 F.3d 1152, 1158 (9th Cir. 2001). Impairments 

must be considered in combination in assessing severity. 20 C.F.R. § 404.1523. 

As the Ninth Circuit explained in Buck v. Berryhill, 869 F.3d 1040, 1048-49 (9th Cir. 

2017), “Step two is merely a threshold determination meant to screen out weak claims. It is not 

meant to identify the impairments that should be taken into account when determining the RFC. 

In fact, in assessing RFC, the adjudicator must consider limitations and restrictions imposed by 

all of an individual’s impairments, even those that are imposed by all of an individual’s 

impairments, even those that are not ‘severe.’ The RFC therefore should be exactly the same 

regardless of whether certain impairments are considered ‘severe’ or not.” (Internal quotes and 

citations omitted.) 

Here, the RFC included no mental limitations. The vocational expert (VE) testified that 

plaintiff had previously worked as a telephone solicitor, administrative clerk, salad counter 

attendant, and cashier. AT 65-66. The VE next testified that someone with plaintiff’s RFC could 

perform unskilled work as an investigator, school bus monitor, or usher. AT 67-68. 

Notably, despite the absence of mental limitations in the RFC, the ALJ questioned the VE 

about unskilled jobs for someone with plaintiff’s physical limitations, and those available jobs 

were the basis of the ALJ’s finding of nondisability. AT 24. Unskilled work requires “little to no 

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judgment to do simple duties that can be learned on the job in a short period of time.” 20 C.F.R. 

§ 404.1568(a). 

Plaintiff has not shown that she had greater mental limitations than the mild variety found 

by the ALJ, a finding supported by Dr. Colsky’s opinion and other cited evidence, including

normal mental status findings and plaintiff’s emphasis on physical limitations in her Function 

Report. Mild mental impairment is generally consistent with unskilled work. See Caldera v. 

Astrue, 2010 WL 2991484 (C.D. Cal. July 27, 2010) (“Nor has Caldera shown any inconsistency 

between a mild mental impairment and her ability to perform simple, unskilled work activities at 

step five of the sequential analysis.”). Thus, given that plaintiff was found nondisabled based on 

her ability to perform unskilled jobs, any error in failing to include mild mental limitations in the 

RFC is harmless. 

CONCLUSION

IT IS HEREBY ORDERED that the Clerk of Court shall assign a district judge to this 

action.

For the reasons discussed above, IT IS HEREBY RECOMMENDED that: 

1. Plaintiff’s motion for summary judgment (ECF No. 8) be denied;

2. The Commissioner’s cross-motion for summary judgment (ECF No. 12) be granted; 

and 

3. Judgment be entered for the Commissioner.

These findings and recommendations are submitted to the United States District Judge 

assigned to the case, pursuant to the provisions of 28 U.S.C. § 636(b)(l). Within fourteen days 

after being served with these findings and recommendations, any party may file written 

objections with the court and serve a copy on all parties. Such a document should be captioned 

“Objections to Magistrate Judge’s Findings and Recommendations.” Failure to file objections 

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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: January 22, 2020

2/alva0086.ssi.ckd.cjra

_____________________________________

CAROLYN K. DELANEY

UNITED STATES MAGISTRATE JUDGE

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