Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_18-cv-01624/USCOURTS-casd-3_18-cv-01624-1/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

COREY BARKER,

Plaintiff,

v.

COMMISSIONER OF SOCIAL 

SECURITY,

 Defendant.

Case No.: 3:18-CV-01624-LAB(KSC)

REPORT & RECOMMENDATION 

RE: PLAINTIFF’S MOTION FOR 

SUMMARY JUDGMENT [DOC. NO. 

17] & DEFENDANT’S CROSS 

MOTION FOR SUMMARY 

JUDGMENT [DOC. NO. 22]

Plaintiff Corey Barker seeks judicial review of defendant Social Security 

Commissioner’s determination that he is not entitled to disability insurance benefits. 

Plaintiff has filed a Motion for Summary Judgment and defendant has filed a Cross-Motion 

for Summary Judgment. (Doc. No. 17 & 22.) At issue is defendant’s assessment of 

plaintiff’s Residual Functional Capacity (“RFC”)1 Plaintiff contends that the RFC he was 

assigned is not supported by substantial evidence because the Administrative Law Judge 

 

1 An RFC is "the most" the plaintiff can do, despite any limitations. Dominguez v. Colvin, 808 F.3d 

403, 405 (9th Cir. 2016).

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(“ALJ”) failed to properly analyze and weigh certain opinion evidence. Specifically, 

plaintiff argues that the ALJ improperly afforded “little weight” to the opinions of 

examining physician Dr. Thomas Moyad, the two State Agency consultants and plaintiff’s 

mother and improperly relied on the opinions of examining physician Dr. Thomas J. 

Sabourin. (Doc. No. 17, pp. 10-11.) 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. PROCEDURAL HISTORY

Plaintiff filed an application for disability insurance benefits on July 21, 2014,

alleging a disability onset date of March 23, 2014. (Administrative Record (“AR”) at 160.)

Plaintiff’s claim was denied at the initial and reconsideration stages and plaintiff, therefore, 

requested a hearing before an ALJ. (Id. at 111-13.)

I. FACTUAL BACKGROUND 

Plaintiff was born on May 31, 1959. (Id. at 71.) He has worked in the furniture, home 

improvement and construction industries and as a cook. (Id. at 46, 166-69.) Plaintiff 

reported that he has not worked since his disability onset date of March 23, 2014.

2

(Id. at 

44.) He went to live with and take care of his parents after he separated from his wife. (Id.

 

2 Although plaintiff reported he has not worked since March 23, 2014, the record indicates he 

received unemployment insurance benefits (UIB) after that date, specifically in the second and third 

quarters of 2014 and the first quarter of 2015. In order to receive UIB one must certify he or she is able 

to work and is looking for employment. (AR at 15-16 & 174-175, http://www.edd 

.ca.gov/unemployment/Eligibility.htm). Additionally, he testified at the Administrative Hearing on 

September 12, 2016, that he had been working part-time, zero to 12 hours a week, delivering flowers, 

since May 2016.(Id. at 43-44.) Plaintiff’s medical records also evidence that plaintiff worked after his 

alleged disability onset date. On June 22, 2016, notes prepared by his physical therapist indicate plaintiff 

reported the flower shop where he worked "moved to another building and he has had to carry heavy 

counters" (Id. at 547-548.) On June 29, 2016, he reported an "increase in back aggravation due to 

lifting/moving objects for work" (Id. at 545-546.) Notes from a physical therapy session on July 11, 

2016, indicate plaintiff missed his physical therapy appointment the prior week but he still worked. (Id.

at 542-543.) Plaintiff also reported to consultative examining physician Dr. Thomas Sabourin, that he 

stopped working the flower delivery job on September 27, 2016. (Id. at 570.)

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at 47.) Now he lives alone. He alleges that his ability to do work is limited by his back pain 

and anxiety. (Id. at 49-50.)

II. MEDICAL RECORDS

Medical records that are relevant to plaintiff’s argument the ALJ’s RFC assessment 

is not supported by substantial evidence and this Court’s review thereof are summarized 

below. 

A. Kekoa C. Ede, M.D., Neighborhood Healthcare, Treating Psychiatric 

Specialist

Plaintiff was seen by Dr. Ede on August 21, and September 18, 2013, for a 

psychiatric evaluation. (Id. at 288-292.) On these visits, plaintiff reported that he was not 

able to sleep very well, he was “pretty anxious” about a job interview and was having 

anxiety attacks twice a week. (Id. at 288.) On September 18, 2013, Dr. Ede noted that 

plaintiff seemed well developed and nourished with no acute distress. (Id.)

Psychologically, Dr. Ede found no delusions or hallucinations and that plaintiff was 

cognitively alert and oriented. (Id.) Dr. Ede diagnosed plaintiff with panic disorder without 

agoraphobia and prescribed him Sertraline and Gabapentin. (Id. at 288-91.)

B. William Bailey, M.D., Partners Urgent Care, Treating Physician 

Dr. Bailey saw the plaintiff on April 15, 2014, for lower back pain. (Id. at 351.) At 

that time, plaintiff reported he had terrible back pain making it difficult to walk or move.

(Id.) Dr. Bailey observed plaintiff to be uncomfortable and exhibiting very antalgic position 

changes. (Id.) He noted plaintiff had right hip shift elevation, his back was very tender, he 

experienced paralumbar spasms and he had very guarded motion. (Id.) Dr. Bailey 

diagnosed plaintiff as having lumbar sprain and strain, prescribed him a Toradol injection 

as well as Norco and Cyclobenzaprine and instructed plaintiff to seek further treatment if

he had no improvement. (Id. at 351-52.)

/ /

/ /

/ /

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C. Shahla Ramin, M.D., Vallette and Associates, Consultative Examining

Psychiatrist Specialist 

Plaintiff saw Dr. Ramin on September 30, 2014, for a consultative psychiatric 

evaluation. (Id. at 304-06.) Dr. Ramin noted that it was difficult to render a psychiatric 

opinion because no psychiatric records existed at the time, so he relied on plaintiff’s selfreport and his brief observations during this visit. (Id. at 305.) Dr. Ramin’s impression was 

that plaintiff had adjustment disorder with depressed mood and psychological and 

environmental (occupational) problems. (Id. at 306.) Dr. Ramin assigned plaintiff a GAF 

score of 65. (Id.) He found no real limits on plaintiff’s mental or social abilities. (Id. at 305-

06.) He further noted that plaintiff is able to complete simple and detailed tasks and 

activities of daily living without supervision. (Id. at 305.)

D. Thomas Moyad, M.D., Orthopedic Surgery, Consultative Examining

Physician 

Plaintiff first saw Dr. Moyad, an orthopedic surgeon, on October 1, 2014, for 

evaluation of plaintiff’s chief complaint, his back problems. (Id. at 309-312.) Dr. Moyad’s 

general examination findings were: (1) the trunk and extremities demonstrated TTP [tender 

to palpitation] along medial scapula border on the left upper back; (2) mild TTP on lumbar 

spine midline; (3) positive SLR [straight leg raise] in supine position on the left side with 

pain radiating to thigh, negative SLR on right side; (4) pain in the right shoulder with 160 

degrees flexion and positive Hawkin’s sign on the right shoulder; (5) pain in left medial 

scapula with full left shoulder flexion at 180 degrees; (6) positive crepitus in the right 

Subacromial shoulder with circular motion at the GHJ [glenohumeral joint]; (7) lumbar 

spine is painful with radiating pain down the left leg when ranging to maximal 80 degrees 

of lumbar flexion; (8) pain with 30 degrees lumbar extension without radicular symptoms; 

(9) pain (noted with facial grimace) with lateral bending of the lumbar spine bilaterally to 

30 degrees; and (10) mild lumbar spasm palpation. (Id. at 310.) He also conducted a 

comprehensive range of motion test. (Id.) The only finding was pulses in the bilateral distal 

extremities. (Id.) 

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Dr. Moyad ordered a spine exam which showed: (1) mild anterolisthesis of L4 and 

L5 with mild disc space narrowing present at L4/L5 and L5/S1; (2) mild anterolisthesis of 

L4 and L5 which may be related to pars defect at L4; (3) peri-apophyseal sclerosis present 

from L3/L4 to L5/S1; and (4) formation of anterior osteophyte at L4 and L5. (Id. at 312, 

321.) The impression from this exam was that plaintiff has moderative degenerative 

changes with anterolisthesis (mild) at L4 and L5. (Id.) 

Based on the above examinations and findings, Dr. Moyad diagnosed plaintiff with: 

(1) lumbar spondylosis and L4-5 Spondylosis with Stenosis; (2) mild left leg radiculopathy; 

(3) right thoracic back rhomboid chronic strain; and (4) left shoulder sub-acromial 

impingement/Bursitis. (Id. at 312.) 

Dr. Moyad also completed a functional assessment for the plaintiff. (Id.) He opined

that in an 8-hour workday with normal breaks, plaintiff can be expected to sit 6 hours and 

stand or walk no more than 6 hours and that he can lift/carry 20 pounds occasionally and 

10 pounds frequently. (Id.) The main limiting factors identified were painful lumbar 

Stenosis, Radiculopathy, and Degenerative Spondylolisthesis with evidence of nerve root 

impingement. (Id.) As to postural limitations, Dr. Moyad found plaintiff could be expected 

to climb, stoop, bend, and crouch only occasionally due to his degenerative lumbar spine 

and intermittent radicular symptoms. (Id.) He further noted plaintiff’s manipulative 

limitations, finding he should be limited in reaching with his right shoulder because of 

Subacromial Bursitis, which was observed during the exam with a demonstration of pain

when reaching overhead. (Id.)

E. J. Hartman, M.D., State Agency Consultant 

On November 13, 2014, Dr. Hartman conducted a consultative review of medical 

records relating to plaintiff’s primary diagnosis of discogenic and degenerative back 

disorder and secondary diagnosis of affective mood disorder. (Id. at 70-82.) Specifically, 

he reviewed the medical records from Dr. Ramin, Dr. Moyad, Dr. Ede and Dr. Bailey, 

which are summarized above. (Id. at 72-74.) He gave great weight to the opinions of Dr. 

Ramin and Dr. Moyad. (Id. at 78.) 

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Based on these records, Dr. Hartman concluded plaintiff’s back disorders were 

severe and his affective mood disorder was not severe. (Id. at 77.) He assessed that plaintiff

was mildly restricted with respect to activities of daily living, had mild difficulties in 

maintaining social function and mild difficulties in maintaining concentration, persistence, 

and pace. (Id.) He noted that one or more of plaintiff’s impairments can be expected to 

cause his pain or other symptoms, but observed that plaintiff’s statements about the 

intensity, persistence and limiting effects of his symptoms were not supported by the 

medical evidence alone. (Id. at 78.) The external limitations he determined to be applicable

to plaintiff are: (1) can occasionally carry/lift 20 pounds; (2) can frequently carry/lift 10 

pounds; (3) can stand or walk with normal breaks for 6 hours in an 8-hour work day; (4) 

can sit with normal breaks for 6 hours in an 8-hour work day; and (5) can push and pull 

other than that shown for lift/carry. (Id. at 79.) Regarding postural limitations, Dr. Hartman 

noted plaintiff could never climb ladders, ropes, and scaffolds, but could occasionally 

climb ramps, balance, stoop, crouch and crawl. (Id.) Dr. Hartman believed plaintiff

frequently had manipulative limitations such as reaching in any direction, and specifically 

reaching left and overhead. (Id. at 79-80.) 

F. A. Khong, M.D., State Agency Consultant 

On February 5, 2015, Dr. Khong performed a consultative review of plaintiff’s back 

and affective mood disorder. (Id. at 84-95.) His review was limited to the records from Dr. 

Ramin, Dr. Moyad, Dr. Ede and Dr. Bailey. (Id. at 85-87.) He gave great weight to the 

opinions of Dr. Ramin and Dr. Moyad, but noted Dr. Moyad had a short relationship with 

plaintiff. (Id. at 93.)

Dr. Khong noted there was no change in plaintiff’s condition and he had no new 

physical or mental limitations. (Id. at 85.) He concurred with the external limitations

assigned by Dr. Hartman. (Id. at 91.) Dr. Khong projected improvement with physical

therapy, and that plaintiff would be capable of medium lifting and carrying and occasional 

stooping by April 1, 2015, at which point plaintiff could perform past relevant work. (Id.

at 85, 93-94.)

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G. Family Health Centers of San Diego, Treating Medical Professionals 

(2014-2015)

1. Suriti Kundu, M.D. and Steven Santoyo, M.D. (October 2014 -

February 2015)

Plaintiff started receiving treatment at Family Health Centers of San Diego on 

October 2, 2014. (Id. at 332-34, 495-497.) At his first visit he was seen by Dr. Kundu. (Id.) 

Plaintiff reported having recent panic attacks, which Dr. Kundu theorized may be due to 

mild depression. (Id.) With respect to his back problems, plaintiff reported his pain level

as 7 out of 10, which he admitted was more than usual. (Id.) He denied having any 

weakness, numbness or tingling. (Id.) Dr. Kundu noted subjective tenderness in the left 

lower back to the left of the spine and ordered physical therapy, x-rays and lab work. (Id.) 

On October 16, 2014, plaintiff returned to Dr. Kundu to review the lab results and 

x-rays. (Id. at 335-337, 498-500.) The x-rays showed plaintiff had: (1) forward subluxation 

of L4 and L5 with probable associated pars defect; (2) narrowing of L3, L4, and L5 with 

osteophyte formation, indicating degenerative disc disease at L3, L4 and L5; and (3) Grade 

1 spondylolisthesis at L4. (Id. at 322.) Plaintiff reported having 4 days of acute midthoracic 

back pain to the right of his spine in the T11-12 area, which he described as severe and 

burning and rated as a pain level of 9 out 10. (Id. at 335.) He described the pain as being 

typical of other flareups. (Id.) Dr. Kundu found reduced flexion/extension and localized 

tenderness at the T11-12 area. (Id.) The doctor observed plaintiff had two areas of concern 

with respect to his back: lower back pain with asymptomatic Grade 1 spondylolisthesis;

and acute thoracic spinal pain consistent with back strain. (Id. at 336.) Plaintiff was 

prescribed Mobic and Robaxin and directed to treat his back with moist heat. (Id.) An 

additional x-ray was conducted on October 17, 2014, which showed degenerative disc 

disease from approximately T6-T9, with disc narrowing and degenerative changes in this 

area. (Id. at 320.) 

On November 20, 2014, plaintiff was seen at the Family Health Centers by Dr. 

Santoyo. (Id. at 338-340, 501-503.) Notes of this visit indicate the subject of the visit was 

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primarily hypertension. (Id.) No back problems were reported at the time. On January 7, 

2015, plaintiff returned to Dr. Kundu. (Id. at 341-342) Dr. Kundu observed plaintiff’s 

appearance to be well. (Id. at 341.) The subject of that visit was his anxiety. He had been 

taking Celexa for two months and reported feeling angry and irritable, which were the same 

side effects he experienced when taking Zoloft. (Id.) Dr. Kundu directed him to taper off 

Celexa and ordered a trial for Atarax. (Id.) No back problems were reported or observed 

during this visit. 

On January 19, 2015, plaintiff was seen by Monica Farfan, a registered dietitian, for 

help with his hypertension, hyperlipidemia and weight management. (Id. at 344-345.) On 

February 26, 2015, he had an appointment with Dr. Kundu, but left without being seen. (Id.

at 493-494.)

2. Physical Therapy Sessions (January - June 2015)

Plaintiff underwent his first series of physical therapy sessions through Family 

Health Centers from January to June 2015. (Id. at 355-357, 359-366, 370-372, 437-464, 

469-492, 506-513.) On February 10, 2015, he reported increased pain in his lower back, 

which he reported he had strained while renovating a kitchen. (Id. at 480.) At the February 

13 and 19, 2015 sessions, he reported some improvement but was still working on the 

kitchen renovation, which aggravated his lower back pain. (Id. at 483, 486) The stiffness 

and lower back pain continued in February, March, April, and May of 2015, although 

plaintiff showed continued steady progress towards improvement. (Id. at 420, 440-441, 

442-443, 448-462.) 

On April 7, 2015, it was noted good progress had been made, but plaintiff continued 

to report back pain limiting his functional capacity and decreased ability to lift/carry weight 

due to pain. (Id. at 361.) Plaintiff also failed to meet certain goals such as ability to lift and 

carry 20 pounds or have the ability to return to work, full duty, without restrictions. (Id. at 

359.) It was recommended he continue physical therapy for another four weeks to address 

pain, work limitations, and postural deficits. (Id. at 361.) On June 4, 2015, plaintiff noted 

increased pain in the mid-back area, which he rated as 6 out of 10. (Id. at 507.) 

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On June 17, 2015, plaintiff was seen for physical therapy reassessment and 

treatment, by which time he had attended a total of 23 sessions at a frequency of twice a 

week. (Id. at 355-357.) He reported minimal to no lower back pain, but had aggravated 

pain, which he rated as 7 out of 10, in the upper thoracic area after moving a piece of heavy 

furniture. (Id. at 355.) The physical therapist recommended plaintiff be discharged from 

physical therapy because all treatment goals for his lower back problems had been met, 

and that he be referred to a chiropractor and/or a pain management specialist for treatment 

of the thoracic area. (Id. at 356-357.)

3. P.A. Martini Murialdo and Dr. Sally Alassil (June - November 2015)

On June 9, 2015, plaintiff saw Physician Assistant (“P.A.”) Murialdo for a physical. 

(Id. at 465-468.) The symptoms which prompted that visit were an intermittent cough, 

depression, insomnia and back pain. (Id.) With respect to his mental health, plaintiff 

reported he was sometimes stressed and anxious due to responsibilities at home. (Id. at 

465.) He was mildly depressed and said he did not like leaving his home. (Id.) He was not 

interested in counseling, but said he would try Amitryiptyline. (Id. at 465-466.) P.A. 

Murialdo noted the physical therapist’s recommendation that plaintiff try chiropractic 

treatment and/or be referred to pain management but, because his insurance denied 

coverage for chiropractic treatment, she made a pain management referral. (Id. at 466.) On 

November 18, 2015, plaintiff was seen by Dr. Alassil to review lab results. (Id. at 435-

436.) He did not report any back pain at that time. 

H. Hussein Abdulhadi, M.D., Treating Pain Management Specialist 

Plaintiff saw Dr. Abdulhadi on January 9, 2016. (Id. at 367.) During this visit, 

plaintiff reported having lower back, leg and thoracic pain, which he rated as mild when 

resting and severe with physical activity. (Id.) Dr. Abdulhadi found lumbosacral 

tenderness, SLR, and thoracic tenderness and assessed plaintiff with: (1) degenerative disc 

disease; (2) Listhesis of L4-L5; (3) Stenosis back pain; (4) sciatica 2 degrees above; and 

(5) degenerative disc disease of thoracic pain/mid thoracic. (Id.) Dr. Abdulhadi noted 

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plaintiff was unable to do activities of daily life and physical therapy due to pain and

prescribed Tramadol and Neurontin. (Id.)

I. Family Health Centers of San Diego (February – July 2016)

1. Dr. Alassil and P.A. Randall Culler (February – May 2016)

Plaintiff met with Dr. Allassil on February 18, 2016, at which time the doctor 

addressed plaintiff’s hypertension and chronic pain. (Id. at 432-434.) With respect to his 

back issues, the doctor reported increased muscle tension over the upper back, lower back, 

and cervical paraspinal muscles and point tenderness to palpation over scapulae. (Id. at 

433.) Plaintiff reported Tramadol was not helping with his back pain, and it was noted his 

insurance had twice denied coverage for an epidural injection. (Id.) 

On March 28, 2016, plaintiff returned to Family Health Centers after having been 

treated at the Grossmont Hospital Emergency Room on March 25, 2016, for pain in his left 

leg.3(Id. at 373-375.) He was seen by P.A. Culler, who noted that plaintiff reported having 

low back pain and burning down his left leg for about 3 months, but was experiencing very 

minimal pain that day. (Id. at 373.) He also noted decreased range of motion in forward 

and side flexion. (Id. at 374.) PA Culler ordered an MRI of the lumbar spine, referred 

plaintiff for an orthopedic evaluation and for follow up with pain management. (Id.) The 

MRI, which was conducted on April 29, 2016, showed pars defects of L4 with grade I 

anterolisthesis and subsequent severe bilateral foraminal narrowing with L4 nerve root 

impingement, but no spinal stenosis. (Id. at 376-377.) 

On April 13, 2016, plaintiff returned to see Dr. Alassil regarding his hypertension 

and back pain. (Id. at 429-431.) He reported the physical therapy he did in 2015 yielded 

minimal improvement to his lower back pain and again reported that taking Tramadol for 

 

3

 Records of plaintiff’s treatment at Grossmont Hospital on March 25, 2016, are not part of the 

Administrative Record.

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pain management did not help. (Id. at 429.) Treatment notes from this visit indicate plaintiff 

went to the emergency room for excruciating back pain a few weeks earlier.

4

(Id.) He 

reported he was prescribed a Medrol dose pack, which alleviated his pain for about a week,

but it had since returned. (Id.) At the time of this visit, he was suffering lower back pain 

and reported left lower back burning pain. (Id.) He also noted occasional left foot weakness 

and numbness. (Id.) The doctor observed an increase in muscle tension over plaintiff’s

lower back and ordered an MRI and orthopedic evaluation. (Id. at 429-430.) 

On May 18, 2016, Dr. Alassil met with plaintiff again. (Id. at 426-428.) With respect 

to his back issues, she noted he was scheduled for an orthopedic evaluation on June 8, 

2016. (Id.) He had started physical therapy a few days prior and she advised him to continue 

with this course of treatment. (Id.)

2. Physical Therapy Sessions (May - July 2016)

Plaintiff underwent a second round of physical therapy from May to July of 2016. 

(Id. at 417-425, 542-550, 561-565.) At his first visit on May 20, 2016, he was observed to 

have an antalgic guarded gait. (Id. at 423.) He said he was not having radiating symptoms 

into his lower extremities because he had not been standing. (Id.) He reported he had started 

a new job that was more physical than expected. (Id.) On May 23, 2016, he reported some 

stiffness in his lower back. (Id. at 420.) On May 25, 2016, the pain and stiffness in his

lower back had lessened. (Id. at 417.) On June 14, 2016, he reported increased pain since 

his last visit and said he had been lifting and carrying heavy furniture. (Id. at 549.) He 

skipped the following visit because he was in too much pain after lifting and carrying heavy 

counters at the flower shop where he worked. (Id. at 547.) On June 22, 2016, his pain level 

was low. (Id.) On June 29, 2016, he described a general increase in back pain due to lifting 

and moving objects at work, but his pain was not bad at that time because he had not been 

on his feet long. (Id. at 545.) He missed his next appointment because he had the flu;

 

4

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however, he reported that he still worked and built a retaining wall. (Id. at 542.) On July 

22, 2016, it was observed that his pain was more localized, and he rated it as a 5 out of 10. 

(Id. at 563-564.) He was advised to decrease the intensity of his activities and to take a 

week off of work, which was noted to be an aggravating factor for his back problems. (Id.) 

At his last visit on July 28, 2016, he reported his leg pain had improved and he had no 

significant pain in his lower back. (Id. at 561-562.) 

J. Tara M. Kelly, Nurse Practitioner, UCSD Health

On June 8, 2016, plaintiff was seen by Nurse Practitioner (“N.P.”) Kelly for an 

orthopedic surgery referral. (Id. at 534-37) He reported low back pain into his left buttocks 

and down his left leg, as well as numbness on the medial foot and lower leg. (Id. at 534.) 

An MRI of his lumbar spine revealed: (1) degenerative disc disease at L1-L4 without any 

central or foraminal stenosis; (2) pars defect at L4-L5 with severe bilateral foraminal 

narrowing; (3) grade 1 anterolisthesis; and (4) disc bulge at L5-S1. (Id. at 536.) N.P. Kelly 

noted plaintiff appeared oriented, had good coordination and gait and did not need assistive 

devices. (Id.) She further noted normal results regarding the following tests: lumbar spine, 

range of motion, motor strength, deep tendon reflexes and straight leg raising. (Id.) N.P. 

Kelly further assessed him as having midline low back pain with left-sided sciatica, 

anterolisthesis and spinal stenosis. (Id.) She concluded that plaintiff was not a current 

candidate for surgery because he had not exhausted non-operative pain management 

options. (Id.) It was recommended that he use Lumbar ESI since he still had pain despite 

physical therapy and medication. (Id.) Referral to pain management was also

recommended. (Id.)

K. Family Health Centers of San Diego (July - September 2016)

On July 29, 2016, plaintiff was seen by Dr. Alassil to follow-up on his cough and 

back issues. (Id. at 555-557.) Noting he was not a candidate for surgery, she referred him 

for pain management. (Id.)

On August 30, 2016, plaintiff was seen by Internal Resident Najwan Al Ani for 

lower and upper back pain, which he reported had increased over the last few months due 

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to heavy lifting, and was worse when standing and walking. (Id. at 551-553.) He also had 

a foot injury he incurred two weeks prior while playing sports. (Id. at 551.) He had just 

completed twelve physical therapy sessions. (Id.) Resident Al Ani identified trigger points 

over plaintiff’s upper back and paraspinal muscle spasms. (Id. at 552.) Plaintiff’s gait was

noted to be normal, his strength was 5/5 in all extremities, he had full range of motion on 

both sides, and he was able to change position from standing, sitting and onto the exam 

table without evidence of pain or hesitation. (Id.) She recommended plaintiff schedule 

another appointment for trigger point injections and deferred pain medication, noting 

plaintiff had an appointment to see a new pain management specialist on September 14, 

2016. (Id. at 551-552.)

On September 9, 2016, plaintiff was seen by Internal Resident Phillip So for trigger 

point injections to treat his back pain. (Id. at 540-541.) Plaintiff reported relief after getting 

the injections. (Id. at 541.) He was advised he may need to repeat the trigger point injections 

for full relief and that he should return for more injections as needed. (Id.) He was also 

encouraged to continue physical therapy and strengthening exercises. (Id.) 

L. Deborah Birnbaum, M.D., Treating Psychiatry Specialist

On July 22, 2016 plaintiff visited Dr. Birnbaum for evaluation and treatment. (Id. at

558-60.) Plaintiff reported he was “doing well” since discontinuing Effexor, and that he 

wanted to continue with taking Xanax and Trazodone. (Id. at 558-559.) He reported he still 

had occasional panic attacks, but felt very stable overall. (Id. at 558.) Dr. Birnbaum refilled 

his Xanax and Trazodone prescriptions and directed him to return for follow-up in three 

months. (Id. at 559.)

M.Thomas J. Sabourin, M.D., Consultative Examining Orthopedic Surgeon 

On September 24, 2016, plaintiff visited Dr. Sabourin for an orthopedic consultation 

examination. (Id. at 569-574.) Dr. Sabourin examined plaintiff but did not look at any xrays or medical records. (Id. at 573.)

At that time, plaintiff reported that when he had back pain, it was worse in the midback than his lower back. (Id. at 569.) He told Dr. Sabourin that he first injured his back 

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playing baseball when he was 17; in 1980 he reinjured it in a car accident; and in March 

2014, while at work as a cabinet refinisher, he injured it again. (Id.) He reported that two 

months prior he injured his left foot while playing frisbee. (Id.) He has had physical therapy 

for his back problems and has seen a pain management doctor. (Id.) One month prior to his 

visit, he was placed on Percocet but it had not helped. (Id.) He last worked on September 

27, 2016, doing flower deliveries, but stopped when he became homeless. (Id. at 570.) 

Dr. Sabourin’s examination notes indicate plaintiff sat and stood with normal posture

and demonstrated no evidence of any tilt or list. (Id. at 571.) Plaintiff sat comfortably

throughout the examination, was able to rise from a chair without difficulty, and had no 

difficulty getting on and off the examination table. (Id.) Station and gait were satisfactory

and toe and heel walking was normal, although plaintiff complained of some pain in the 

left metatarsal area where he had recently injured himself. (Id.) 

Dr. Sabourin observed no issues with respect to plaintiff’s cervical spine. (Id.) With 

regard to the lumbar area, he noted an apparent apex left lumbar scoliosis, but minimal to 

none in the thoracic or cervical areas. (Id.) Plaintiff had minimal pain in the mid back with 

forward flexion and tenderness over the T8 spinous process. (Id.) There was no spasm, 

swelling or heat. (Id.) His range of motion was normal in all respects. (Id.)

When examining plaintiff’s extremities, the doctor observed he had grossly normal 

and painless range of motion in his shoulders, elbows, wrists, hands and fingers, hips, knees 

and ankles and satisfactory range of motion as to his toes. (Id. at 571-572.) The neurological 

exam indicated normal motor strength and sensation to light touch and pinprick throughout 

the upper and lower extremities on both sides. (Id.) Deep tendon reflexes were also normal. 

(Id.) 

Dr. Sabourin’s impression was that plaintiff had chronic thoracic and lumbar strain 

and sprain and mild scoliosis, apex left lumbar. (Id. at 572-573.) He opined that plaintiff:

(1) could lift and carry 50 pounds occasionally and 25 frequently; (2) could stand and walk 

6 hours of 8-hour workday and the same for sitting; (3) could push, pull, lift and carry; (4) 

could climb, stoop, kneel, and crouch frequently; (5) had no manipulative limitations; and 

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(6) had no need for assistive devices. (Id.) He further opined plaintiff could stand and walk 

for up to 2 hours at a time and sit for up to 6 hours at a time without interruption. (Id. at 

576.) He placed no limitation on plaintiff’s ability to use his hands and feet, including 

overhead reaching motion. (Id. at 577.) 

N. Douglas Engelhorn, M.D., Consultative Examining Psychiatric Specialist

On November 16, 2016, plaintiff visited Dr. Engelhorn for a psychiatric 

consultation. (Id. at 585-588.) Dr. Engelhorn’s diagnostic impressions were that plaintiff

had a recurrent type of major depression [a mild form] and panic disorder with 

agoraphobia. (Id. at 587.) He also noted no real mental limitations from this impression.

(Id. at 589-90.) The doctor noted that plaintiff’s physical issues, mainly chronic pain, 

predominate. (Id. at 589.)

III. THIRD-PARTY FUNCTION REPORT

Plaintiff’s mother, Gloria Barker, completed a function report on August 8, 2014. 

(Id. at 222-230.) She reported plaintiff’s back pain limits his activities because lifting and 

standing is painful. (Id. at 222.) She also reported stress seems to be a big limiting factor 

because it affects him going to the store and being around other people. (Id.) Ms. Barker 

reported that plaintiff tends to get very agitated at his parents and that he does not attend 

social functions unless it is with other family members. (Id. at 227). She also noted that he 

cannot handle stress or change of routine at all. (Id. at 228.) Medication seems to make him 

more anxious and stressed. (Id. at 229.)

With respect to plaintiff’s daily activities, Ms. Barker stated most days plaintiff

watches television, gets on the computer and helps or prepares meals if she is unable to do 

so. (Id. at 223). Plaintiff cares for both her and his father, as well as a pet that he sometimes 

feeds or walks. (Id.) Prior to his disability plaintiff was able to cook meals and do yard 

work, however, they buy more prepared food now and he can no longer do yard work due 

to his back. (Id. at 223 & 225.) He does his own laundry and vacuums, but only when his 

mother asks him. (Id.) Ms. Barker noted there has been no change in plaintiff’s ability to 

do his hobbies and interests, such as watching TV or reading. (Id. at 226.) He has difficulty 

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putting on shoes and socks, getting out of shower/bathtub enclosure and standing when 

showering. (Id.) She also noted that plaintiff’s condition affects his sleep as he is unable 

to rest at bedtime and has a hard time sleeping. (Id.) 

With respect to plaintiff’s abilities, his mother stated his condition affects his ability 

to lift, walk, bend, stand, reach, talk, climb stairs, concentrate, and get along with others. 

(Id. at 227.) She further noted he can only stand for 15 minutes without needing at least a 

5 minute rest. (Id. at 228.) 

IV. THE ADMINISTRATIVE HEARING

The Administrative Hearing was held on September 12, 2016, at which time plaintiff 

and vocational expert Mark Remas offered testimony. 

A. Plaintiff

Plaintiff testified regarding his activities of daily life and his past work, briefly 

touching upon his medical visits and alleged disabilities (Id. at 41-64.) At the time of the 

hearing, he was 57 and had been working part-time as a flower delivery driver since May

2016. (Id. at 43-44.) He worked 0 to 12 hours per week and made about $2.50 per delivery. 

(Id. at 44) Before that he had not worked since March 2014, when he was employed as a 

cabinet refinisher. (Id.) From 2007 to 2012, he worked for his then-wife’s home 

improvement business as a handyman. (Id. at 46.) In 2000, he worked as a cook at Brian 

Head Resort in Utah. (Id. at 45.)

Since he separated from his wife he has lived with his parents. (Id. at 47.) He used 

to provide caregiving services and do housework for them, but is unable to now due to his 

back problems. (Id.) He no longer vacuums or does laundry. (Id. at 60.) He recently 

vacuumed and afterwards had to lay down the entire next day. (Id. at 47.) He can only stand 

or walk for about 15-20 minutes before needing to rest; he no longer cooks or walks the 

dog. (Id. at 48-49.) Plaintiff reported that when he used to walk the dog he would also 

throw a ball or stick and the next day he would be stiff, hurting, and in pain. (Id. at 62.) If 

he cooks for his parents, he has to take breaks and lie down because standing for more than 

15-20 minutes is too painful. (Id. at 49.) He has also has difficulty showering. (Id. at 60.) 

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Elaborating on his limitations, plaintiff stated that he cannot walk around the home 

more than 5 minutes before the pain starts, but he will continue walking through the pain 

for up to 20 minutes before he has to rest, at which point he must rest for about 30 minutes 

before he can start walking again. (Id. at 57.) He can carry a bouquet of flowers or 5 pounds 

without any problems. (Id. at 58.) He estimated he can sit for 20 to 30 minutes before 

having any problems and after that he has to lie down to rest. (Id. at 59.) 

Plaintiff stated that physical therapy has not helped him. (Id. at 55.) He said the most 

effective way to alleviate his back pain is to lie down. (Id. at 56.) He estimated that in an 8 

hour day he has to lay down for about 7 hours. (Id.) Lastly, plaintiff noted that he would 

rather have Cortisone injections than surgery, due to the risks associated with surgery. (Id.

at 64.) 

As for his anxiety, plaintiff reported that he is not sure what triggers it but things like 

driving on the freeway or his pain can. (Id.) He also stated that it is too stressful for him to 

go shopping and he only goes if it will be a quick trip. (Id. at 49.) His anxiety causes him 

to throw up every morning. (Id. at 62.) He further noted that some of the medication he 

took helped him, but only for about three weeks to a month. (Id. at 63.)

B. Vocational Expert

Vocational expert Mark Remas testified that an individual like plaintiff, who was 

capable of light work, frequent postural activities, occasional stooping and crouching, 

could return to his previous work as a short order cook. (Id. at 66.) This individual would 

also be able to work as a fast food worker, lunch room or coffee shop counter attendant or 

bench assembler. (Id.) An individual with plaintiff’s work history would be precluded from 

his past work if he was only capable of sedentary work. (Id.)

V. THE ALJ’S DECISION 

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

 ....

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2. The claimant has the following severe impairments: lumbar and 

thoracic degenerative disc disease and chronic lumbar and thoracic 

strains and sprains (20 CFR 416.920(c)).

The above medically determinable impairment(s) significantly limits the 

ability to perform basic work activities as required by SSRs 85-28 and 96-

3p. The impairments above are severe because they are medically

determinable impairments diagnosed by the treating and examining

physicians. Moreover, they cause more than a minimal effect on his ability 

to do basic work activities. They have lasted for a continuous period of at 

least 12 months. The medical evidence record supports this finding (Ex. 

17F/7).

The claimant's remote fracture of right shoulder, childhood surgery of the

foot, and sprain of left toes are non-severe impairments because they do not 

cause more than a minimal effect on his ability to perform basic work related 

activities or they have not lasted, or are expected to last, a continuous period 

of 12 months. The vast majority of the sparse medical evidence record,

approximately 310 pages, is regarding the claimant's alleged back 

impairment though the medical evidence record as a whole documents his 

condition but shows a history of conservative, routine treatment and many 

normal and mild exam findings (Exs. 1F-18F, Infra).

The claimant's medically determinable mental impairments of affective

disorder and anxiety, considered singly and in combination, do not cause 

more than minimal limitation in the claimant's ability to perform basic 

mental work activities and are therefore non-severe.

In making this finding, the undersigned has considered the four broad areas 

of mental functioning set out in the disability regulations for evaluating 

mental disorders and in the Listing of impairments (20 CFR, Part 404, 

Subpart P, Appendix 1). These four areas of mental functioning are known 

as the "paragraph B" criteria.

The first functional area is understanding, remembering, or applying

information. In this area, the claimant has mild limitation. The next

functional area is interacting with others. In this area, the claimant has mild 

limitation. The third functional area is concentrating, persisting, or 

maintaining pace. In this area, the claimant has mild limitation. The fourth 

functional area is adapting or managing oneself. In this area, the claimant 

has mild limitation.

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There is substantial evidence that supports this finding. [footnote omitted]

For example, the opinions of the independent psychiatric consultative

examiners and the DDS psychiatric and psychological consultants and the 

medical evidence record support this finding.

The independent psychiatric consultative examiners and the DDS psychiatric 

and psychological consultants opined the claimant's mental condition is nonsevere (Exs. 4F/4, 18F/6, 7-9, 2A/7, 4A/6-7). The undersigned gives these 

opinions significant weight because they examined the claimant and

reviewed the claimant's records, they are familiar with the Social Security 

Administration's precise disability guidelines, and their opinions are 

consistent with the medical evidence record as a whole, which shows normal 

Mental Status Examination findings and little treatment.

Throughout the medical evidence record there are many Mental Status 

Examination findings that are normal (Exs. 4F/5, 18F/5, l F/7, 10, l0F/ 12-

13, 15-16, 20-21, 23-24, 25-26, 31-32, 13F/4, 16F/21-22). For example, the 

September 2014 independent psychiatric consultative examiner Ramin

Shahla, M.D. reported the claimant's posture, gait, and mannerisms were 

within normal range. He displayed pain behavior in regard to his back pain. 

He was well dressed and groomed with good hygiene. He was polite, 

respectful, and cooperative. He put forth good effort into the evaluation. In 

general, his speech was well organized and did not require redirection. His 

speech was normal in rate, volume, and tone. This evaluator could

understand 100% of his verbalizations. His psychomotor activity was within 

normal limits. He had good eye contact. He was oriented to time, place, 

person, and situation. He knew that the interview was for a psychiatric 

evaluation for Social Security Disability. He remembered 3 of 3 objects 

immediately and 3 of 3 objects in delayed recall. He was able to complete 

serial threes. He was able to follow a three-step command. He displayed 

good attention and concentration. When asked about similarities between an 

apple and an orange, he stated, "Fruit." When asked what he would do if 

there was a fire, he replied that he would leave. His mood at this time

appears dysthymic. This evaluator observed his affect as being constricted. 

His thought processes were goal-directed. He denied delusions or 

hallucinations. (Ex. 4F/5).

The claimant reported to September 2014 independent psychiatric

consultative examiner Dr. Shahla that he denies having a history of 

psychiatric hospitalization. Currently, the claimant is not receiving mental 

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health services. The claimant's family psychiatric history is unremarkable for 

mental illness. No history of suicidal or homicidal ideation. No history of 

mania, delusions, or hallucinations. No history of being on psychotropic 

medications. (Ex. 4F/3).

The November 23, 2016 independent psychiatric consultative examiner H. 

Douglas Engelhom, M.D. noted many normal Mental Status Examination 

findings. The Mental status examination reveals an alert, cooperative, white 

male appearing his stated age of 57 wears his hair ponytail. He is adequately 

dressed and groomed and is probably of average intelligence. His speech is 

normal and there are no unusual mannerisms noted. He actually appears to 

be in good physical health. He is fully ambulatory without assistance and 

does not appear to be in any physical distress. He easily gets from a sitting to 

standing position. He walks without assistance. His thinking is logical, and 

he makes good eye contact. There is no evidence or psychosis. There is no 

evidence of active depression. He was not noted to be at all tearful, sad or 

emotional. He seems to harbor some resentment toward his parents because 

they asked him to move out of their home. There is no evidence or 

excessive levels or anxiety. He appears to make an honest presentation. He 

is an adequate historian. His sensorium is clear, and he is fully oriented. 

There is no cognitive impairment. He could give me the exact date as well as 

the day of the week. He could correctly identify the current season or the 

year. He could name his city and state of residence. He could give me his 

address, telephone number, Social Security number and date of birth. He 

could name the current president of the United States as well as the most 

recent ex- president. He could name the capital city of this country. He 

could name the governor of California and the state capital. His 

concentration and attention were adequate as judged by accurate and rapid 

responses to serial sevens. His insight and judgment seemed fully intact, 

although not formally tested. There is no evidence or psychomotor 

retardation, flat affect, loosening of associations, delusions or hallucinations. 

(Ex. 18F/5). Dr. Engelhom also notes that the claimant continues to 

occasionally use marijuana, which he has been using since high school (Ex. 

18F/6).

There is also no evidence of extended hospitalizations, a structured

environment or an assisted care arrangement (Exs. 4F/3, 18F/4, 1F-18F).

In addition, the record shows that the claimant engages in many activities of 

daily living (ADLs), further demonstrating he has no more than mild limits. 

For example, the September 2014 independent psychiatric consultative 

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examiner Dr. Shahla reported the claimant's typical daily activities include 

the claimant gets up, watches TV, does some light housework, prepares 

dinner, and watches TV in bed. He takes care of his mother who has 

Alzheimer's. He also reports that he is painting his parent's house. He can 

take care of chores such as vacuuming, laundry, cooking, shopping, and 

doing yard work. The claimant reports enjoying reading, hiking, fishing, and

walking the dog. There is no anhedonia; i.e., there is no inability to feel 

pleasure. The claimant is able to drive. The claimant handles his own funds. 

It is also noted that he lives with his parents and he drove to the consultative 

examiner appointment (Ex. 4F/5, 3).

The November 2016 independent psychiatric consultative examiner Dr. 

Engelhorn reported the claimant lived with his parents for several years and 

provided general services to them. He has recently been living in Fontana, 

California in a camper shell because his parents apparently asked him to 

leave their home (Ex. 18F/6).

The November 2016 independent psychiatric consultative examiner Dr. 

Engelhorn reported the claimant engages in many ADLs. He is currently 

living in a camper shell located in Fontana, California. He has been living in 

this camper shell for about two months. However, he continues to visit his 

parents with regularity. He was living with his parents for the greater part of 

the past three years. He states that he is allowed to use the house where his 

camper shell is located in Fontana. He uses the bathroom, kitchen and 

laundry facilities. He drives a car and occasionally attends church services. 

He has no outside social life or close friends. He frequently watches 

television and enjoys reading. He has access to a home computer. As noted 

previously, he frequently drives down from Fontana to Santee to visit his 

parents as much as once or twice each week (Ex. 18F/4-5). He continues to 

spend considerable time with his parents here in the Santee area. He has four 

siblings and has contact with all of them. (Ex. 18F/3).

Furthermore, the claimant indicates in a function report dated August 2014 

that he lives in a house with family. On a daily basis, he gets dressed, has 

coffee and watches television or reads, helps his elderly parents, makes 

dinner, reads or watches television, and goes to bed. He shops and cooks for 

his parents. He also feeds and walks the dog. He has no problems with 

personal care (e.g. dressing, bathing, caring for hair, feeding self, using the 

toilet) except physical issues. He prepares meals daily such as sandwiches, 

dinners, and complete meals. He does chores, such as laundry, light 

housework and light yard work. He goes outside. He travels by driving, 

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walking, riding in a car, and riding a bicycle. He is able to go out alone. He 

shops in stores for groceries and books. He is able to handle finances, like 

paying bills, counting change, handling a savings account, and using a 

checkbook/money orders. His ability to handle money has not changed since 

his conditions began. In addition to reading and watching television, he uses 

Facebook daily. He also spends time with others, using Facebook and going 

to church. He also attends church regularly. He does not need reminders to 

take care of personal needs, take medicine, or go places. He does not have 

any problems getting along with family, friends, neighbors or others except 

he notes that he gets irritated and he does not like to go to parties unless it is 

with family. He gets along well with authority figures. He has never been 

fired or laid off from a job because of problems getting along with other 

people. He can pay attention as long as needed. He finishes what he starts 

(e.g. a conversation, chores, reading, watching a movie.) He does very well 

at following written and spoken instructions (Exs. 4E/6-14).

In addition, in a disability report dated March 5, 2015, when asked what 

changes have occurred in his daily activities since he last completed a 

disability he report, he states he has "been remodeling a kitchen." (Ex. 9E/4-

5).

Because the claimant's medically determinable mental impairments cause no 

more than "mild" limitation in any of the functional areas, they are nonsevere (20 CPR 416.920a(d)(l)).

The limitations identified in the "paragraph B" criteria are not a residual 

functional capacity assessment but are used to rate the severity of mental 

impairments at steps 2 and 3 of the sequential evaluation process. The 

mental residual functional capacity assessment used at steps 4 and 5 of the 

sequential evaluation process requires a more detailed assessment by 

itemizing various functions contained in the broad categories found in 

paragraph B of the adult mental disorders listings in 12.00 of the Listing of 

Impairments (SSR 96-8p). Therefore, the following residual 

functional capacity assessment reflects the degree of limitation the 

undersigned has found in the "paragraph B" mental function analysis.

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 20 CFR Part 404, Subpart P, Appendix 1(20 CFR 

416.920(d), 416.925 and 416.926).

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The undersigned considered the applicable listings, including 1.04, 1.02, and 

11.14, but the medical evidence record does not demonstrate that his 

conditions are listing level. There is substantial evidence in the medical 

evidence record that supports this finding. For example, there is no medical 

expert, or treating or examining physician, who opines that the claimant's 

conditions, singly or in combination, are listing level. As discussed below, 

the medical evidence record also supports this finding (Exs. 1F-18F, Infra).

4. After careful consideration of the entire record, the undersigned finds 

that the claimant has the residual functional capacity to perform the full 

range of medium work as defined in 20 CFR 416.967(c).

In making this finding, the undersigned has considered all symptoms and the 

extent to which these symptoms can reasonably be accepted as consistent 

with the objective medical evidence and other evidence, based on the 

requirements of 20 CPR 416.929 and SSR 96-4p. The undersigned has also 

considered opinion evidence in accordance with the requirements of 20 CPR 

416.927 and SSRs 96-2p, 96-5p, 96-6p and 06-3p.

In considering the claimant's symptoms, the undersigned must follow a twostep process in which it must first be determined whether there is an 

underlying medically determinable physical or mental impairment(s)--i.e.,

an impairment(s) that can be shown by medically acceptable clinical and 

laboratory diagnostic techniques--that could reasonably be expected to 

produce the claimant's pain or other symptoms.

Second, once an underlying physical or mental impairment(s) that could

reasonably be expected to produce the claimant's pain or other symptoms 

has been shown, the undersigned must evaluate the intensity, persistence, 

and limiting effects of the claimant's symptoms to determine the extent to 

which they limit the claimant's functional limitations. For this purpose, 

whenever statements about the intensity, persistence, or functionally limiting 

effects of pain or other symptoms are not substantiated by objective medical 

evidence, the undersigned must consider other evidence in the record to 

determine if the claimant's symptoms limit the ability to do work-related 

activities.

As discussed within, the medical evidence record documents the claimant's 

condition but shows a history of conservative, routine treatment and many 

physical and mental exam findings that are normal (Supra, Infra). Moreover, 

there are many ADLs, including taking care of his mother who has 

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Alzheimer's, painting his parent's house, remodeling a kitchen, handling 

finances, light housework, vacuuming, laundry, cooking, shopping, and 

doing yard work, and reading, hiking, fishing, and walking the dog, that 

further contradicts his allegations and demonstrates his ability to work 

(Supra, Infra).

Despite the many normal exam findings and numerous ADLs, the claimant 

alleges in his July 16, 2014 Supplemental Security Income application that 

he is disabled and unable to work as of March 23, 2014, due to the 

following: back problem and anxiety disorder. The claimant reports that his 

conditions affect the following abilities: lifting, bending, standing, reaching, 

walking, sitting, talking, memory, concentration, and getting along with 

others. He cannot lift heavy things. His back gets stiff when he sits. His 

back problem makes it hard to stand for long periods. His anxiety affects 

talking, concentration, and getting along with others. He can walk 15 

minutes before needing to stop and rest for five minutes before resuming 

walking. He gets irritated with family. He does not like to go to parties 

unless it is with family. He has a hard time talking to people face-to-face and 

meeting new people. He gets really nervous in interviews and cannot 

concentrate. He has a hard time being around people. He cannot handle 

crowds. He also does not handle stress or changes in routine well. He loses 

his complete train of thought, and sometimes breaks down and cries. In a 

subsequent disability report, he indicates there has not been a change in his 

condition. Regarding his ability to care for his personal needs, he cannot be 

in crowds. He does not eat or he eats only a small meal a day. Raising his 

arms above his head hurts his back. He has a hard time sleeping. The pain 

wakes him up when he turns over. It is hard to put on socks and shoes. He is 

"still absolutely disabled." In a subsequent disability report, he indicates 

there has not been a change in his condition except he has "no patience with 

anything." Regarding his ability to care for his personal needs, he shaves 

once or twice a month. He does not prepare meals every night. He cleans 

his room. He misses church. He forgets things. If he goes shopping, he 

cannot remember what he needs. When asked what changes have occurred 

in his daily activities since he last completed a disability report, he states he 

has "been remodeling a kitchen." He attends therapy counseling and pain 

management. The claimant testified that he is unable to work due to his back 

issue. He described one time where he strained his back while pushing a 

vacuum and it required injections. The doctors have time him he has a 

pinched nerve in his sciatic muscle down to his leg. The doctors want him to 

take drugs but he does not want to take them. He can only stand for 15 to 20 

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minutes then he has to lay down because he is in so much pain. He has had 

back problems most of his life but his condition has gotten worse, especially 

the last two and a half years. He occasionally grocery shops for his parents 

but he has too much difficulty because it is too stressful. He testified he 

drove to the hearing and parked on the sixth floor of the parking structure. 

He also testified he gets vertigo. He attended physical therapy, going once a 

week for about 24 weeks and then did another 12 week period of physical 

therapy, but it did not help. The pain goes from between his shoulder blades 

down his sciatic nerve into his ankles. The pain in his shoulder blades is 

constant while the leg pain comes and goes. He can walk for about five 

minutes before he is in pain and 20 minutes before he cannot walk anymore, 

then he lies down. He has to lie down for 30 to 45 minutes before he can 

resume his activity. He can lift about five pounds but it hurts needs to rest. 

He can sit for 20 to 30 minutes before he has to lie down. Sometimes he lies 

on the floor. He also has anxiety and depression. His therapist has given 

him some relaxation tools to help with his anxiety. He takes the following 

medications: Darvocet (back pain), Flexeril (muscle relaxer), Galpin 

(anxiety), Hydrocodone (back pain), Lorazepam 0.5 mg to 1 mg daily as 

needed (anxiety), Norco (pain), Xanax (anxiety), Atorvastatin calcium 

(cholesterol), Citalopram (anxiety), Lisinopril (inflammation), Robaxin 500 

mg 8tablets (back pain), Hydroxyzine 25 mg once day (anxiety), Effexor 

125 mg once a day (depression) (Exs. lD/ 1, 2E/1-10, 4E/6-14, 7E/ 1- 6, 

9E/1-6, 13E/ 1, 14E/ 1, 15E/ 1, 18E/3, 19E/ 1-2, Testimony).

After careful consideration of the evidence, the undersigned finds that the 

claimant's medically determinable impairments could reasonably be 

expected to cause the alleged symptoms; however, the claimant's statements 

concerning the intensity, persistence and limiting effects of these symptoms 

are not entirely consistent with the medical evidence and other evidence in 

the record for the reasons explained in this decision.

Although the claimant's alleged onset date of disability (AOD) is March 23,

2014, the claimant's Title XVI claim was filed on July 16, 2014; thus, the 

relevant period for functional limitations is from July 16, 2014 through the 

present (Supra).

There is substantial evidence in the record that supports the residual 

functional capacity (RFC). For example, the opinion of the independent 

orthopedic consultative examiner Thomas J. Sabourin, M.D., who is a board 

certified orthopedic surgeon. Dr. Sabourin's opinion also undermines the 

claimant's allegations, including the severity of his impairments and their 

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limiting effects. In addition, the sparse medical evidence record, 

approximately 310 pages, documents his condition but shows a history of 

conservative, routine treatment and many normal and mild exam findings. 

Furthermore, there are many ADLs, including taking care of his mother who 

has Alzheimer's, painting his parent's house, remodeling a kitchen, handling 

finances, light housework, vacuuming, laundry, cooking, shopping, and 

doing yard work, and reading, hiking, fishing, and walking the dog, that 

further undermines his allegations and demonstrates his ability to work.

As far as Dr. Sabourin's opinion, Dr. Sabourin, who is a board certified 

orthopedic surgeon, examined the claimant in October 2016 and opined the 

claimant would have limits as follows: he could only lift and carry 50 

pounds occasionally and 25 pounds frequently; he could stand an walk six 

hours of an eight-hour workday and sit for six hours of an eight-hour 

workday; push and pull limitations are equal to lift and carry limitations; 

postural limits are all frequent; he has no manipulative limitation; he has no 

need for assistive devices to walk; an environmental activities are unlimited 

except frequent exposure to extreme cold, extreme heat, and vibration, and 

occasional to unprotected heights (Ex. 17F/7, 9-14). The undersigned gives 

Dr. Sabourin's opinion significant weight because he is an independent 

consultative examiner, he is a board certified orthopedic surgeon, he 

examined the claimant, he is familiar with the Social Security

Administration's precise disability guidelines, and his opinion is consistent 

with his exam findings, which are generally normal, and the medical 

evidence record as a whole, which documents his condition but shows a 

history of conservative, routine treatment and many normal and mild exam 

findings. The record also demonstrates that the claimant engages in many 

ADLs.

During the relevant period of July 16, 2014 (Supplemental Security Income 

application filing date) through the present, the sparse medical evidence 

record, approximately 310 pages, documents his conditions but only shows 

conservative, routine treatment and many normal and mild findings.

At the September 30, 2014 independent psychiatric consultative exam, the 

examiner Dr. Shahla noted the claimant's posture and gait were within 

normal limits (Ex. 4F/5).

The October 2016 independent orthopedic consultative exam revealed many 

exam findings that are normal, including the following. The claimant has no 

neurological deficit. He does have a mild scoliosis, apex, left lumbar. He is 

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a well-nourished male in no acute distress. He is alert and oriented as to 

time, place, and person. The claimant sits and stands with normal posture. 

There is no evidence of any tilt or list, and the claimant sits comfortably 

during the examination. In obtaining the upright position, the claimant rises 

from a chair without difficulty. Station and gait in this claimant is 

satisfactory. He has no assistive devices. Toe and heel walking is normal. 

He complains of some pain in the left metatarsal area where he had the 

recent injury with toe walking. He has no assistive devices with him. He has 

no difficulty getting on and off the examination table. (Ex. 17F/5, 7).

The October 2016 independent orthopedic consultative exam further

revealed many normal musculoskeletal exam findings. The cervical spine is 

normal - range of motion of the cervical spine is grossly normal and

painless, and there is no deformity, scar, tenderness, spasm, swelling, or 

warmth in the neck. Regarding the lumbar spine, he has minimal pain in the 

mid back with forward flexion. He does have an apparent scoliosis, apex left 

lumbar, but minimal to none in the thoracic or cervical areas. Scars are none. 

He is tender approximately over the T8 spinous process. There is no spasm, 

swelling, or heat. Range of motion of the lumbar spine is within normal 

limits except a slight decrease with extension (forward flexion is 90/90 

degrees, extension is 20/25, lateral flexion is 25/25, and rotation is 30/30). 

Straight leg raise is negative in the supine and sitting positions. 

Trendelenburg test is normal. Axial load tests are normal. the upper and 

lower extremities are normal -there is no tenderness, warmth, crepitus, 

instability, or swelling and range of motion is within normal limits except 

some tenderness of the feet and well-healed scars along the medial border of 

the foot over the area of the posterior tibial tendon, navicular and first 

metatarsal base. Pulses are normal, 2+, throughout (Ex. 17F/5-6).

The October 2016 independent orthopedic consultative exam further 

revealed many normal neurological exam findings. There is normal motor 

strength throughout the upper and lower extremities bilaterally (5/5). There 

is normal sensation to light touch and pinprick in the upper and lower 

extremities bilaterally. Deep tendon reflexes are normal, 2+. There is no 

clonus, spasticity, or rigidity. Babinski and Hoffmann tests are negative (Ex. 

17F/6-7).

The October 2016 independent orthopedic consultative examiner also noted 

the claimant drinks a six-pack of beer and a pint of liquor a week. He is a 

former methamphetamine user being sober for 15 years. He uses medical 

marijuana occasionally. The claimant drove himself to the

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examination (Ex. 17F/4).

An October 1, 2014 exam reports the claimant is well-developed and 

appears comfortable and in no acute distress. His gait is non-antalgic; he has 

coordinated gait with normal heel-toe progression. The Spurling's test is 

negative. Babinski 's is also negative. The neurological exam findings are 

normal. He has subjective complaints of tenderness to palpation of the left 

upper back and lumbar spine. Straight leg raise is negative on the right and 

positive on the left. There is mild lumbar spasm. There is decreased range of 

motion and a positive Hawkin's of the right shoulder. The x-rays reveal

degenerative disc disease with lumbar spondylosis and L4-5 

spondylolisthesis. There is also a diagnosis of left shoulder subacromial 

impingement/ bursitis. Motor strength is normal, 5/5, throughout the upper 

and lower extremities. Sensation is normal. Pulses are present in the 

bilateral distal extremities. Deep tendon reflexes are also normal, 2+, 

throughout (Ex. 5F/4-5).

At the November 23, 2016 independent psychiatric consultative exam, the 

examiner Dr. Engelhorn noted the claimant "actually appears to be in good 

physical health. He is fully ambulatory without assistance and does not 

appear to be in any physical distress. He easily gets from a sitting to standing 

position. He walks without assistance" (Ex. 18F/5).

An April 5, 2014 visit notes many normal exam findings, including 

neurological (Ex. 7F/6).

An October 14, 2014 x-ray of the lumbar spine reports degenerative disc 

disease at L3, L4, and L5 and grade I spondylolisthesis (Exs. 6F/ 10, 

10F/10). An x-ray of the thoracic spine shows degenerative disc disease, 

most marked at T6-T9 (Exs. 6F/8, 10F/11).

October 16, 2014 notes document that the claimant has "no problems with 

weakness/numbness" (Exs. 6F/23, 11F/83).

An October 22, 2014 visit documents that the claimant "denies 

weakness/numbness/tingling" (Ex. 6F/20).

A January 7, 2015 visit notes many normal exam findings, including 

neurological (Exs. 6F/30, 11F/89).

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A January 15, 2015 visit notes many normal exam findings, including 

neurological (Exs. 12F/3, 13F/3). It also states the claimant denies joint 

pains and joint swelling. There are no musculoskeletal or neurological 

issues noted (Exs. 12F/2-3, 13F/2-3).

Notes from February 10, 2015 indicate the claimant is working renovating a 

kitchen and ''tweek[ed]" his back (Ex. 11F/65).

A February 13, 2015 visit reflects that the claimant reports his lower back 

pain has subsided since his last visit (Ex. 11F/68).

A February 19, 2015 visit reports the claimant reports his back is slightly 

better as he continues working on the kitchen, which aggravates his back 

(Ex. 11F/71).

Notes from February 23, 2015 document the claimant aggravated his back 

"doing some kitchen remodeling over the weekend" (Ex. 11F/74).

A February 25, 2015 visit documents the claimant "reported feeling better" 

(Ex. 11F/76). 

On February 26, 2015, the claimant left without being seen (Ex. 11F/78). 

A March 26, 2015 visit reports the claimant does not have much low back 

pain, but more tightness. He fell from a tree trying to cut a branch and has 

increased pain in his limbs, especially the left elbow (Ex. 11F/54).

Notes from March 30, 2015 state the claimant's lower back is feeling better 

but he has midback tightness (Ex. 11F/59).

An April 7, 2015 visit indicates the claimant reports he can lift or carry 50 

pounds at waist level and more than five to 10 pounds overhead (Ex. 8F/7).

Notes from April 9, 2015 state the claimant denies depression and anxiety, 

and he denies joint pain and joint swelling. There are no musculoskeletal or 

neurological issues noted (Ex. 13F/4-5)

Physical therapy notes from May 15, 2015 state that the claimant reported 

his "back symptoms are feeling better, however still notes tightness" (Ex. 

11F/36). The exam findings, including neurological, are normal (Ex. 

11F/39).

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A May 27, 2015 visit notes the claimant reports increased tightness and 

lower back pain "secondary to lifting and moving objects around the house" 

(Ex. 11F/47).

A June 4, 2015 visit notes the claimant was "moving and lifting furniture" 

and has an increase in mid-back pain (Ex. 11F/92).

A June 17 and 24, 2015 visits reflect that the claimant reports he has some 

mid back pain but his lower back pain is minimal to nil (Ex. 8F/3, 11F/22). 

The June 17 [2015] notes state that the claimant has "T/S pain after moving 

a heavy piece of furniture over the weekend" (Ex. 8F/3).

An April 29, 2016 magnetic resonance imaging (MRI) scan of the lumbar 

spine shows mild degenerative disc disease, grade I anterolisthesis, and a 

two mm bulge at L5-S 1 with an annular tear but no central stenosis or 

foraminal narrowing (Exs. 10F/8-9, 15F/5).

Notes from May 20, 2016 report the claimant has a new job and it is "more 

physical than he expected," complaining of low back pain (Ex. 11F/8).

A June 8, 2016 visit reports normal physical and mental exam findings. His 

upper extremities and lower extremities have good range of motion with no 

significant deformities. His gait is brisk with good coordination. He does not 

use any assistive devices. The lumbar spine is non-tender. He can heel-to-toe 

walk without deficit. Sensation is intact but there is a positive Trendelenburg 

sign (Ex. 15F/4).

A June 22, 2016 visit states that the claimant reports that the flower shop 

(where he works) "moved to another building and he has had to carry heavy 

counters" (Ex. 16F/10).

Notes from a June 29, 2016 visit evidence that the claimant reports an 

"increase in back aggravation due to lifting/moving objects for work" (Ex. 

16F/8).

A July 11, 2016 visit reports the claimant missed his physical therapy 

appointment last week but he still worked. It also notes that the claimant 

built a retaining wall (Ex. 16F/5).

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Notes from August 30, 2016 report the claimant has been lifting heavy 

objects over the last few months and resulted in some back pain (Ex. 16F/ 

14).

The August 30, 2016 visit notes motor strength is normal, 5/5, sensation is 

normal, deep tendon reflexes are normal, and gait is normal but there is 

muscle spasm. Further, the claimant is able to change position from 

standing, sitting, and onto the exam table without evidence of pain or 

hesitation (Ex. 16F/15).

An August 31, 2016 x-ray of the left foot is negative for fracture (Ex. 

16F/29).

The medical evidence record reflects many normal and mild exam findings 

and that the claimant had physical therapy and some injections (Exs. 9F/2-3, 

10F, 11F, 1F-18F). There are also some positive exam findings such as a 

positive straight leg raise (11F/ 15) but they are contrary to the medical 

evidence record as a whole.

As for the opinion evidence, the remaining opinions are given little weight.

The opinion of Thomas F. Moyad, M.D. is given little weight because it is 

not consistent with the record as a whole, which documents his condition but 

shows a history of conservative, routine treatment and many normal and 

mild exam findings, and that the claimant engages in many ADLs. Dr. 

Moyad opined the claimant would have limits as follows: lift or carry 20 

pounds occasionally and 10 pounds frequently; stand and/or walk no more 

than six hours in an eight- hour day with normal breaks; sit six hours in an 

eight-hour day with normal breaks; he does not need an assistive device for 

short and long distances and uneven terrain; postural limitations are 

occasional climbing, stooping, bending, and crouching; manipulative 

limitations are occasional reaching with the right shoulder; and there are no 

visual, communicative, or environmental limitations (Ex. 5F/6).

The DDS medical consultants J. Hartman, M.D. and A. Khong, M.D. 

reviewed the claimant's medical records in October 2014 and February 

2015, respectively. Dr. Hartman opined the claimant would have limits as 

follows: he can occasionally lift and/or carry (including upward pulling) 20 

pounds and frequently lift and/or carry (including upward pulling) 10 

pounds; he can stand and/or walk (with normal breaks) for a total of about 

six hours in an eight-hour workday; he can sit (with normal breaks) for a 

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total of about six hours in an eight-hour workday; push and/or pull 

(including operation of hand/foot controls) is unlimited, other than shown 

for lift and/or carry; postural limitations are all occasional except no 

climbing ladders, ropes or scaffolds; manipulative activities are unlimited 

except he is limited to frequent overhead reaching with the left upper 

extremity; and there are no visual, communicative, or environmental 

limitations (Ex. 2A/9-10). Dr. Khong opined the claimant would have limits 

as follows: he can occasionally lift and/or carry (including upward pulling) 

20 pounds and frequently lift and/or carry (including upward pulling) 10 

pounds; he can stand and/or walk (with normal breaks) for a total of about 

six hours in an eight-hour workday; he can sit (with normal breaks) for a 

total of about six hours in an eight-hour workday; push and/or pull 

(including operation of hand/foot controls) is unlimited, other than shown 

for lift and/or carry; postural limitations are frequent climbing stairs or 

ramps, frequent climbing ladders, ropes, or scaffolds, frequent kneeling, 

occasional stooping, occasional crouching, and occasional crawling, and no 

limits with balancing; and there are no manipulative, visual, 

communicative, or environmental limitations (Ex. 4A/8-9). The undersigned 

gives these DDS medical consultants' opinions little weight because their 

opinions are not consistent with the record as a whole, which documents his

condition but shows a history of conservative, routine treatment and many 

normal and mild exam findings, and that the claimant engages in many 

ADLs.

The Global Assessment of Functioning (GAF) score opinions are given little 

weight because they are a snapshot in time and do not accurately, reflect the 

claimant's functional abilities. Moreover, they also do correlate with the 

Social Security Administration' s precise disability guidelines, including the 

B and C criteria of the listings or an RFC.

The opinions of disabled are given little weight because they are not 

consistent with the many normal and mild exam findings and conservative, 

routine treatment in the medical evidence record. Moreover, those opinions 

evidence a lack of familiarity with the Social Security Administration' s 

precise disability guidelines, as they do not address the listings or any 

exertional or non-exertional limitations. Further, the finding of disabled is 

one reserved for the Commissioner.

The only other opinion is from the claimant's mother Gloria Barker who 

reports that the claimant's conditions affects lifting, bending, standing, 

reaching, walking, talking, stair climbing, concentration, and getting along 

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with others. He can walk for about 15 minutes before needing to stop and 

rest for five minutes. He gets very agitated at his parents at times and does

not go to any social functions unless it is with family. He has back pain that 

limits his activities where lifting and standing are painful. Stress also seems 

to be a factor, causing him to be unable to go in stores, shop or be around 

other people. At times, he has left stores due to anxiety. He also does not 

handle stress or changes in routine well (Ex. 5E/5-13). Ms. Barker's opinion 

is given little weight because she is not familiar with the Social Security 

Administration's precise disability guidelines as evidenced by her opinion, 

which fails to discuss any listings, including 1.04 and 1.02 and the B or C 

criteria of 12.04, 12.06 and 12.15. She also has an inherent bias as the 

claimant's mother. There is also no indication that she is a licensed health 

care provider, further undermining her qualifications to offer an opinion 

regarding the claimant 's disability and functional limitations. More 

importantly, her opinion is not consistent with the record as a whole, which 

documents his condition but shows a history of conservative, routine 

treatment and many normal and mild exam findings, and that the claimant 

engages in many ADLs.

The claimant's ADLs also support the RFC finding above and undermine the 

claimant's allegations. The record shows that the claimant engages in many 

ADLs. For example, the September 2014 independent psychiatric 

consultative examiner Dr. Shahla reported the claimant's typical daily 

activities include the claimant gets up, watches TV, does some light 

housework, prepares dinner, and watches TV in bed. He takes care of his 

mother who has Alzheimer's. He also reports that he is painting his parent's 

house. He can take care of chores such as vacuuming, laundry, cooking, 

shopping, and doing yard work. The claimant reports enjoying reading, 

hiking, fishing, and walking the dog. There is no anhedonia; i.e., there is no 

inability to feel pleasure. The claimant is able to drive. The claimant handles 

his own funds. It is also noted that he lives with his parents and he drove to 

the consultative examiner appointment (Ex. 4F/5, 3).

The November 2016 independent psychiatric consultative examiner Dr. 

Engelhorn reported the claimant lived with his parents for several years and 

provided general services to them. He has recently been living in Fontana, 

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California in a camper shell because his parents apparently asked him to 

leave their home (Ex. 18F/6). 5

The November 2016 independent psychiatric consultative examiner Dr. 

Engelhorn reported the claimant engages in many ADLs. He is currently 

living in a camper shell located in Fontana, California. He has been living in 

this camper shell for about two months. However, he continues to visit his 

parents with regularity. He was living with his parents for the greater part of 

the past three years. He states that he is allowed to use the house where his 

camper shell is located in Fontana. He uses the bathroom, kitchen and 

laundry facilities. He drives a car and occasionally attends church services. 

He has no outside social life or close friends. He frequently watches 

television and enjoys reading. He has access to a home computer. As noted 

previously, he frequently drives down from Fontana to Santee to visit his 

parents as much as once or twice each week (Ex. 18F/4-5). He continues to 

spend considerable time with his parents here in the Santee area. He has four 

siblings and has contact with all of them. (Ex. 18F/3).

Furthermore, the claimant indicates in a function report dated August 2014 

that he lives in a house with family. On a daily basis, he gets dressed, has 

coffee and watches television or read helps his elderly parents, makes 

dinner, reads or watches television, and goes to bed. He shops and cooks for 

his parents. He also feeds and walks the dog. He has no problems with 

personal care (e.g. dressing, bathing, caring for hair, feeding self, using the 

toilet) except physical issue He prepares meals daily such as sandwiches, 

dinners, and complete meals. He does chores, such as laundry, light 

housework and light yard work. He goes outside. He travels by driving, 

walking, riding in a car, and riding a bicycle. He is able to go out alone. He 

shops in stores for groceries and books. He is able to handle finances, like 

paying bills, counting change, handling savings account, and using a 

checkbook/money orders. His ability to handle money has not changed since 

his conditions began. In addition to reading and watching television, he uses 

Facebook daily. He also spends time with others, using Facebook and going 

to church. He also attends church regularly. He does not need reminders to 

take care of personal needs, take medicine, or go places. He does not have 

any problems getting along with family, friends, neighbors or others except 

he notes that he gets irritated and he does not like to go to parties unless it is 

 

5 Portions of the ALJ’s decision at step 4 are repetitive of his discussion at step 2, supra. The Court 

recitation of the relevant portions of the ALJ’s decision is verbatim, and includes the repeated discussion 

points as they appear in the Administrative Record.

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with family. He gets along well with authority figures. He has never been 

fired or laid off from a job because of problems getting along with other 

people. He can pay attention as long as needed. He finishes what he starts 

(e.g. a conversation, chores, reading, watching a movie. He does very well at 

following written and spoken instructions (Exs. 4E/6-14).

In addition, in a disability report dated March 5, 2015, when asked what 

changes have occurred in his daily activities since he last completed a 

disability report, he states he has "been remodeling a kitchen." (Ex. 9E/4-5).

In addition, the claimant's work history undermines the claimant's 

allegations, including the severity of his impairments and their limiting 

effects. His reported earnings show earnings of $4,767.50 in 2014, and no 

earnings thereafter (Exs. 4D/2-3, 3D/ 1, 2D/ 1-4).

Furthermore, the claimant indicated in his initial disability report that he 

stopped working as of March 22, 2014, due to his condition(s) (Ex. 2E/2).

As of November 2016 at the consultative exam, he reported, "He last worked 

in 2014 at which time he was working for a company that refinished Kitchen 

cabinets. He states that he has not worked since 2014" (Ex. 18F/4). "[F]or 

the majority of his life he has worked in factories, manufacturing and 

cabinetry work. He has not worked in any capacity since March of 2014" 

(Ex. 18F/6).

However, the record also indicates that, after his alleged onset date of

disability (AOD) of March 23, 2014, he received unemployment insurance 

benefits (UIB) in the second and third quarters of 2014 and the first quarter 

of 2015. In order to receive UIB one certifies he is able to work and is 

looking for work (Ex. 5D/ 1-2, 

http://www.edd.ca.gov/unemployment/Eligibility.htm).

In addition, the claimant testified that he is currently working part-time, zero 

to 12 hours a week, delivering flowers. He makes $2.50 per delivery. He has 

been doing this work since May 2016. He also testified that, prior to the 

flower delivery job , he has not done any work since March 2014 when he 

was doing work as a cabinet refinisher (Testimony).

A June 22, 2016 visit states that the claimant reports that the flower shop 

(where he works) "moved to another building and he has had to carry heavy 

counters" (Ex. 16F/ 10).

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Notes from a June 29, 2016 visit evidence that the claimant reports an 

"increase in back aggravation due to lifting/moving objects for work"(Ex. 

16F/8).

A July 11, 2016 visit reports the claimant missed his physical therapy 

appointment last week but he still worked. It also notes that the claimant 

built a retaining wall (Ex. 16F/5).

The claimant also testified that he worked for his wife's home improvement 

work from 2007 through 2012 but states he was not paid. Since he separated 

from his wife, he has been taking care of his parents (Testimony).

The claimant reported to the independent consultative examiner that he 

worked in home improvement with his wife from 2007 through January 

2013. His wife left him at that time so the business stopped. He worked in 

the past as a cabinet finisher. He last worked as a painter in a spray shop 

from November 2013 through March 2014. He stopped working because 

there was a pay problem as his boss was not paying him overtime. This is 

why he quit. He is currently looking for work online and is looking at jobs 

including being a caretaker, cook, etc. He reports that he completed one year 

of college so that he could work in a hospital, but he has a felony and has not 

been able to obtain a job. (Ex. 4F/3).

He also testified that the only work he did "under the table" is where he 

spent one week painting a friend's house (Testimony).

Overall, despite his claim of only one time he was paid "under the table," the 

record indicates the claimant has been working "under the table" for most of 

his life, not reporting income. The record also demonstrates that he 

misrepresented himself to the consultative examiners when he informed 

them he has not worked since March 2014.

Finally, the claimant's demeanor and testimony at the hearing supports the 

RFC and undermines the claimant's allegations, including the severity and 

limiting effects of his impairments. For example, at the hearing, he was 

lucid and responsive to questioning. His answers demonstrated good 

memory recall and logical thinking, as his answers were relevant and 

responsive. His demeanor and testimony also reflected good social 

interaction and concentration, persistence and pace. He was also 

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cooperative, voluntarily offered information, and seemed at ease with the 

hearing process.

In sum, the above residual functional capacity assessment is supported by 

the opinion Dr. Sabourin, the independent orthopedic consultative examiner 

who is a board certified orthopedic surgeon, the medical evidence record, the 

claimant's ADLs, the claimant's work history, and the claimant's demeanor 

and testimony at the hearing.

5. The claimant is capable of performing past relevant work as a short 

order cook. This work does not require the performance of workrelated activities precluded by the claimant's residual functional 

capacity (20 CFR 416.965).

. . . .

6. The claimant has not been under a disability, as defined in the Social 

Security Act, since July 16, 2014, the date the application was filed (20 

CFR 416.920(f)).

. . . .

(Id. at 10-38 (emphasis added).)

VI. 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 “disabled.” Id. Further, the applicant bears the 

burden of proving that 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: (1) whether the claimant is presently working 

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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 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 that 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).

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 the ALJ's findings are based on legal error or are 

not supported by substantial evidence in the record as a whole. Schneider v. Comm’r of 

Soc. Sec. Admin., 223 F.3d 968, 973 (9th Cir. 2000). Substantial evidence means “more 

than a mere scintilla but less than a preponderance; it is such relevant evidence as a 

reasonable mind might accept as adequate to support a conclusion.” Andrews v. Shalala, 

53 F.3d 1035, 1039 (9th Cir. 1995); See also Richardson v. Perales, 402 U.S. 389 (1971) 

(substantial evidence is “such relevant evidence as a reasonable mind would accept as 

adequate to support a conclusion.”) The possibility of drawing more than one inconsistent 

conclusion or rational interpretation from the evidence does not prevent an administrative 

agency’s findings from being supported by substantial evidence.” Tommasetti v. Astrue, 

533 F.3d 1035, 1038 (9th Cir. 2008).

The Court must consider the record as a whole, weighing both the evidence that 

supports and detracts from the ALJ’s conclusion. See Mayes v. Massanari, 276 F.3d 453, 

------------------

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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. Vasquez, 572 

F.3d 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 Social Security Administration for further proceedings. Id.

VII. DISCUSSION 

Plaintiff contends that the RFC assigned by the ALJ is not supported by substantial 

evidence because he failed to properly analyze and weigh opinion evidence. Specifically, 

plaintiff argues that the ALJ improperly afforded “little weight” to the opinions of Dr. 

Moyad, the State Agency consultants, and plaintiff’s mother, and improperly relied solely 

on the opinions of Dr. Sabourin, “who did not review any imagery and only examined 

plaintiff one time.” (Doc. No. 17, pp. 10-11.) 

A. The ALJ’s Weighing of the Opinions of Dr. Moyad, State Agency 

Consultants Dr. Khong and Dr. Hartman, and Dr. Sabourin is Supported by 

Substantial Evidence.

Plaintiff argues the ALJ failed to properly analyze and weigh the opinion evidence 

of Dr. Moyad and State Agency consultants Dr. Khong and Dr. Hartman with respect to 

their assessment of plaintiff’s RFC and, thus, his determination is not supported by 

substantial evidence. (Doc. No. 17, p. 10.) Defendant argues these opinions were properly 

analyzed and weighed because Dr. Moyad’s, Dr. Khong’s and Dr. Hartman’s RFC 

assessments are inconsistent with a record as a whole, which demonstrated conservative 

routine treatment, many normal and mild examination findings and relatively normal

activities of daily living. (Doc. No. 22, p. 6.)

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A hierarchy exists with regard to the weighing of medical opinions, distinguishing 

between the opinions of three types of physicians: (1) those who treat the claimant (treating 

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

and (3) those who neither examine nor treat the claimant (nonexamining physicians). As a 

general rule, more weight should be given to the opinion of a treating source than to the 

opinion of doctors who do not treat the claimant. Lester v. Chater, 81 F.3d 821, 830 (9th 

Cir. 1995). An examining physician’s uncontradicted opinion cannot be rejected without 

the ALJ providing “clear and convincing reasons.” Stewart v. Colvin, 575 Fed. Appx. 775, 

777 (9th Cir. 2014). Even if contradicted, an examining physician’s opinions is still owed 

deference and is entitled to the greatest weight even if it does not meet the test for 

controlling weight. Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007). When assigning little 

weight to an examining physician’s opinion, the ALJ must set “out a detailed and thorough 

summary of the facts and conflicting clinical evidence, stating [her] interpretation thereof, 

and making findings." Tommasetti v. Astrue, 533 F.3d 1035, 1041 (9th Cir. 2008). 

Dr. Moyad is an examining non-treating physician who saw plaintiff on one 

occasion, on October 1, 2014. Dr. Khong and Dr. Hartman are non-treating, non-examining 

physicians, whose opinions were largely based on their review of Dr. Moyad’s notes. The 

ALJ, who is solely responsible for determining a claimant’s RFC, rejected these doctors’

opinions only with regard to their assessment of plaintiff’s RFC. See 20 C.F.R. §§ 416.927 

(d), 416.945; SSR 96-5p; Vertigan v. Halter, 260 F.3d 1044, 1049 (9th Cir. 2001) (“[i]t is 

clear that it is the responsibility of the ALJ, not the claimant’s physician, to determine 

residual functional capacity”).

In rejecting these opinions, the ALJ did precisely what he was supposed to do – he 

discussed plaintiff’s longitudinal medical history, the objective evidence and findings, each 

of the medical opinion evidence, assessed weight to the evidence and stated his reasons for 

discounting certain opinions. (AR 13-33); 20 C.F.R. § 416.920c (describing how the 

agency considers and articulates medical opinions)). He articulated clear and convincing 

reasons for finding Dr. Moyad and the State Agency Consultants’ assessment of plaintiff’s 

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RFC is not supported by the record on the whole. As noted in Section V, above, the ALJ 

observed the record is replete with medical records that show normal to mild findings with 

respect to plaintiff’s back issues. (AR 24-26.) He cited numerous examples of medical 

evidence that are inconsistent with these doctors’ RFC assessments including notes of:

plaintiff denying any weakness or trembling (Id. at 24); normal exam findings (Id.); 

treatment throughout 2014, 2015 and 2016 of numerous instances where plaintiff’s back 

pain had flared up but then later improved (Id. at 24-26); normal range of motion with his 

upper extremities (Id. at 25); normal motor strength and gait (Id. at 24-25); and 

conservative treatment (Id.). The Court notes nearly all these medical records are from 

treatment plaintiff received after Dr. Moyad and the State Agency Consultants formed their 

opinions and, thus, were not reviewed by any of these doctors. After these physicians’ 

opinions were rendered, plaintiff: underwent physical therapy and reported improvement

(consistent with Dr. Khong’s projection); received pain management treatment; and was 

ruled out as a candidate for surgery because he had not exhausted his options for 

conservative treatment. Records of his later received treatment were not considered by Dr. 

Moyad or either State Agency Consultant when they formed their opinions. 

Furthermore, inconsistency with the claimant’s daily activities is a legitimate basis 

for devaluing a medical opinion. Ghanim v. Colvin, 763 F.3d 1154, 1162 (9th Cir. 2014). 

The RFC assigned by these doctors is inconsistent with plaintiff’s own reports of his 

activities. As the ALJ correctly noted, the record includes numerous instances of plaintiff 

engaging in activities that are inconsistent with the physicians’ RFC assessment. The ALJ 

observed that plaintiff: renovated a kitchen in February 2015 (AR 24-25); fell from a tree 

trying to cut a branch in March 2015 (Id. at 25); moved and lifted heavy furniture in June 

2015 (Id.); started a new job that is physical in May 2016 (Id.); carried heavy counters and 

objects at work from June to August 2016 (AR 26); and built a retaining wall in July 2016 

(Id.). These physically intensive activities, admitted to by plaintiff, demonstrate 

inconsistency with the opinions of Dr. Moyad, Dr. Khong and Dr. Hartman, who opined 

that plaintiff would have more restrictive physical limitations. See Shavin v. Com’r of 

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Social Sec. Admin., 488 Fed. Appx. 233, 224 (9th Cir. 2012) (inconsistencies and 

ambiguities with the record as a whole may be a sufficient reason to give little weight or 

devalue a medical opinion).

The ALJ had sufficient reason to weigh the opinion of Dr. Sabourin more heavily 

than the RFC assessments of Dr. Moyad and the State Agency Consultants. In reviewing 

contradictory medical opinions, it should be considered that early evaluations of a 

worsening condition are less probative than later evaluations. Delegans v. Colvin, 584 Fed. 

Appx. 328, 331 (9th Cir. 2014). When the claimant suffers from a progressively 

deteriorating health condition, as plaintiff does, the most recent medical report is the most 

probative. Stone v. Heckler, 761 F.2d 530, 532 (9th Cir. 1985). Here, Dr. Moyad and the 

State Agency Consultants’ opinions regarding plaintiff’s RFC are inconsistent with those

of Dr. Sabourin, a board certified surgeon who conducted a consultative orthopedic 

consultation two years after Dr. Moyad’s initial assessment and a year after the State 

Agency Consultants’ review. Moreover, Dr. Sabourin’s opinion as to plaintiff’s RFC is 

consistent with the medical record on the whole so it was not improper for the ALJ to 

assign his RFC assessment greater weight. 20 C.F.R. § 416.927 (c)(3),(4) (more weight is 

given to an opinion and/or medical source if it is well-supported. . . and consistent with the 

record as a whole); SSR 96-6p (same).

In sum, the ALJ gave clear and convincing reasons supported by substantial 

evidence for why the opinions of Dr. Moyad and the State Agency Consultants should be 

afforded less weight, as they were inconsistent with the record as a whole.

B. The ALJ Properly Analyzed and Weighed the Opinion of Plaintiff’s Mother.

Plaintiff also argues the ALJ failed to properly analyze and weigh the opinion 

evidence of his mother. (Doc. No. 17, p. 10). 

“[L]ay testimony as to a plaintiff’s symptoms is ‘competent evidence’ that an ALJ 

must consider and it must be taken into account.” Lopez v. Astrue, 497 Fed. Appx. 717, 

719 (9th Cir. 2012). It may not be rejected without comment. Id. “[I]f the ALJ wishes to 

discount the testimony of lay witnesses, he must give reasons that are germane to each 

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witness.” Lubin v. Commissioner of Social Sec. Admin., 507 Fed. Appx. 709, 712 (9th Cir. 

2013). The fact that the lay opinion is from a family member is not grounds to reject it. 

Goulart v. Colvin, 604 Fed. Appx. 585, 586 (9th Cir. 2015). The ALJ may discount lay 

testimony when presented with contradictory evidence. March v. Commissioner of Soc. 

Sec. Admin., 462 Fed. Appx. 671, 672 (9th Cir. 2011). 

Here, the ALJ discounted the third party function report by plaintiff’s mother 

because it was not supported by the record on the whole, which showed a history of 

conservative treatment, many normal and mild exam findings and that plaintiff engages in 

many activities of daily living. (AR 28.) As discussed in Section VII. A, supra, the record 

contains substantial evidence of conservative routine treatment and normal and mild exam 

findings that contradict the mother’s statement. The ALJ also specifically commented on 

inconsistencies between her statement and plaintiff’s self-reporting: of his typical daily 

activities to Dr. Shahla in September 2014, as well as to Dr. Engelhorn in November 2016 

(Id.); in his function report which he completed in August 2014 (Id.); in his disability report

prepared in March 2015 (AR 29); of his work history (Id.); of lifting and moving of heavy 

counters and objects in June 2016 (Id.); and of building a retaining wall in July 2016 (Id.). 

Thus, the ALJ gave legitimate and germane reasons, supported by substantial evidence, 

and properly discounted plaintiff’s mother statement.

VIII. CONCLUSION 

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

DENIED and defendant’s cross-motion for summary judgment should be GRANTED. 

This report and recommendation will be submitted to the Honorable Larry A. Burns,

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 12, 2019. The document should be captioned “Objections to 

Report and Recommendation.” Any reply to the Objections shall be served and filed on or 

before July 19, 2019. The parties are advised that failure to file objections within the 

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specified time may waive the right to appeal the district court’s order. Martinez v. Ylst, 

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

IT IS SO ORDERED.

Dated: June 28, 2019 !@ ·_.-1/, ,-' 

---- --:· --~--

~Crawford 

United States Magistrate Judge 

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