Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_21-cv-01021/USCOURTS-caed-1_21-cv-01021-3/pdf.json

Parties Involved:
Brian Carr
Plaintiff
Commissioner of Social Security
Defendant

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

BRIAN CARR,

Plaintiff,

v.

KILOLO KIJAKAZI,

1 Acting Commissioner 

of Social Security,

Defendant.

Case No. 1:21-cv-01021-CDB (SS)

ORDER GRANTING PLAINTIFF’S 

MOTION FOR SUMMARY JUDGMENT; 

DENYING DEFENDANT’S CROSSMOTION FOR SUMMARY JUDGMENT

(Docs. 14, 20)

Plaintiff Brian Carr (“Plaintiff”) seeks judicial review of a final decision of the 

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

disability insurance benefits under the Social Security Act. (Doc. 1). The matter is currently 

before the Court on the parties’ briefs, which were submitted without oral argument. (Docs. 14, 

20).2 Upon review of the Administrative Record (“AR”) and the parties’ briefs, the Court finds 

1 Martin O'Malley became the Commissioner of Social Security on December 20, 2023. See

Commissioner SSA, https://www.ssa.gov/agency/commissioner/ (last visited November 27, 2024). 

Accordingly, Martin O'Malley should be substituted for Kilolo Kijakazi as the defendant in this lawsuit.

See Fed. R. Civ. P. 25(d) (“An action does not abate when a public officer who is a party in an official 

capacity dies, resigns, or otherwise ceases to hold office while the action is pending. The officer’s 

successor is automatically substituted as a party”).

2 Following the parties’ expression of consent to the jurisdiction of a U.S. magistrate judge for all 

purposes, this action was reassigned to the presiding U.S. magistrate judge pursuant to 28 U.S.C. §

636(c)(1). (Doc. 11).

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and rules as follows.

I. BACKGROUND

A. Administrative Proceedings and ALJ’s Decision

On December 3, 2018, Plaintiff filed an application for Title II disability insurance 

benefits, alleging disability beginning February 12, 2018. (AR 89). The claim was denied on 

May 10, 2019. (AR 88). It was denied again upon reconsideration on June 12, 2019. (AR 106).

On October 16, 2019, Plaintiff filed a request for hearing. (AR 129). The hearing was 

scheduled for October 9, 2020, at 9:00 a.m. (AR 147). On that day, Administrative Law Judge 

(“ALJ”) Kurt Schuman presided over the hearing. (AR 32-68). Plaintiff appeared along with his 

attorney, as did impartial vocational expert Bonnie Martindale. On November 4, 2020, the ALJ 

issued his decision, finding Plaintiff not disabled. (AR 12-31). On January 4, 2021, Plaintiff 

filed a request for review with the Appeals Council. (AR 204-207). The request was denied on 

May 7, 2021. (AR 1-6).

After reviewing the evidence, the ALJ considered Plaintiff’s claims using the five-step 

sequential evaluation required by 20 C.F.R § 416.920(a). At step one, the ALJ found that 

Plaintiff had not engaged in substantial gainful activity since February 12, 2018, the date of the 

application. (AR 17). At step two, the ALJ found that Plaintiff had the following severe 

impairments: spine disorders; asthma; left shoulder lesions; trauma and stressor-related disorders; 

anxiety and obsessive-compulsive disorders; and depressive, bipolar and related disorders. The 

ALJ determined Plaintiff had the following non-severe impairments: hypertension, 

gastroesophageal reflux disease, gastritis without bleeding, and obesity. Id. The ALJ noted he

did consider these non-severe impairments in assessing the claimant’s residual functional 

capacity. (AR 18).

At step three, the ALJ determined that Plaintiff did not have an impairment, or any 

combination of impairments, that met or medically equaled one of the listed impairments in 20 

CFR Part 404, Subpart P, Appendix 1. The ALJ provided a discussion of the reasoning as to why

each impairment failed to meet the requirements of the listings. When evaluating the severity of 

the Plaintiff’s mental impairments, the ALJ reached this determination by considering the four

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broad functional areas of mental functioning listed in the “paragraph B” criteria.3 (AR 18).

The first functional area is understanding, remembering, or applying information. The 

ALJ found that Plaintiff had no limitation. The ALJ supported his finding by noting Plaintiff did 

not indicate problems with memory, understanding, or following instructions; the ALJ provided a 

general citation to Exhibit 4E. The ALJ noted that, during the psychological consultative exam, 

Plaintiff was fully oriented and could recall three out three words immediately and then after five 

minutes. The ALJ found that Plaintiff’s short-term, long-term, and working memory appeared 

intact; the ALJ provided a general citation to Exhibit 6F. (AR 18).

The second functional area is interacting with others. The ALJ found that Plaintiff had a 

moderate limitation. The ALJ noted that Plaintiff reported that he has problems getting along 

with others, but that he spends time with others and goes to church; the ALJ provided a general 

citation to Exhibit 4E. The ALJ stated Plaintiff testified that he has issues trusting people and 

that, during the psychological consultative exam, his attitude was positive and he was 

cooperative. (AR 18-19). The ALJ stated Plaintiff maintained appropriate eye contact but

exhibited paranoia and reported engaging in hypervigilant behavior such as always watching 

people; the ALJ provided a general citation to Exhibit 6F. (AR 19).

The third functional area is concentrating, persisting, or maintaining pace. The ALJ found 

that Plaintiff had no limitation. The ALJ stated that Plaintiff did not indicate problems 

completing tasks, concentrating, or following instructions; the ALJ cited generally to Exhibit 4E. 

The ALJ provided that, during the psychological consultative exam, Plaintiff could perform 

3 The “paragraph B” criteria evaluates mental impairments in the context of four broad areas of 

functioning: (1) understanding, remembering, or applying information; (2) interacting with others; (3) 

concentrating, persisting, or maintaining pace; and (4) adapting or managing oneself. 20 C.F.R. § Pt. 404, 

Subpt. P, App. 1. The severity of the limitation a claimant has in each of the four areas of functioning is 

identified as either “no limitation,” “mild,” “moderate,” “marked,” or “extreme.” Id. To satisfy the

paragraph B criteria, a claimant must have an “extreme” limitation in at least one of the areas of mental 

functioning, or a “marked” limitation in at least two of the areas of mental functioning. Id. An “extreme” 

limitation is the inability to function independently, appropriately, or effectively, and on a sustained 

basis. Id. A “marked” limitation is a seriously limited ability to function independently, appropriately, or 

effectively, and on a sustained basis. Id. A “moderate” degree of mental limitation means that functioning 

in this area independently, appropriately, effectively, and on a sustained basis is “fair.” Id. And a “mild” 

degree of mental limitation means that functioning in this area independently, appropriately, effectively, 

and on a sustained basis is “slightly limited.” Id. See Carlos v. Comm’r of Soc. Sec., 1:21-cv-00517-SAB,

2023 WL 1868870, at *4 n.7 (E.D. Cal. Feb. 9, 2023).

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simple calculations and serial sevens. The ALJ noted that Plaintiff did not display any difficulties 

with concentration and noted that he spelled “world” forward and backward with ease; the ALJ 

cited generally to Exhibit 6F. (AR 19). 

The fourth functional area is adapting or managing oneself. The ALJ found that Plaintiff

had no limitation. The ALJ stated that Plaintiff drives a car, goes grocery shopping, and does not 

need someone to accompany him places; the ALJ cited generally to Exhibit 4E. The ALJ stated 

that Plaintiff testified he was working part-time as a co-pastor at his church, that he did not attend 

counseling for his mental health issues, and that he could dress and bathe himself. The ALJ 

provided that, during the psychological consultative exam, Plaintiff was neatly dressed and 

displayed good grooming and hygiene; the ALJ cited generally to Exhibit 6F. (AR 19).

The ALJ concluded that Plaintiff’s mental impairments did not cause at least two 

“marked” limitations or one “extreme” limitation and, as such, the “paragraph B” criteria were 

not satisfied. The ALJ then considered the “paragraph C” criteria,

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finding that the evidence fails 

to establish the presence of the “paragraph C” criteria because Plaintiff has more than minimal 

capacity to adapt to changes in his environment or to demands that are not already part of his 

daily life. The ALJ found no evidence in the record establishing that changes or increased 

demands have led to exacerbation of symptoms and signs and to deterioration in Plaintiff’s

functioning, concluding that while Plaintiff suffers from depression, anxiety, and PTSD, he had a 

mostly normal psychological consultative exam (citing generally to Exhibit 6F), and had no 

mental health treatment or psychiatric hospitalizations during the relevant period. (AR 19). 

Prior to step four, the ALJ found that Plaintiff had the residual functional capacity to 

perform light work, as defined in 20 CFR 404.1567(b). (AR 19-20). When considering the 

Plaintiff’s symptoms, the ALJ noted that he must follow the two-step process, as set forth in SSR 

16-3p. First, he must determine whether there is an underlying medically determinable physical 

or mental impairment; namely, an impairment or impairments that can be shown by medically 

4 “Paragraph C,” subsection (1) requires a “highly structured setting that is ongoing that 

diminishes the signs and symptoms of [Plaintiff’s] mental disorder.” 20 C.F.R. § Pt. 404, Subpt. P, App. 1 

§ 12.04(C)(1). “Paragraph C,” subsection (2) requires that Plaintiff “have minimal capacity to adapt to 

changes in [Plaintiff’s] environment or to demands that are not already part of [Plaintiff’s] daily life.” Id.

at subsection (C)(2). 

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acceptable clinical or laboratory diagnostic techniques that could reasonably be expected to 

produce the Plaintiff’s symptoms. Second, once an underlying physical or mental impairment(s) 

that could reasonably be expected to produce Plaintiff’s symptoms has been shown, he must 

evaluate the intensity, persistence, and limiting effects of Plaintiff’s symptoms to determine the 

extent to which they limit Plaintiff’s work-related activities. For this purpose, whenever 

statements about the intensity, persistence, or functionally limiting effects of symptoms are not 

substantiated by objective medical evidence, the ALJ must consider other evidence in the record 

to determine if Plaintiff’s symptoms limit the ability to do work-related activities. (AR 20).

The ALJ found that Plaintiff’s medically determinable impairments could reasonably be 

expected to cause the alleged symptoms, but that his statements concerning the intensity, 

persistence, and limiting effects of those symptoms were not entirely consistent with the medical 

evidence and other evidence in the record. (AR 20-21).

The ALJ recounted details of Plaintiff’s worker’s compensation exams in February and 

June 2018, related to follow-up for a 2006 work injury to his back. The ALJ provides extensive 

pin cites to Exhibit 2F and a general citation to Exhibit 15F, while detailing the medical findings. 

(AR 21). 

The ALJ found that, when presenting to his psychological consultative exam, Plaintiff was 

neatly dressed, displayed good grooming and hygiene, was positive and cooperative, maintained 

appropriate eye contact, spoke normally, and displayed linear and organized thought processes. 

The ALJ appeared to quote the exam record in providing that Plaintiff stated his mood was “good 

most days, [but] depressed some days particularly when [he is] bored”; the ALJ did not provide a 

pin cite for this quote. The ALJ found that Plaintiff could recall three out of three words 

immediately and again after five minutes; that his short-term, long-term, and working memory 

appeared intact; that he could perform simple calculations and serial sevens; that he did not 

display any difficulties with concentration; and that he spelled the word “world” forward and 

backward with ease. The ALJ notes that the examiner diagnosed Plaintiff with PTSD; he cites 

generally to Exhibit 6F. (AR 21).

The ALJ then discussed the findings of Plaintiff’s April 2019 medical consultative exam. 

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The ALJ noted that Plaintiff could easily get up out of his chair, walk, sit comfortably, get on and 

off the exam table, bend over at the waist, walk easily on heels and toes, and remove his shoes 

and socks and put them back on. He was pleasant, cooperative, with a normal gait, did not use an 

assistive device, and his lungs were clear. The examiner diagnosed him with mild asthma, neck 

pain, left shoulder pain, and low back pain, finding he had a good range of motion in his neck 

following a surgery earlier in his life, and well-maintained range of motion in his left shoulder. 

The ALJ cited to pages 1 to 3 and 9 to 12 of Exhibit 7F. (AR 22).

The ALJ then considered an August 2019 visit by Plaintiff to his primary care provider for 

his asthma, “mild-to-moderate anxiety,” left shoulder tendinitis, and lumbar disc disease. The 

provider noted that his asthma was stable, and that his “anxiety nervousness agitation” was 

episodic. He was found to have tenderness and reproducible pain in his shoulder but no 

weakness. The provider recommended icing, a splint, anti-inflammatory medicine, and possibly 

an injection. He had point tenderness at the lumbar area with diffuse paraspinal muscle spasm 

and strain. The provider recommended a back brace, icing, and anti-inflammatory and muscle 

relaxant medicine. In March 2020, Plaintiff received trigger point injections in his lumbar spine.

The ALJ cites to pages 36, 37, and 41 of Exhibit 16F. (AR 22).

The ALJ found that the Plaintiff’s statements concerning the intensity, persistence, and 

limiting effects of his symptoms were inconsistent. In support, the ALJ noted that Plaintiff drives 

a car, goes grocery shopping, spends time with others, goes to church, and does not need to be 

accompanied to places. He did not indicate problems with memory, completing tasks, 

concentrating, understanding, or following instructions. He can lift 50 to 75 pounds; the ALJ 

cites generally to Exhibit 4E. He does not attend counseling for his mental health issues, works 

part-time as a co-pastor at his church, and can dress and bathe himself. He had a mostly normal 

psychological consultative exam; the ALJ cites generally to Exhibit 6F. He had no mental health 

treatments or psychiatric hospitalizations during the relevant period. (AR 22).

The ALJ continues by noting that, during an exam in June 2018, Plaintiff had normal 

cervical and lumbar lordosis. He had no neck or back spasms and had normal cervical and 

lumbar range of motion, with a normal gait, and with normal muscle strength throughout; the ALJ 

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cites to pages 26 to 27 of Exhibit 2F, and generally to Exhibit 15F. The ALJ then recounts some 

of his earlier findings, stating that, during the April 2019 medical consultative exam, Plaintiff 

could easily get up out of the chair and walk to the exam room without assistance. He sat 

comfortably and could easily get on and off the exam table. He could easily bend over at the 

waist, take his shoes and socks off, and put them back on. He could easily walk on toes and 

heels. He had a normal gait. His straight leg raise was negative bilaterally and his strength was 

5/5 throughout including grip. The ALJ states that the examiner noted Plaintiff’s asthma was 

mild and well controlled. He had not required an inhaler in a year. He had good range of motion 

of his neck following his surgery. He had well-maintained left shoulder range of motion; the ALJ 

cited to pages 9 to 12 of Exhibit 7F. His lumbar spine x-rays showed only mild disc space loss at 

L5-S1 and his left shoulder x-rays showed only mild narrowing of the subacromial space; the ALJ 

cites to pages 1 and 2 of Exhibit 7F. Plaintiff’s primary care provider noted that his asthma was 

stable and recommended only conservative treatment for his shoulder and back; the ALJ cites to 

page 37 of Exhibit 16F. (AR 22).

The ALJ considered the opinions of the state agency medical consultants concluding that 

Plaintiff can perform medium work, finding them unpersuasive due to lack of any supporting 

summaries and consistency with the record as whole. The ALJ states that Plaintiff underwent a 

discectomy and fusion, with a later lumbar spine MRI showing impingement of nerve roots, as 

well as a disc protrusion, annular tear, and straightening of the lumbar lordosis. During exams, 

Plaintiff had pain to palpation of his lumbar and cervical spine. The ALJ cites to generally to 

Exhibits 1A, 3A, 15F, and 16F, as well as to page 41 of Exhibit 2F and page 6 of Exhibit 9F. 

(AR 23).

The ALJ also considered the state agency psychological consultant’s opinions, finding 

them partially persuasive due to being supported by a partially persuasive summary of the record 

and partially consistent with the record as a whole (demonstrating only moderate social 

limitations). The ALJ provides that Plaintiff can complete simple and detailed instructions; 

follow directions without additional assistance; maintain adequate attention, concentration, 

persistence, and pace as needed to complete a full workday/workweek; maintain appropriate 

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behavior in a context of limited social demands; accept instructions and respond appropriately to 

feedback from supervisors; be aware of ordinary hazards, make decisions, utilize transportation, 

and cope with the demands of a routine, work-like environment. The ALJ cited generally to 

Exhibits 1A and 3A. The ALJ notes that, in a function report (citing generally to Exhibit 4E), 

Plaintiff reported that he has problems getting along with others, but that he drives a car, goes 

grocery shopping, spends time with others, goes to church, and does not need someone to 

accompany him places. He did not indicate problems with memory, completing tasks, 

concentrating, understanding, or following instructions. (AR 23).

The ALJ repeats some of the prior findings in his opinion, namely that, during the 

psychological consultative exam, Plaintiff was neatly dressed. He displayed good grooming and 

hygiene. His attitude was positive and he was cooperative. He maintained appropriate eye 

contact. He could recall three out of three words immediately and after five minutes. His shortterm, long-term, and working memory appeared intact. He could perform simple calculations and 

serial sevens. He did not display any difficulties with concentration. He spelled the word “world” 

forward and backward with ease. The ALJ cites generally to Exhibit 6F.

The ALJ similarly considered the opinions of the psychological consultative examiner, 

finding them partially persuasive due to being partially supported by the exam and partially 

consistent with the record as a whole. The ALJ repeated that Plaintiff has no impairment in his 

ability to perform simple, repetitive, detailed, or complex tasks. He has no impairment in his 

ability to understand and accept instructions from supervisors. He has moderate impairment in 

his ability to interact with coworkers and the public. He has no impairment in his ability to 

perform work activities on a consistent basis without special or additional instructions. He has 

moderate impairment in his ability to maintain regular attendance and complete a normal 

workday or workweek without interruptions. He has moderate impairment in his ability to deal 

with the usual stressors encountered in the workplace. The ALJ cites generally again to Exhibit 

6F. (AR 23).

The ALJ also notes that Plaintiff reported that he has problems getting along with others, 

but that he drives a car, goes grocery shopping, and does not need someone to accompany him 

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places. He did not indicate problems with memory, completing tasks, concentrating, 

understanding, or following instructions. The ALJ cites generally to Exhibit 4E. (AR 24).

The ALJ found that the opinion of the medical consultative examiner, namely that 

Plaintiff can perform medium work, was partially persuasive. The ALJ noted that, while 

supported by the exam, the opinion is inconsistent with the record as a whole, which supports a 

limitation to light work. In support, the ALJ repeated the findings of the April 2019 medical 

consultative exam, citing to Exhibits 2F, 7F (pages 1, 2, and 9 to 12), 15F, and 16F. (AR 24).

The ALJ found it unnecessary to evaluate the persuasiveness of the workers’ 

compensation doctors, who indicated in their records that Plaintiff should remain off work, as 

they did “not provide functional limitations.” The ALJ cites to page 2 of Exhibit 11F, page 2 of 

Exhibit 12F, page 2 of Exhibit 13F, and page 2 of Exhibit 14, as well as to Exhibit 2F generally. 

(AR 24).

Finally, the ALJ considered the opinions of the workers’ compensation provider, 

physician Virginia Alvidrez, finding her conclusions partially persuasive as they were partially 

supported by the provider’s exam and partially consistent with the record as a whole, namely in 

that it shows environmental limitations and an inability to return to past work. In June 2018, 

Alvidrez concluded that Plaintiff could return to modified work, defined as not driving a patrol 

car, no work in dusty environments, no work in stressful situations, and no work as a deputy 

sheriff. The ALJ cited to page 2 of Exhibit 15F. The ALJ reasoned that Alvidrez, however, is not 

a mental health provider and is therefore not qualified to give opinions as to the Plaintiff’s stress 

tolerance. The ALJ compared the results of Alvidrez’s exam to other exams in the record, 

regarding Plaintiff’s impairments and symptoms, and found it partially persuasive. (AR 24). 

At step four, the ALJ found that Plaintiff was unable to perform any past relevant work, 

noting that the vocational expert testified as such when asked whether an individual with 

Plaintiff’s RFC could perform it. (AR 25). At step five, based on the testimony of the vocational 

expert, the ALJ concluded that Plaintiff could perform jobs that exist in the national economy, 

such as router clerk, marker, and package sorter. The ALJ found the Plaintiff to have not been 

under a disability from February 12, 2018 through the date of the decision. (AR 26). 

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After the Appeals Council denied review, Plaintiff initiated this action, filing his motion 

for summary judgment on May 3, 2022. (Doc. 14). Defendant filed an opposition and crossmotion for summary judgment on July 19, 2022. (Doc. 20).

B. Medical Record and Hearing Testimony

The relevant hearing testimony and medical record were reviewed by the Court and will 

be referenced below as necessary to this Court’s decision.

II. STANDARD OF REVIEW

A district court’s review of a final decision of the Commissioner of Social Security is 

governed by 42 U.S.C. § 405(g). The scope of review under § 405(g) is limited; the 

Commissioner’s decision will be disturbed “only if it is not supported by substantial evidence or 

is based on legal error.” Hill v. Astrue, 698 F.3d 1153, 1158 (9th Cir. 2012). “Substantial 

evidence” means “relevant evidence that a reasonable mind might accept as adequate to support a 

conclusion.” Id. at 1159 (quotation and citation omitted). Stated differently, substantial evidence 

equates to “more than a mere scintilla[,] but less than a preponderance.” Id. (quotation and 

citation omitted). “It is such relevant evidence as a reasonable mind might accept as adequate to 

support a conclusion.” Healy v. Astrue, 379 F. App’x 643, 645 (9th Cir. 2010). In determining 

whether the standard has been satisfied, a reviewing court must consider the entire record as a 

whole rather than searching for supporting evidence in isolation. Id.

In reviewing a denial of benefits, a district court may not substitute its judgment for that of 

the Commissioner. “The court will uphold the ALJ’s conclusion when the evidence is susceptible 

to more than one rational interpretation.” Tommasetti v. Astrue, 533 F.3d 1035, 1038 (9th Cir. 

2008). Further, a district court will not reverse an ALJ’s decision on account of an error that is 

harmless. Id. An error is harmless where it is “inconsequential to the [ALJ’s] ultimate 

nondisability determination.” Id. (quotation and citation omitted). The party appealing the ALJ’s 

decision generally bears the burden of establishing that it was harmed. Shinseki v. Sanders, 556 

U.S. 396, 409-10 (2009).

A. Applicable Legal Standards

A claimant must satisfy two conditions to be considered “disabled” within the meaning of 

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the Social Security Act. First, the claimant must be “unable to engage in any substantial gainful 

activity by reason of any medically determinable physical or mental impairment which can be 

expected to result in death or which has lasted or can be expected to last for a continuous period 

of not less than twelve months.” 42 U.S.C. § 1382c(a)(3)(A). Second, the claimant’s impairment 

must be “of such severity that he is not only unable to do his previous work[,] but cannot, 

considering his age, education, and work experience, engage in any other kind of substantial 

gainful work which exists in the national economy.” 42 U.S.C. § 1382c(a)(3)(B). 

The Commissioner has established a five-step sequential analysis to determine whether a 

claimant satisfies the above criteria. See 20 C.F.R. § 416.920(a)(4)(i)-(v). At step one, the 

Commissioner considers the claimant’s work activity. 20 C.F.R. § 416.920(a)(4)(i). If the 

claimant is engaged in “substantial gainful activity,” the Commissioner must find that the 

claimant is not disabled. 20 C.F.R. § 416.920(b).

If the claimant is not engaged in substantial gainful activity, the analysis proceeds to step 

two. At this step, the Commissioner considers the severity of the claimant’s impairment. 20 

C.F.R. § 416.920(a)(4)(ii). If the claimant suffers from “any impairment or combination of 

impairments which significantly limits [his or her] physical or mental ability to do basic work 

activities,” the analysis proceeds to step three. 20 C.F.R. § 416.920(c). If the claimant’s 

impairment does not satisfy this severity threshold, however, the Commissioner must find that the 

claimant is not disabled. Id.

At step three, the Commissioner compares the claimant’s impairment to impairments 

recognized by the Commissioner to be so severe as to preclude a person from engaging in 

substantial gainful activity. 20 C.F.R. § 416.920(a)(4)(iii). If the impairment is as severe or more 

severe than one of the enumerated impairments, the Commissioner must find the claimant 

disabled and award benefits. 20 C.F.R. § 416.920(d).

If the severity of the claimant’s impairment does not meet or exceed the severity of the 

enumerated impairments, the Commissioner must pause to assess the claimant’s “residual 

functional capacity.” Residual functional capacity (RFC), defined generally as the claimant’s 

ability to perform physical and mental work activities on a sustained basis despite his or her 

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limitations (20 C.F.R. § 416.945(a)(1)), is relevant to both the fourth and fifth steps of the 

analysis.

At step four, the Commissioner considers whether, in view of the claimant’s RFC, the 

claimant is capable of performing work that he or she has performed in the past (past relevant 

work). 20 C.F.R. § 416.920(a)(4)(iv). If the claimant is capable of performing past relevant 

work, the Commissioner must find that the claimant is not disabled. 20 C.F.R. § 416.920(f). If 

the claimant is incapable of performing such work, the analysis proceeds to step five.

At step five, the Commissioner considers whether, in view of the claimant’s RFC, the 

claimant is capable of performing other work in the national economy. 20 C.F.R. § 

416.920(a)(4)(v). In making this determination, the Commissioner must also consider vocational 

factors such as the claimant’s age, education, and past work experience. Id. If the claimant is 

capable of adjusting to other work, the Commissioner must find that the claimant is not disabled. 

20 C.F.R. § 416.920(g)(1). If the claimant is not capable of adjusting to other work, the analysis 

concludes with a finding that the claimant is disabled and is therefore entitled to benefits. Id.

The claimant bears the burden of proof at steps one through four above. Tackett v. Apfel, 

180 F.3d 1094, 1098 (9th Cir. 1999). If the analysis proceeds to step five, the burden shifts to the 

Commissioner to establish that (1) the claimant is capable of performing other work; and (2) such 

work “exists in significant numbers in the national economy.” 20 C.F.R. § 416.960(c)(2); Beltran 

v. Astrue, 700 F.3d 386, 389 (9th Cir. 2012).

III. ISSUES AND ANALYSIS

Plaintiff seeks judicial review of the Commissioner’s final decision denying his

application. (Doc. 1). Plaintiff raises the following issues:

1. The ALJ failed to discuss additional limitations imposed by Plaintiff’s irritable bowel 

syndrome (“IBS”) and gastroesophageal reflux disease (“GERD”) (Doc. 14 at 4) and

failed to analyze the need for additional unscheduled work breaks (id. at 6); and

2. The ALJ provided no basis for rejecting treating and evaluating sources from the 

workers’ compensation claim (id. at 5).

//

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A. Whether the ALJ Failed to Provide a Proper Basis for the RFC and Failed to 

Consider Limitations from Plaintiff’s IBS and GERD

Plaintiff asserts that the ALJ erred in finding an RFC limiting Plaintiff to light work, and 

in particular failed to consider limitations related to Plaintiff’s IBS and GERD conditions. Id. at 

4. Regarding the ALJ’s limitation of two hours of concentration with normal breaks, Plaintiff 

argues that he cannot “plan out his 2 hour periods of concentration sufficiently to fit within such 

narrow constraints” and claims this supports the need for additional unscheduled breaks, which 

was not adequately analyzed. Id. at 6.

Defendant asserts that substantial evidence supports the ALJ’s finding and Plaintiff’s 

argument that the ALJ should have included additional limitations to account for gastrointestinal 

issues is not supported by the overall record. Defendant states that Plaintiff has not met his 

burden to establish such limitations (Doc. 20 at 10) nor to establish a greater degree of limitations 

as to unscheduled breaks (id. at 13).

Here, although Plaintiff’s arguments are extremely brief (amounting to a few sentences of 

written argument, in total), the Court construes his principal argument to be an attack on the 

ALJ’s formulation of the RFC. This argument squarely calls on the Court to resolve whether 

whether the ALJ properly rejected Plaintiff’s subjective symptom testimony. The Court cannot 

assess whether the ALJ appropriately accounted for Plaintiff’s IBS and GERD limitations without 

first assessing whether Plaintiff’s subjective symptom testimony was properly considered. See 

Chaudhry v. Astrue, 688 F.3d 661, 670 (9th Cir. 2012). An ALJ’s failure to properly consider 

Plaintiff's subjective symptom testimony may independently be reversible error. See BrownHunter v. Colvin, 806 F.3d 487, 489 (9th Cir. 2015) (finding that an ALJ’s failure to identify and 

explain why a claimant’s subjective testimony is not credible constitutes reversible error because 

the reviewing court cannot determine if the ALJ’s decision was supported by substantial 

evidence).

Before discrediting a claimant’s subjective symptom testimony, an ALJ must first 

determine if objective medical evidence of an underlying impairment “could reasonably be 

expected to produce the pain or other symptoms alleged.” Trevizo v. Berryhill, 871 F.3d 664, 678

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(9th Cir. 2017). The ALJ found this was the case here. (AR 20). The second step is for the ALJ 

to describe specific, clear, and convincing reasons to reject the claimant’s testimony on the 

severity of his symptoms. Trevizo, 871 F.3d at 678. The Court finds that the ALJ failed to satisfy 

the second step.

This is not a scenario where Plaintiff appears to have invented brand-new ailments out of 

whole cloth. Accounts of Plaintiff’s gastrointestinal issues exist throughout the record. (AR 345-

346, 348, 393-394, 400, 402-403, 451, 538-542, 554, 612, 622, 626, 667, 670, 687, 693, 701, 706, 

708, 719-24). That, along with his testimony during the hearing regarding his symptoms (AR 45-

46, 51), establishes for the ALJ a duty to discuss Plaintiff’s impairments and resulting subjective 

symptom testimony and, if the ALJ finds such testimony should be rejected, the ALJ must 

describe his reasons with specificity under the relevant clear and convincing standard. It follows 

that Defendant’s argument that Plaintiff failed to meet his burden of establishing such limitations 

is unpersuasive. See, e.g., Jonathan A. Z. v. Kijakazi, No. 20-CV-07381-RMI, 2022 WL 799082, 

at *5 (N.D. Cal. Mar. 16, 2022) (“Here, Plaintiff not only put forth medical documentation 

substantiating his IBS, his GERD . . . but he also testified (albeit briefly) about how those 

conditions affect his ability to function and how they exacerbate his other impairments. The court 

finds that those medical records, in conjunction with that testimony, triggered the ALJ’s duty to 

further develop the record regarding the nature and extent of the limitations caused by the 

combination of these gastrointestinal impairments.”).

While the Court may be able to draw inferences about what testimony may be

inconsistent, the ALJ must identify those inconsistencies with specificity. Lambert v. Saul, 980 

F.3d 1266, 1278 (9th Cir. 2020) (citing Brown-Hunter, 806 F.3d at 494) (“Although the 

inconsistencies identified by the district court could be reasonable inferences drawn from the 

ALJ’s summary of the evidence, the credibility determination is exclusively the ALJ’s to make,” 

and the reviewing court is “constrained to review the reasons the ALJ asserts.”).

In his decision, the ALJ cites only two pages of the record when discussing Plaintiff’s 

gastrointestinal issues (namely, AR 451 and 538). Indeed, the entirety of the ALJ’s discussion 

can be quoted here: “His medical records evidence gastroesophageal reflux disease (GERD) and 

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gastritis without bleeding, which was described as stable. He testified that he only takes AlkaSeltzer in the evenings and does not take any prescription medication for his acid reflux.” (AR 

17) (internal citation omitted). Later in the ALJ’s decision, when discussing the Plaintiff’s 

allegations regarding the intensity, persistence, and limiting effects of his symptoms, the ALJ did 

not mention Plaintiff’s gastrointestinal issues. (AR 20). He discusses them no further in his 

decision beyond the quote supplied above. Plaintiff’s testimony during the hearing (AR 45-46, 

51), beyond the ALJ’s reference to Plaintiff taking Alka-Seltzer, is never referred to or cited. 

During the hearing, Plaintiff mentioned he did not eat breakfast regularly and, if he did 

and left home, he would need have regular access to a bathroom. He states he will use the 

bathroom “five or six times,” due to GERD and IBS. He testifies that if he “eats anything,” he 

will have to use the bathroom. He remarks that he attempts to eat soups and sandwiches to 

minimize this. (AR 45-46). He later mentions, when questioned by the ALJ about medications 

he uses for his stomach issues, that he was prescribed “a lot of different types of pills.” He states 

he only uses Alka-Seltzer before bed, providing that though he had taken many medications in the 

past none seemed to work. (AR 51). 

The ALJ did not question Plaintiff any further during the hearing regarding his 

gastrointestinal issues and did not provide any specific discussion with clear and convincing 

rationale sufficient to reject this symptom testimony and exclude it from factoring into his 

decision. 

Insofar as the ALJ intended his discussion of Plaintiff’s reported activities (AR 22) to act 

as an explanation regarding the inconsistency of Plaintiff’s IBS and GERD symptom testimony or 

its lack of credibility otherwise, that discussion is insufficient. The ALJ does not mention IBS, 

GERD, Plaintiff’s symptom testimony, or provide any reasoning regarding it. An ALJ is not 

“required to believe every allegation of disabling pain” or other non-exertional impairment. See 

Fair v. Bowen, 885 F.2d 597, 603 (9th Cir.1989). However, to discredit a claimant’s testimony 

when the claimant produces medical evidence of an underlying impairment (as Plaintiff did here), 

the ALJ must provide “‘specific, cogent reasons for the disbelief.’” Morgan v. Comm’r, 169 F.3d 

595, 599 (9th Cir. 1999) (quoting Lester v. Chater, 81 F.3d 821, 834 (9th Cir. 1995)), superseded 

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on other grounds by 20 C.F.R. Parts 404 & 416. The ALJ must “cit[e] the reasons why the 

[claimant's] testimony is unpersuasive.” Where, as here, the ALJ did not find “affirmative 

evidence” that the claimant was a malingerer, those “reasons for rejecting the claimant's 

testimony must be clear and convincing.” Id.

The ALJ failed to reject Plaintiff’s symptom testimony as it relates to his gastrointestinal 

issues with specific reasons that meet the relevant clear and convincing evidentiary standard. 

Regarding the ALJ’s RFC limitations, Plaintiff argues that the two-hour concentration 

limitation within normal breaks provided by the ALJ is “fiction not supported by the record.” 

Plaintiff’s arguments in support of this are somewhat difficult to parse, but he appears to claim 

that this is due to his mental health impairments, asthma, hypertension, and GERD. (Doc. 14 at 

5-6). He also appears to argue that the ALJ misunderstood or misconstrued Plaintiff’s “8-10 

hours” a week volunteering as a co-pastor at his church as him “working part-time.” (AR 22). 

Plaintiff claims these impairments were not “adequately analyzed.” Id. However, as 

noted in Section I above, the ALJ did consider Plaintiff’s mental health impairments, asthma, and 

hypertension in his decision. Regarding mental health, the ALJ engaged in an analysis utilizing 

the “paragraph B” and “paragraph C” criteria and discussed mental health impairments when 

analyzing Plaintiff’s symptom testimony. (AR 18-19, 22). As to asthma, the ALJ notes the 

evidence fails to establish it as a listed impairment. (AR 18). The ALJ noted his asthma was 

found to be “stable” and “mild and well controlled.” (AR 22). The ALJ included as a limitation 

that Plaintiff “is further limited in that he must avoid frequent exposure to irritants such as fumes, 

odors, dust, and gases, as well as poorly ventilated areas” (AR 20) which appears consistent with 

Plaintiff’s testimony regarding his asthma (AR 58-59). The ALJ discusses Plaintiff’s

hypertension as a non-severe impairment, stating providers described it as “stable and 

recommended conservative treatment” (AR 17). Plaintiff did not provide any notable symptom 

testimony regarding hypertension, noting he was on Zestril for it (AR 50) and providing only that, 

otherwise, his heart had healed (AR 50-51).

Though the ALJ did describe Plaintiff’s volunteering with his church as “part-time work”

(AR 25), despite Plaintiff’s testimony that he simply volunteered eight to ten hours a week (AR 

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42-43) and Plaintiff’s counsel’s objection to the position being included as past relevant work 

(AR 61-62), this appears to be a harmless error. See Molina v. Astrue, 674 F.3d 1104, 1115 (9th 

Cir. 2012) (“We have, for example, deemed errors harmless where the ALJ misstated the facts 

about the claimant, but we were able to conclude from the record that the ALJ would have 

reached the same result absent the error.”). Plaintiff was not found to be able to perform his past 

relevant work, regardless of whether the ALJ or vocational expert credited his volunteering as copastor as previous part-time work. (AR 25, 63-64). 

However, the ALJ’s failure to address Plaintiff’s symptom testimony as to his IBS and 

GERD is not harmless error because, if considered, it may implicate the frequency of work breaks 

required by the Plaintiff. As noted by the vocational expert in response to a hypothetical posed 

by the ALJ during the hearing, if Plaintiff were to require additional breaks of duration between 

10 and 15 minutes each day, in addition to regularly scheduled breaks, and with more than two 

unscheduled absences per month, there would be no occupations that Plaintiff could perform. 

(AR 65).

As the ALJ did not properly evaluate the Plaintiff’s symptom testimony as to his IBS and 

GERD limitations, and did not pose a properly crafted hypothetical including any such breaks that 

might be needed as a consequence of Plaintiff’s IBS and GERD symptoms, it is unclear whether

Plaintiff would then be considered disabled.

B. Whether the ALJ Failed to Provide a Basis for Rejecting Treating and 

Evaluating Sources from the Workers’ Compensation Claims

Plaintiff argues that the ALJ provided no basis for rejecting treating and evaluating 

sources from the state workers’ compensation claim. (Doc. 14 at 5).

Plaintiff's claim for benefits is governed by the agency’s “new” regulations concerning 

how ALJs must evaluate medical opinions for claims filed on or after March 27, 2017. 20 C.F.R. 

§ 404.1520c. The regulations set “supportability” and “consistency” as “the most important 

factors” when determining the opinions’ persuasiveness. 20 C.F.R. § 404.1520c(b)(2). And 

although the regulations eliminate the “physician hierarchy,” deference to specific medical 

opinions, and assigning “weight” to a medical opinion, the ALJ must still “articulate how [they] 

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considered the medical opinions” and “how persuasive [they] find all of the medical opinions.” 

20 C.F.R. § 404.1520c(a)–(b). Accordingly, under the new regulations, “the decision to discredit 

any medical opinion, must simply be supported by substantial evidence.” Woods v. Kijakazi, 32 

F.4th 785, 787 (9th Cir. 2022).

In conjunction with this requirement, “[t]he agency must ‘articulate ... how persuasive’ it 

finds ‘all of the medical opinions’ from each doctor or other source, and ‘explain how [it] 

considered the supportability and consistency factors’ in reaching these findings.” Id. at 792 

(citing 20 C.F.R. § 404.1520c(b)). See 20 C.F.R. § 416.920c(b). “Supportability means the 

extent to which a medical source supports the medical opinion by explaining the ‘relevant ... 

objective medical evidence.’” Woods, 32 F.4th at 791–92 (quoting 20 C.F.R. § 404.1520c(c)(1)). 

See 20 C.F.R. § 416.920c(c)(1). “Consistency means the extent to which a medical opinion is 

‘consistent ... with the evidence from other medical sources and nonmedical sources in the 

claim.’” Id. at 792 (quoting 20 C.F.R. § 404.1520c(c)(2)). See also id. § 416.920c(c)( 2).

An ALJ may properly reject the “ultimate conclusions” of disability made in the context 

of another type of proceeding such as a workers’ compensation case. 20 C.F.R. § 404.1504 (“A 

decision by any nongovernmental agency or any other governmental agency about whether you 

are disabled or blind is based on its rules and is not our decision about whether you are 

disabled...”); 20 C.F.R. § 416.920(c) (providing that an ALJ must consider medical opinions or 

prior administrative medical findings using multiple factors, the most important of which are 

supportability and consistency). See Nyman v. Heckler, 779 F.2d 528, 531 (9th Cir. 1985) 

(“Conclusory opinions by medical experts regarding the ultimate question of disability are not 

binding on the ALJ”).

However, an ALJ “may not disregard a ... medical opinion simply because it was initially 

elicited in a state workers’ compensation proceeding ...” Booth v. Barnhart, 181 F. Supp. 2d 

1099, 1105 (C.D. Cal. 2002). Instead, an ALJ must evaluate the medical records prepared in the 

context of workers’ compensation in the same way he or she would evaluate records obtained 

otherwise. Id. (citing Coria v. Heckler, 750 F.2d 245, 248 (3d Cir. 1984)) (“[T]he ALJ should 

evaluate the objective medical findings set forth in the medical reports for submission with the 

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workers’ compensation claim by the same standards that s/he uses to evaluate medical findings in 

reports made in the first instance for the Social Security claim”); cf. Lester, 81 F.3d at 832

(holding that the ALJ erred in rejecting a physician’s reports because they “were clearly obtained 

by the claimant’s attorney for the purpose of litigation,” and stating that “[t]he purpose for which 

medical reports are obtained does not provide a legitimate basis for rejecting them”). 

In analyzing medical opinions using state workers’ compensation terminology, the ALJ 

“is entitled to draw inferences logically flowing from the evidence.” Macri v. Chater, 93 F.3d 

540, 544 (9th Cir. 1996) (quotations omitted) (holding that the ALJ reasonably inferred that a 

worker who had “lost approximately half of his pre-injury capacity for lifting, bending and 

stooping” under the California workers’ compensation guidelines, and whose prior job required 

lifting forty pounds occasionally, twenty-five pounds frequently, and constant bending, could 

perform light work under the Commissioner’s regulations); Carpenter v. Apfel, No. C 98-4891 

SC 2000 WL 973681 at *3-4 (N.D. Cal. July 5, 2000) (holding that the opinion of an examining 

physician that the claimant had “lost some capacity for lifting and bending, and was precluded 

from any heavy lifting” under the California workers’ compensation guidelines supported the 

ALJ’s finding that the claimant could perform light work).

Defendant argues that the ALJ’s refusal to examine the persuasiveness of the state 

workers’ compensation medical records was correct. Defendant states that these statements do 

not “constitute ‘opinions’ as defined in the revised regulations because ... a medical opinion is a 

statement about what an individual can still do despite his or her impairments, and includes 

limitations or restrictions ...” (Doc. 20 at 11-12). Defendant argues that the blanket statement 

“remain off-work” does not fall within this definition and is not “valuable nor persuasive.” Id. at 

12. Defendant also contends that several of the records were made prior to the date Plaintiff 

alleged he became disabled and were thus outside the period the ALJ was required to consider. 

Id. 

There is, however, an important distinction between rejecting a conclusion, such as 

“remain off-work,” and rejecting medical opinions and work-related limitations. See Neves v. 

Comm’r of Soc. Sec., No. 1:15-CV-01194-EPG, 2017 WL 1079754, at *6 (E.D. Cal. Mar. 21, 

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2017) (“To be very clear, rejecting the ultimate conclusion concerning disability and rejecting 

findings concerning work-related limitations are two vastly different propositions that should not 

be conflated.”) (emphasis in original); De Magana v. Comm’r of Soc. Sec., No. 1:21-CV-01288-

CDB, 2024 WL 870821, at *9 (E.D. Cal. Feb. 29, 2024) (“The ALJ was entitled to reject the 

conclusion of Dr. Vanderhyde that Defendant ‘Remain off-work.’ However, an ALJ may not 

reject work-related limitations simply on the grounds that a source also addressed the ultimate 

issue ... Here, the ALJ did not address the functional limitations identified by Dr. Vanderhyde on 

July 31, 2018. Thus, the ALJ erred by failing to address the functional limitations proposed by 

Dr. Vanderhyde and did not identify germane reasons for rejecting said limitations.”) (citing 

Neves).

The ALJ states that, when referring to workers’ compensation doctors’ records, he “finds 

it unnecessary to evaluate the persuasiveness of these work status forms, as they do not provide 

functional limitations.” He cites specifically to Exhibits 1F, 2F, 11F, 12F, 13F, and 14F. (AR

24). However, the ALJ extensively cites to Exhibit 2F across his decision, including in the 

preceding and subsequent paragraphs. See (AR 17, 21-24). It is unclear why the ALJ cites 

Exhibit 2F among the exhibits whose persuasiveness he need not consider, despite the fact the 

ALJ continually cites to it. Indeed, it seems, as the ALJ is citing Exhibit 2F’s findings, he should 

then consider its persuasiveness under the factors of supportability and consistency. See De 

Magana, 2024 WL 870821, at *10 (“The ALJ must explain in his decision how persuasive he 

finds a medical opinion and/or a prior administrative medical finding based on these two factors

[of supportability and consistency].”) (citations omitted).

Defendant is correct as to the date of Exhibit 11F falling prior to the date Plaintiff alleges 

as the onset of his disability (February 12, 2018). (AR 682). It appears, however, that Exhibits 

12F, 13F, and 14F are dated after February 12, 2018. Defendant is correct that the ALJ need not 

consider the “remain off-work” conclusion but it appears that at least two of these exhibits 

evidence potential limitations (AR 691, 703), and all evidence symptom testimony and/or medical 

findings. (AR 689-690, 695-696, 702-703). 

An ALJ properly may refuse to consider the workers’ compensation record’s conclusions 

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as to disability status. But the ALJ may not simply refuse to evaluate the persuasiveness of the 

accompanying medical and symptom testimony, particularly in regard to limitations, within these 

records under the supportability and consistency factors merely because they are workers’ 

compensation documents that provide a conclusory finding of “remain off-work.” See Booth v. 

Barnhart, 181 F. Supp. 2d 1099, 1109 (C.D. Cal. 2002) (finding that, because the ALJ did not 

adequately “translate” physician’s opinion into Social Security terms, and because he did not 

analyze her opinion in light of the relevant factors, the ALJ committed legal error).

* * * * *

In sum, the ALJ failed to consider or properly reject Plaintiff’s symptom testimony 

regarding his IBS and GERD under the applicable standard and failed to evaluate state workers’ 

compensation medical records under the relevant factors.

The decision whether to remand for further proceedings or simply to award benefits is 

within the discretion of the Court. See Salvador v. Sullivan, 917 F.2d 13, 15 (9th Cir. 1990). 

Remand for further proceedings is warranted where additional administrative proceedings could 

remedy defects in the decision. See Kail v. Heckler, 722 F.2d 1496, 1497 (9th Cir. 1984). 

Remand for the payment of benefits is appropriate where no useful purpose would be served by 

further administrative proceedings (Kornock v. Harris, 648 F.2d 525, 527 (9th Cir. 1980)); where 

the record has been fully developed (Hoffman v. Heckler, 785 F.2d 1423, 1425 (9th Cir. 1986)); 

or where remand would unnecessarily delay the receipt of benefits to which the disabled Plaintiff 

is entitled (Bilby v. Schweiker, 762 F.2d 716, 719 (9th Cir. 1985)).

The Court concludes that remand for further proceedings is warranted because additional 

administrative proceedings may remedy the defects in the ALJ’s decision noted above.

Remainder of This Page Intentionally Left Blank

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IV. CONCLUSION

For the reasons set for above, the Court finds the ALJ erred in evaluating opinions in the 

record and failed to apply the proper legal standards. Accordingly, IT IS HEREBY ORDERED 

that:

1. Plaintiff’s motion for summary judgment (Doc. 14) is GRANTED.

2. Defendant’s cross-motion for summary judgment (Doc. 20) is DENIED.

3. This matter is REMANDED pursuant to sentence four of 42 U.S.C. §405(g) for further 

proceedings consistent with this decision; and 

4. The Clerk of the Court is DIRECTED to enter judgment in favor of Plaintiff Brian Carr

and against Defendant Commissioner of Social Security. 

IT IS SO ORDERED.

Dated: January 16, 2025 ___________________ _

UNITED STATES MAGISTRATE JUDGE

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