Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-1_15-cv-00753/USCOURTS-caed-1_15-cv-00753-5/pdf.json

Parties Involved:
Commissioner of Social Security
Defendant
Ruben Holguin
Plaintiff

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

RUBEN HOLGUIN,

Plaintiff,

v.

COMMISSIONER OF SOCIAL 

SECURITY,

Defendant.

Case No. 1:15-cv-00753-SAB

ORDER DENYING PLAINTIFF’S SOCIAL 

SECURITY APPEAL

(ECF Nos. 13, 19)

I.

INTRODUCTION

Plaintiff Ruben Holguin (“Plaintiff”) seeks judicial review of a final decision of the 

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

disability benefits pursuant to the Social Security Act. The matter is currently before the Court 

on the parties’ briefs, which were submitted, without oral argument, to Magistrate Judge Stanley 

A. Boone.1

Plaintiff suffers from hypertension, acute right scapular fracture, lymphadenopathy, fatty 

liver, mild splenomegaly, human immunodeficiency virus (“HIV”), diabetes mellitus, chronic 

liver disease, cirrhosis, affective disorder, and drug abuse. For the reasons set forth below, 

 

1 The parties have consented to the jurisdiction of the United States Magistrate Judge. (See ECF Nos. 6, 8.)

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Plaintiff's Social Security appeal shall be denied.

II.

FACTUAL AND PROCEDURAL BACKGROUND

Plaintiff protectively filed an application for a period of disability and disability insurance 

benefits and a Title XVI application for supplemental security income on December 13, 2011. 

(AR 59, 101.) Plaintiff’s applications were initially denied on June 20, 2012, and denied upon 

reconsideration on January 29, 2013. (AR 111-144, 146-149, 152-155, 158-162.) Plaintiff 

requested and received a hearing before Administrative Law Judge Daniel G. Heely (“the ALJ”). 

Plaintiff appeared for a hearing on September 10, 2013. (AR 27-58.) On October 25, 2013, the 

ALJ found that Plaintiff was not disabled. (AR 6-21.) The Appeals Council denied Plaintiff’s 

request for review on March 30, 2015. (AR 1-3.)

A. Relevant Hearing Testimony

Plaintiff testified at the September 10, 2013 hearing. (AR 30-52, 53-54.) Plaintiff 

attended school through the eleventh grade and completed beauty college in 1983. (AR 31.) 

Plaintiff worked as hair stylist about seven hears prior to the hearing. (AR 53-54.) Plaintiff was 

concerned about cutting himself and passing HIV on to his clients. (AR 48.) In 2009, Plaintiff 

worked as in home health support services for his aunt for two months. (AR 32-33.) Plaintiff 

has looked for work but has been unable to find a job. (AR 33-34.) Plaintiff has been arrested 

for petty theft and has served a couple days in county jail. (AR 38, 39-40.)

Plaintiff is homeless and on occasion his ex-boyfriend allows him to go over and shower 

and stay at his house. (AR 40-42.) He has another friend that also allows him to stay at his 

house. (AR 42.) When staying with his friends Plaintiff is able to prepare food, do laundry, and 

wash dishes. (AR 43.) 

Plaintiff has been diagnosed with HIV and is waiting to be put on medication. (AR 34.) 

Plaintiff does not take any medication for mental health issues. (AR 47.) Plaintiff’s HIV causes 

him to sleep a lot, about ten to twelve hours per day. (AR 35, 49.) He gets bladder infections 

and has to take antibiotics. (AR 36.) Plaintiff has had incontinence problems the past year and is 

being referred to a urologist. (AR 49-50.) Plaintiff is a type two diabetic and has numbness in 

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his feet. (AR 36.) Plaintiff does not take insulin and the last time he checked his blood it was 

fine. (AR 37.) 

Plaintiff smokes on and off. (AR 37.) A pack of cigarettes will last him a month to a 

month and a half. (AR 37.) Plaintiff does not drink alcohol or use any illegal drugs. (AR 37.) 

Plaintiff used marijuana in the past to relax himself and last used two months prior to the 

hearing. (AR 37-38.) Plaintiff has not used any other illegal drugs over the past year. (AR 38.) 

Plaintiff does not bend or lift much. (AR 43.) He does not watch television. (AR 43.) If 

someone else has the television on he will watch, but he is not allowed to turn on the television 

because he does not pay for electricity. (AR 42-43.) Plaintiff has a Facebook page that he can 

access by going to the library. (AR 44-45.) Plaintiff last visited the page four or five months 

prior to the hearing. (AR 44.) 

Plaintiff attends church on Sundays and an HIV group on Thursdays. (AR 45, 47.) 

Plaintiff receives food stamps and does his shopping at Walmart. (AR 46.) Plaintiff walks to 

where he needs to go or on occasion will take the bus. (AR 46.) Plaintiff is unable to work 

because his self-esteem is shot. (AR 47.) 

An impartial vocational expert (“VE”) Jacklyn A. Benson-Dehaan also testified at the 

hearing. (AR 52-56.) 

B. ALJ Findings

The ALJ made the following findings of fact and conclusions of law:

 Plaintiff met the insured status requirements of the Social Security Act through 

June 30, 2010. 

 Plaintiff has not engaged in substantial gainful activity since June 1, 2006 the 

alleged onset date.

 Plaintiff has the following severe impairments: human immunodeficiency virus, 

diabetes mellitus, chronic liver disease, cirrhosis, affective disorder, and drug 

abuse.

 Plaintiff does not have any impairment or combination of impairments that meets 

or medically equals the severity of the listed impairments.

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 Plaintiff has the residual functional capacity to perform medium work except that 

he can lift or carry 50 pound occasionally and 25 pounds frequently; stand and/or 

walk 6 hours in an 8 hour workday with regular breaks; sit 6 hours in an 8 hour 

workday with regular breaks; and occasionally climb ramps and stairs. Plaintiff is 

precluded from working around hazards such as dangerous moving machinery; 

climbing ladders, ropes, or scaffolds; or operating equipment such as a motor 

vehicle. Plaintiff is limited to simple and routine repetitive tasks and occasional 

public contact.

 Plaintiff is unable to perform any past relevant work.

 Plaintiff was born on March 18, 1965 and was 41 years old on the alleged 

disability onset date.

 Plaintiff has a limited education and is able to communicate in English.

 Considering Plaintiff’s age, education, work experience, and residual functional 

capacity, there are jobs that exist in significant numbers in the national economy 

that Plaintiff can perform.

 Plaintiff has not been under a disability as defined in the Social Security Act from 

June 1, 2006 through the date of the decision.

(AR 11-21.) 

III.

LEGAL STANDARD

To qualify for disability insurance benefits under the Social Security Act, the claimant 

must show that she is 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 12

months.” 42 U.S.C. § 423(d)(1)(A). The Social Security Regulations set out a five step 

sequential evaluation process to be used in determining if a claimant is disabled. 20 C.F.R. § 

404.1520; Batson v. Commissioner of Social Security Administration, 359 F.3d 1190, 1194 (9th 

Cir. 2004). The five steps in the sequential evaluation in assessing whether the claimant is 

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disabled are:

Step one: Is the claimant presently engaged in substantial gainful activity? If so, 

the claimant is not disabled. If not, proceed to step two.

Step two: Is the claimant’s alleged impairment sufficiently severe to limit his or 

her ability to work? If so, proceed to step three. If not, the claimant is not 

disabled.

Step three: Does the claimant’s impairment, or combination of impairments, meet 

or equal an impairment listed in 20 C.F.R., pt. 404, subpt. P, app. 1? If so, the 

claimant is disabled. If not, proceed to step four.

Step four: Does the claimant possess the residual functional capacity (“RFC”) to 

perform his or her past relevant work? If so, the claimant is not disabled. If not, 

proceed to step five.

Step five: Does the claimant’s RFC, when considered with the claimant’s age, 

education, and work experience, allow him or her to adjust to other work that 

exists in significant numbers in the national economy? If so, the claimant is not 

disabled. If not, the claimant is disabled.

Stout v. Commissioner, Social Sec. Admin., 454 F.3d 1050, 1052 (9th Cir. 2006).

Congress has provided that an individual may obtain judicial review of any final decision 

of the Commissioner of Social Security regarding entitlement to benefits. 42 U.S.C. § 405(g). 

In reviewing findings of fact in respect to the denial of benefits, this court “reviews the 

Commissioner’s final decision for substantial evidence, and 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 more than a 

scintilla, but less than a preponderance. Smolen v. Chater, 80 F.3d 1273, 1279 (9th Cir. 1996) 

(internal quotations and citations omitted). “Substantial evidence is relevant evidence which, 

considering the record as a whole, a reasonable person might accept as adequate to support a 

conclusion.” Thomas v. Barnhart, 278 F.3d 947, 955 (9th Cir. 2002) (quoting Flaten v. Sec’y of 

Health & Human Servs., 44 F.3d 1453, 1457 (9th Cir. 1995)). 

“[A] reviewing court must consider the entire record as a whole and may not affirm 

simply by isolating a specific quantum of supporting evidence.” Hill, 698 F.3d at 1159 (quoting 

Robbins v. Social Security Administration, 466 F.3d 880, 882 (9th Cir. 2006). However, it is not 

this Court’s function to second guess the ALJ’s conclusions and substitute the court’s judgment 

for the ALJ’s. See Burch v. Barnhart, 400 F.3d 676, 679 (9th Cir. 2005) (“Where evidence is 

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susceptible to more than one rational interpretation, it is the ALJ’s conclusion that must be 

upheld.”).

IV.

DISCUSSION AND ANALYSIS

In this appeal, Plaintiff challenges only the mental health findings contending that the 

ALJ erred by improperly rejecting the opinion of examining physician, Dr. Philip Cushman. 

Specifically, Plaintiff contends that the ALJ rejected the findings that Plaintiff would have 

difficulties working a normal workday in part due to fatigue and will have difficulties in dealing 

with the usual stressors encountered in a competitive work environment. Defendant responds 

that the ALJ properly analyzed Drs. Cushman and Lampe’s opinion and considered the record as 

a whole in determining Plaintiffs’ residual functional capacity. 

A. Adverse Credibility Finding

Defendants argue that in determining Plaintiff’s residual functional capacity the ALJ 

provided a proper basis for determining that Plaintiff’s complaints were not credible. Defendants 

contend that the ALJ properly evaluated Plaintiff’s credibility and did not include those 

limitations that were not supported by the medical evidence. 

The ALJ can only reject the claimant’s testimony regarding the severity of his symptoms 

by offering “clear and convincing reasons” for the adverse credibility finding.2 Carmickle v. 

Commissioner of Social Security, 533 F.3d 1155, 1160 (9th Cir. 2008). Plaintiff did not 

challenge the adverse credibility finding, which is likely due to the fact that the ALJ provided 

clear and convincing reasons supported by substantial evidence in the record to find that 

Plaintiff’s subjective complaints are less than fully credible.

In assessing the claimant’s credibility, the ALJ may consider “(1) ordinary techniques of 

credibility evaluation, such as the claimant’s reputation for lying, prior inconsistent statements 

concerning the symptoms, and other testimony by the claimant that appears less than candid; 

 

2 Defendant argues that the clear and convincing standard should not apply to evaluate the claimant’s testimony, 

however the Ninth Circuit has recently rejected this argument in Garrison v. Colvin, 759 F.3d 995, 1015 n.18 (9th 

Cir. 2014). 

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[and] (2) unexplained or inadequately explained failure to seek treatment or to follow a 

prescribed course of treatment. . . .” Tommasetti v. Astrue, 533 F.3d 1035, 1039 (9th Cir. 2008) 

(quoting Smolen, 80 F.3d at 1284). 

Plaintiff claimed to have a history of depression for many years and difficulty dealing 

with other people due to depression but has not received any treatment for his mental health 

issues. (AR 14, 15, 47.) However, Plaintiff also testified that he attends church for two hours on 

Sundays and meetings for HIV patients. (AR 14, 45, 47, 257.) Plaintiff reported engaging in 

social activities such as visiting with others. (AR 15, 257.) The ALJ properly considered 

Plaintiff’s failure to seek mental health treatment. Molina v. Astrue, 674 F.3d 1104, 1113 (9th 

Cir. 2012).

The ALJ noted that Plaintiff’s failure to follow treatment recommendations demonstrates 

a possible unwillingness to do what is necessary to improve his condition or is an indication that 

his symptoms are not as severe as he purports. (AR 15, 403, 404, 438, 459, 550, 592, 700.) See

Molina, 674 F.3d at 1113. Plaintiff minimalized and misreported his drug usage. (AR 15-16, 

37-38, 319, 348, 476, 532, 591-592, 698, 792, 815, 818.) These inconsistent statements cast 

doubt on his credibility. (AR 16.) The ALJ properly considered Plaintiff’s inconsistent 

statements regarding his drug use. Thomas, 278 F.3d at 959.

Plaintiff alleged that he needed assistance with household chores which is inconsistent 

with his statements at the hearing. (AR 14.) Plaintiff also worked as an in home care provider 

for a number of months after he alleged he was disabled. (AR 15, 32-33, 320.) This work 

activity can be quite demanding both physically and emotionally and indicates that Plaintiff’s 

daily activities have been, at least at times, greater than Plaintiff is reporting. (AR 15.) The ALJ 

properly considered Plaintiff’s daily activities in determining credibility. Burch, 400 F.3d at 

681.

B. Mental Residual Functional Capacity 

Plaintiff contends that ALJ erred by failing to include Dr. Cushman’s findings that 

Plaintiff would have difficulties working a normal workday, in part due, to fatigue and would 

have difficulties in dealing with the usual stressors encountered in a competitive work 

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environment. 

The weight to be given to medical opinions depends upon whether the opinion is 

proffered by a treating, examining, or non-examining professional. See Lester v. Chater, 81 F.3d 

821, 830-831 (9th Cir. 1995). In general a treating physician’s opinion is entitled to greater 

weight than that of a nontreating physician because “he is employed to cure and has a greater 

opportunity to know and observe the patient as an individual.” Andrews v. Shalala, 53 F.3d 

1035, 1040-41 (9th Cir. 1995) (citations omitted). If a treating physician’s opinion is 

contradicted by another doctor, it may be rejected only for “specific and legitimate reasons” 

supported by substantial evidence in the record. Ryan v. Commissioner of Social Sec., 528 F.3d 

1194, 1198 (9th Cir.) (quoting Bayless v. Barnhart, 427 F.3d 1121, 1216 (9th Cir. 2005)). 

Where the treating physician’s opinion is contradicted by the opinion of an examining 

physician who based the opinion upon independent clinical findings that differ from those of the 

treating physician, the nontreating source itself may be substance evidence, and the ALJ is to 

resolve the conflict. Andrews, 53 F.3d at 1041. However, if the nontreating physician’s opinion 

is based upon clinical findings considered by the treating physician, the ALJ must give specific 

and legitimate reasons for rejecting the treating physician’s opinion that are based on substantial 

evidence in the record. Andrews, 53 F.3d at 1041.

The contrary opinion of a non-examining expert is not sufficient by itself to constitute a 

specific, legitimate reason for rejecting a treating or examining physician’s opinion, however, “it 

may constitute substantial evidence when it is consistent with other independent evidence in the 

record.” Tonapetyan v. Halter, 242 F.3d 1144, 1149 (9th Cir. 2001). The ALJ need not accept 

the opinion of any physician that is brief, conclusory, and unsupported by clinical findings. 

Thomas, 278 F.3d at 957. 

1. Fatigue

As relevant here, the ALJ found that Plaintiff had moderate restrictions in his activities of 

daily living and concentration, persistence, and pace. (AR 13.) Plaintiff had mild difficulties in 

social functioning. (AR 13.) The ALJ found that Plaintiff could only perform jobs involving 

simple and routine repetitive tasks and was limited to occasional public contact. (AR 13.) 

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Plaintiff contended that he was unable to work due to fatigue caused by his HIV. (AR 14.) Yet, 

Plaintiff was diagnosed with HIV in 2005 and his condition has been stable with test results 

within the normal range. (AR 15, 16.) 

Dr. Cushman saw Plaintiff on April 11, 2012 for a psychological consultative 

examination. (AR 18, 588-595.) Plaintiff reported that he did not sleep well during the night 

and did not nap during the day. (AR 590.) Plaintiff was noted to have effeminate and 

flamboyant mannerisms and was generally cooperative throughout the interview and testing. 

(AR 589.) His speech was irregular and dramatic and he provided a lot of irrelevant personal 

information. (AR 590.) 

Plaintiff was found to be in the low-average intelligence range. (AR 593.) Based on his 

examination findings, Dr. Cushman opined that Plaintiff did not appear capable of performing 

any detailed or complex tasks in a work setting, but was capable of performing simple and 

repetitive tasks in a work setting. (AR 594.) Plaintiff might have difficulties with regular 

attendance and consistent participation involving transportation and his homeless situation, 

which if resolved he would regularly attend and consistently participate. (AR 594.) Plaintiff 

may have difficulties working a normal workday or workweek due in part to fatigue. (AR 594.) 

Plaintiff might need special or additional supervision in managing interpersonal relationships and 

substance abuse. (AR 594.) Plaintiff is capable of following simple verbal instructions from 

supervisors. (AR 594.) Plaintiff will run into some difficulty getting along with supervisors, 

coworkers and the general public over any length of time and will have difficulty dealing with 

the usual stressors encountered in a competitive work environment. (AR 594.) 

Although Plaintiff alleges that the ALJ ignored Dr. Cushman’s finding that Plaintiff may 

have difficulties working a normal workday or workweek due in part to fatigue, the ALJ 

considered Plaintiff’s allegations and found that it would not limit Plaintiff’s ability to work. 

The ALJ pointed to substantial evidence in the record to support such a finding. 

The ALJ considered the January 27, 2007, mental health analysis by Dr. Stefan Lampe. 

(AR 18, 319-321.) Plaintiff denied any current severe depressive symptomatology. (AR 319.) 

Plaintiff was taking care of his sick partner at this time. (AR 320.) Plaintiff’s mood was mildly 

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depressed and affect was mildly restricted without lability. (AR 320.) Dr. Lampe opined that 

Plaintiff was a gentleman with multiple stressors who developed mild depression and would 

benefit from treatment. (AR 320.) Dr. Lampe found that Plaintiff could relate and interact with 

supervisors and co-workers; understand, remember and carry out simple as well as complex 

instructions; deal with the public; maintain concentration and attention for two-hour increments; 

and from a psychiatric standpoint would be able to withstand the stress and pressure associated 

with an eight-hour workday on an ongoing basis. (AR 320-321.) 

The ALJ also considered the February 2, 2007 consultative examination by Dr. 

Madireddi. (AR 17, 324-325.) Plaintiff reported getting fatigued. (AR 324.) After conducting 

his examination, Dr. Madireddi opined that Plaintiff should observe suitable safety precautions 

due to his HIV, but there were no other restrictions. (AR 325.) 

Dr. Madireddi conducted a second examination on April 5, 2012. (AR 17, 582-585.) 

The record notes “Rombergism is not tolerated most likely because of overall fatigue although he 

did walk 3 miles to keep this appointment.” (AR 584.) Dr. Madireddi stated that “[a]llegations 

of fatigue may be due to any or all of his diagnoses including HIV, but he is not getting any 

specific HIV medications.” (AR 585.) Dr. Madireddi opined that Plaintiff could sit, stand, and 

or walk for six hours in an eight hour workday and did not need any postural restrictions. (AR 

585.) 

The ALJ also considered two questionnaires completed by Dr. Diep. (AR 18.) On May 

15, 2012, Dr. Diep reported that Plaintiff did not appear visibly fatigued and opined that Plaintiff 

had no functional limitations. (AR 602.) On May 29, 2012, Dr. Diep reported that Plaintiff did 

not appear visually fatigued. (AR 269.) There were no indications or findings of a diagnosed 

mental impairment. (AR 270.) Dr. Diep only found some lifting and carrying limitations. (AR 

269.) 

Review of the medical record shows very few reports of fatigue. On June 26, 2008, 

Plaintiff reported some fatigue. (AR 408.) On November 13, 2011, the medical record notes 

fatigue. (AR 430.) On November 27, 2012, Plaintiff appeared with aseptic meningitis and the 

record notes extreme fatigue having not slept all night due to pain. (AR 648.) 

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The Court finds that the ALJ did not err by failing to adopt Dr. Cushman’s finding that 

Plaintiff may have difficulties working a normal workday or workweek due in part to fatigue. 

2. Adapting to Stress in Workplace

Similarly, the Court finds that the ALJ did not err failing to adopt Dr. Cushman’s finding 

that Plaintiff will have difficulty dealing with the usual stressors encountered in a competitive 

work environment. (AR 594.) 

While Dr. Cushman opined that Plaintiff would have difficulty dealing with stress in the 

workplace, he did not indicate the severity of the impairment. The ALJ is to determine 

credibility, resolve conflicts in testimony, and resolve ambiguities; however his findings must be 

supported with specific and rational reasons. Reddick v. Chater, 157 F.3d 715, 722 (9th Cir. 

1998). “The ALJ can meet this burden by setting out a detailed and thorough summary of the 

facts and conflicting clinical evidence, stating his interpretation thereof, and making findings.” 

Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989) (quoting Cotton v. Bowen , 779 F2d 

1403, 1408 (9th Cir. 1989)).

It was for the ALJ to review the evidence to determine from the record how Plaintiff’s 

ability to deal with stress in the workplace would affect his ability to work. The ALJ 

summarized the medical record as set forth above. The ALJ considered that Dr. Lampe found 

that from a psychiatric standpoint Plaintiff would be able to withstand the stress and pressure 

associated with an eight-hour workday on an ongoing basis. (AR 320-321.) Although the 

agency physician, Dr. Coleman, considered Dr. Cushman’s opinion and found that Plaintiff’s 

adaptation would be mildly limited (AR 88), both Dr. Lampe and Dr. Cushman assessed 

Plaintiff’s Global Assessment Functioning score at 60. (AR 17, 18, 320, 594.) The ALJ found 

that this indicates that Plaintiff’s symptoms are moderate, which is generally consistent with the 

objective clinical findings and Plaintiff’s testimony. (AR 19.)

The Court finds that the ALJ properly addressed those limitations set forth in Dr. 

Cushman’s opinion by finding that Plaintiff would be limited to simple and routine repetitive 

tasks and limited to occasional contact with the public.

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V.

CONCLUSION AND ORDER

Based on the foregoing, the Court finds that the ALJ did not improperly reject the 

opinion of examining physician, Dr. Philip Cushman. Accordingly, 

IT IS HEREBY ORDERED that Plaintiff’s appeal from the decision of the 

Commissioner of Social Security is DENIED. It is FURTHER ORDERED that judgment be 

entered in favor of Defendant Commissioner of Social Security and against Plaintiff Ruben 

Holguin. The Clerk of the Court is directed to CLOSE this action.

IT IS SO ORDERED.

Dated: May 9, 2016 

UNITED STATES MAGISTRATE JUDGE

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