Court Opinion

ID: 9368087
Source: CourtListenerOpinion
Date Created: 2023-02-02 19:02:08.111905+00
Date Added: 2024-06-11T17:16:05.616966
License: Public Domain

Filed 2/2/23 Conservatorship of S.A. CA1/2
                  NOT TO BE PUBLISHED IN OFFICIAL REPORTS
California Rules of Court, rule 8.1115(a), prohibits courts and parties from citing or relying on opinions not certified for
publication or ordered published, except as specified by rule 8.1115(b). This opinion has not been certified for publication or
ordered published for purposes of rule 8.1115.

          IN THE COURT OF APPEAL OF THE STATE OF CALIFORNIA

                                      FIRST APPELLATE DISTRICT

                                                   DIVISION TWO

 Conservatorship of the Person
 of S.A.

 CONTRA COSTA COUNTY
 PUBLIC GUARDIAN,
      Petitioner and                                          A164805
 Respondent,
 v.                                                           (Contra Costa County
                                                              Super. Ct. No. P21-01236)
 S.A.,
           Objector and Appellant.

         S.A. appeals from an order of conservatorship under the Lanterman-
Petris-Short Act. She contends the trial court erred in admitting psychiatric
records under the business records exception to the hearsay rule that
contained inadmissible multiple hearsay, opinions and conclusions. We
affirm.
                                                  BACKGROUND
                                                               I.
                                                     The Petition
         On August 26, 2021, the Contra Costa public guardian (public
guardian) filed a petition for appointment of temporary conservator and

                                                               1
conservator of the person of S.A. (Welf. & Inst. Code, §§ 5350, 5352, 5352.1.)
The petition alleged that S.A. was gravely disabled as a result of a mental
disorder and unwilling to accept, or incapable of accepting, treatment
voluntarily. A supporting declaration from a psychiatrist at John Muir
Behavioral Health Center (John Muir) attested to S.A.’s grave disability and
need for a conservatorship, with explanatory details set forth in the
declaration of a treating therapist. An order appointing temporary
conservator was filed the same day.
      S.A. had been admitted to John Muir on August 5, 2021, and was
discharged on September 14, 2021. She subsequently entered a different
psychiatric facility, Canyon Manor, where she remained at the time of trial.
      With S.A.’s concurrence, several hearing dates were continued until, at
a hearing on January 11, 2022, S.A. objected to the petition and requested a
“time not waived” court trial. Trial was set for January 25, then continued
several more times until March 1.
                                      II.
                                  The Trial
      The sole witness at trial was clinical psychologist Dr. Jennifer
Weinstein, who testified for the public guardian as an expert in psychology
and grave disability. Weinstein interviewed S.A. at Canyon Manor on
February 22, 2022, for about 40 minutes, which she testified was an adequate
period of time to evaluate S.A. for grave disability. Weinstein also spoke with
S.A.’s conservator, social worker and father, and reviewed records from John
Muir and Canyon Manor. She testified that the medical records are the kind
of records commonly relied upon in her field. Based on the interviews and
her review of the medical records, Weinstein concluded that S.A. was gravely
disabled.

                                       2
      Weinstein diagnosed S.A. with schizophrenia. This diagnosis requires
the presence for more than a month of two or more symptoms, one of which
must be disorganized speech, delusions or hallucinations (“positive
symptoms”) and the other of which may be a “negative symptom” such as lack
of motivation, isolating oneself or difficulty with activities of daily living. The
symptoms interfere with judgment, insight, cognition, and ability to plan and
follow through on a plan, take care of needs like hygiene and shelter, and
interact socially with appropriateness. Weinstein testified that schizophrenia
is a chronic disorder but there may be times when symptoms are more severe
and times when they are “more managed.” S.A. was taking Clozaril, an
antipsychotic medication that requires a blood test every two weeks to
monitor for a rare blood disease. Weinstein testified that medication can help
reduce symptoms, case management can help maintain self-care and use of
medication, and living in a structured placement can be a treatment for a
patient who needs daily intervention assistance.
      A.    S.A.’s Interview
      Weinstein testified that S.A. was oriented to who and where she was
during the interview on February 22. S.A. told Weinstein that prior to her
placement she had tried to exit a vehicle “while being driven or about to be
driven” by her case manager, and said that she would have been harmed if
she had not tried to exit the vehicle. S.A. made comments that Weinstein
deemed delusional, including that “in 2017 someone on drugs got into her
body and made her overdose on DMT, which is a type of drug” and “ ‘[t]hey
got into my body and lifted up out of my body.’ ”
      Weinstein testified that S.A. had “some insight” into having a mental
health condition: S.A. said she had previously been diagnosed with
“dissociative identity disorder amnesia and bipolar disorder” and “agree[d]

                                        3
with those diagnoses, but [was] also diagnosed with schizoaffective disorder
and [did] not agree with that diagnosis.” Weinstein explained that “insight”
in this context means the patient’s understanding of her own psychiatric
condition and needs for psychiatric care, which is often correlated with an
ability to willingly engage in needed treatment.
      S.A. told Weinstein that her history of symptoms included auditory
hallucinations, depression, anxiety and trouble focusing. She said she had
previously taken the medication Invega Sustenna at a local clinic, and had
been taking Clozaril for five months. She told Weinstein that if the
conservatorship ended, she planned to live with her fiancé. She declined to
give a name or number for the fiancé, saying she had had people stalk her,
she did not feel comfortable sharing and she did not think he would want her
to share his private information. S.A. told Weinstein that people had
followed her to her fiancé’s house and said they would “light a bomb . . . [¶]
[o]n fire” if she went to his house. Weinstein testified that paranoid
delusions—concerns “that others are out to harm oneself” and “collaborating
against oneself”—are a symptom of schizophrenia.
      B.    Records-Based Testimony
      Weinstein was asked about a number of entries in S.A.’s medical
records from John Muir (exhibit 2) and Canyon Manor (exhibit 3), which were
admitted over S.A.’s objections, with redactions, as business records under
Evidence Code section 1271.1

      1Further statutory references will be to the Evidence Code unless
otherwise specified.
      Counsel for the public guardian offered the records into evidence under
section 1271, stating that they were accompanied by declarations complying
with section 1561. S.A.’s attorney objected that several entries within the

                                        4
      Weinstein testified that an entry in exhibit 2 stating that “patient upon
arriving to the unit continued to be very psychotic and disorganized,” and
describing S.A. as “labile, agitated, aggressive towards staff and requiring
physical restraint,” showed the psychiatric symptoms S.A. was suffering from
when she transitioned from the community to the psychiatric facility. A
description of S.A. as “appearing internally preoccupied, uncooperative and
disorganized,” which are symptoms that “can significantly interfere with
functionality” when unmanaged, supported the diagnosis of schizophrenia.
      Asked about the notation “active AH” in an August 9, 2021 entry,
Weinstein testified that “AH” stands for auditory hallucinations. She
testified that the entry, which read, “ ‘active AH, believes she’s possessed by
Satan,’ ” was evidence of a symptom of schizophrenia that she relied upon in
forming her diagnosis, and that auditory hallucinations and “delusional belief
of possession” can interfere with thinking, judgment and decision-making.
      Weinstein testified that a note stating, “ ‘[r]eports being possessed by
multiple persons’” was similar to a statement S.A. made during the
February 2022 interview and revealed a delusion, which is a symptom of
schizophrenia. Another note stated “ ‘DZ Zyprexa due to,’ quote, ‘it has a
chemical in it that’s not good. I want to be back on the Seroquel.’ ” Weinstein
testified that this entry “reveal[ed] that [S.A.’s] mental state or diagnosis or
delusion in this case interfered with her ability to accept treatment.”

exhibits were inadmissible on hearsay or foundation grounds and asked the
court to receive the exhibits subject to examination of the witness and
objection to specific portions. The court received the exhibits subject to
further redactions, and subsequently heard argument and ruled upon
objections to specific portions.

                                        5
      An entry from August 24 stated that S.A. was “still hearing the voice of
Isaiah, her guardian angel” and felt comforted by this; an entry from
August 26 said S.A. denied hearing Isaiah’s voice that day but still felt “in
contact with him.” Weinstein testified that these records “reveal the patient’s
belief that would be labeled a delusion about a contact with somebody who is
otherwise known to others as a fantasy,” which is a symptom of
schizophrenia.
      An October 14, 2021 entry in exhibit 3, the Canyon Manor records,
related that when asked about demons, S.A. said a peer “was possessed by
the demon, and the demon transferred from the peer to her, and she felt it.
She indicates that she prayed to St. Michael, and that it went away. And
that St. Michael and her father are close, but she did not wish to discuss
that.” Weinstein testified this was evidence of a paranoid delusional belief at
a different period of time, further supporting the schizophrenia diagnosis.
      Weinstein saw further evidence of paranoid delusions in a
November 11, 2021 entry relating S.A.’s report that she “has anxiety when
seeing people eating. She gets nauseated and cannot eat in public and then
indicates demons gave her gluttony in the form of an eating disorder. [¶] And
once she ate in a restaurant, and the waiter gave her quote, blood, guts,
fingernails and eyeballs, end quote, instead of food.” Weinstein testified that
these delusions “interfered with [S.A.’s] proper nourishment or ability to
nourish herself.”
      A note from November 24, 2021, said S.A. planned to move to her
fiancé’s cousin’s house but could not talk about her fiancé and said he was
famous. Weinstein testified that this note affected her opinion about S.A.’s
mental health condition in that the plan appeared to “potentially lack
grounding in reality.” Weinstein testified that a belief about having a fiancé

                                       6
“could be a delusion” and a belief that the fiancé is famous was “possibly or
likely a grandiose delusion,” which is a belief that “oneself or others
connected to oneself are of a super extraordinary nature or have powers or
are somehow extraordinary.”
       A further entry related that S.A. “ ‘indicates that the demons are less
bothersome because she’s not at home, and then pauses and says she doesn’t
believe in demons anymore,’ that it was, quote ‘set up by human people,’ end
quote. And then: ‘She suspects people from high school who don’t like that
she’s marrying a famous person harass her.’ ” Weinstein testified that this
entry revealed paranoid delusions, confusion about whether the delusions
exist and “paranoia about being harassed or set up by others.”
       A December 2021 note that reported S.A. saying she “doesn’t have
distorted thoughts anymore and denies demons currently,” showed that S.A.’s
“delusion beliefs” had changed; the same entry related that S.A. planned to
discharge to her fiancé’s house, which indicated that a “possibly or likely a
delusion” continued despite the change regarding the delusion about the
demon.
       A note dated January 17, 2022, indicated that S.A. had started
attending “higher functioning groups,” her participation was “limited” and
she still did not understand why she was at Canyon Manor and wanted to be
released from conservatorship. Weinstein testified that this note revealed
that “while there has been some improvement in symptom reduction, her
ability to grasp the reason behind her admission and her ability to
meaningfully engage[] in the treatment is limited.” It also showed a
“fixation” or “focus” on being released, which Weinstein had also observed in
S.A.

                                        7
      In Weinstein’s opinion, S.A. had “some insight” into the fact that she
had a mental health “difficulty or diagnosis,” but it was “limited by her
symptoms . . . and her diagnosis,” leaving her unable to understand the
nature of her psychiatric condition and her need for the psychiatric care she
was receiving. Asked if she believed S.A. would continue to take her
medication if she was released from conservatorship, Weinstein said S.A. had
not spoken of planning to stop taking her medication but opined that S.A.
would not have enough assistance or structure in the community to support
continuing her current medication regimen, with its required blood draw.
Although S.A.’s symptoms had lessened since her admission to John Muir,
Weinstein testified that symptoms “[m]ost often” return and become more
severe when medication is stopped.
      Asked how S.A.’s mental disorder affected her ability to provide for her
basic needs, Weinstein stated that S.A.’s symptoms—including paranoid and
grandiose delusional thinking and auditory hallucinations—interfered with
her ability to differentiate reality from fantasy, make decisions, take care of
herself on a day-to-day basis, and use judgment. In Weinstein’s opinion, S.A.
was not at that time able to “rationally advocate for herself in order to obtain
shelter.”
      C.    Cross examination
      Weinstein testified on cross examination that during her interview S.A.
said she was not currently experiencing symptoms of mental illness but a
year and a half ago had heard voices for a week. S.A. said she had received
an injection of Invega Sustenna at a clinic in September 2021 and had been
receiving these shots on a monthly basis; she did not feel safe in the car with
the case manager who was driving her to get the injections; and this case
manager was the driver in the incident that occurred prior to her

                                        8
hospitalization. She told Weinstein that she had previously taken a different
medication called Latuda, which Weinstein testified was a mental health
medication. S.A. told Weinstein that she received $990 per month in Social
Security disability payments and, if released from conservatorship, she would
have her disability income changed to direct deposit and Uber to the grocery
store or use a delivery service to obtain food. She also suggested an
alternative post-discharge plan of working with the social worker at Canyon
Manor to arrange for transfer to an “equal level” placement called Villa
Fairmont. She told Weinstein she had been assaulted by a resident at
Canyon Manor.
      D.      Conclusion of the Trial
      After the public guardian rested its case in chief and S.A. rested
without presenting evidence, the court overruled S.A.’s general hearsay
objection to exhibit 2, explaining that it had reviewed the document and
found it trustworthy pursuant to Conservatorship of S.A. (2018)
25 Cal.App.5th 438 (S.A.). The court recognized there could still be objections
to specific entries and asked S.A.’s counsel to identify the portions he objected
to. In addition to entries that appeared to be summaries or restatements of
entries by other staff, counsel objected to entries “indicating a clinical
judgment”—specifically, “poor insight,” “psychotic” and “processing or fully
comprehending information.” The court overruled these objections.
      Regarding exhibit 3, S.A. objected to information that did not clearly
come from within the facility or from S.A. herself, as well as
“recommendations, opinions, goals of the facility.” Counsel then stated
objections to specific entries in exhibit 3. After hearing argument, the court
overruled many of the objections and sustained others, resulting in further
redactions.

                                        9
      Following arguments on the merits, the court found S.A. was gravely
disabled and was to “remain at the MHRC [Mental Health Rehabilitation
Center] level.” The court found clear and convincing evidence to support
imposition of three of the four disabilities the public guardian requested:
S.A. was not permitted to have a driver’s license, to possess a firearm or other
deadly weapon, or to enter into legal contracts. The court did not find clear
and convincing evidence to support removing S.A.’s power to refuse or
consent to treatment.
                                DISCUSSION
      Where specified conditions are met, the business records exception to
the hearsay rule allows admission of a writing “made as a record of an act,
condition, or event” “in the regular course of a business” to prove the act,
condition or event. (§ 1271.) S.A. acknowledges that medical records may be
admissible under the business records exception “to prove the acts,
conditions, and events recorded therein.” (S.A., supra, 25 Cal.App.5th at
p. 447; § 1271.) She argues, however, that much of the contents of the
records here was not admissible because it did not satisfy requirements of the
exception, including personal knowledge of the person who created the
record, contemporaneous recording and demonstration of applicable
exceptions for hearsay within the records. Her claims fall into two main (and
sometimes overlapping) categories: Objections to admission of multiple levels
of hearsay and objections to records relating opinions and conclusions rather
than observations of acts, conditions or events.
                                       I.
                            Governing Principles
      “The business records exception requires a foundational showing that
(1) the writing was made in the regular course of business; (2) at or near the

                                       10
time of the act, condition, or event; (3) the custodian or other qualified
witness testifies to its identity and mode of preparation; and (4) the sources of
information and mode and method and time of preparation indicate
trustworthiness.” (S.A., supra, 25 Cal.App.5th at p. 447; § 1271.) “These
requirements may be satisfied by affidavit.” (S.A., at p. 447; § 1561.)2 “The
trial court has wide discretion to determine whether there is a sufficient
foundation to qualify evidence as a business record; we will overturn its
decision to admit such records only upon a clear showing of abuse.” (S.A., at
p. 447.)
       “The key to establishing the admissibility of a document made in the
regular course of business is proof that the person who wrote the information
or provided it had knowledge of the facts from personal observation.”
(Jazayeri v. Mao (2009) 174 Cal.App.4th 301, 322.) “Only that portion of the
record is admissible which states facts which would be admissible had the
person who made the record been called as a witness and had been examined
in court; that is, only that portion of the record, made by one who could
qualify as a perceptive witness to the matter recorded, is admissible.” (People
v. Salcido (1966) 246 Cal.App.2d 450, 462.) Where a record contains
statements of others, those statements cannot be admitted for their truth

      2 Section 1561 requires that records be accompanied by “the affidavit of
the custodian of records or other qualified witness” and specifies the matters
that must be addressed. Most relevant here is that “[t]he records were
prepared by the personnel of the business in the ordinary course of business
at or near the time of the act, condition, or event.” (§ 1561, subd. (a)(3).)
      S.A. does not raise any issues on appeal pertaining to the affidavits
accompanying the records; her claims focus on the content of particular
entries within the records.

                                       11
unless there is an applicable hearsay exception for each level of hearsay.
(People v. Sanchez (2016) 63 Cal.4th 665, 674-675.)
      Psychiatric records have been distinguished from what S.A. calls
“purely medical” records in that psychiatric records “tend to be opinions,
rather than the record ‘of an act, condition or event’ which is admissible
under Evidence Code section 1271” and a “psychiatric diagnosis is often
merely the reasoning or thought process of the psychiatrist rendering the
opinion, and as such cannot be deemed to be the record ‘of an act, condition or
event.’ ” (People v. Young (1987) 189 Cal.App.3d 891, 912; People v. Reyes
(1974) 12 Cal.3d 486, 503.) Reyes commented on the distinction between such
a psychiatric diagnosis and one based on straightforward observation: “ ‘ “It
is true that some diagnoses are a statement of a fact or condition, for
example, a diagnosis that a man has suffered a compound fracture of the
femur is a record of what the person making the diagnosis has seen[,] but this
is not true where the diagnosis is but the reasoning of the person making it
arrived at from the consideration of many different factors.” ’ ” (Ibid.)
      The trial court in the present case took particular guidance from S.A.,
which held that a conservatee’s medical records, redacted for “conclusions,
opinions, and remote or immaterial matters” she identified, were admissible
under the business records exception. (S.A., supra, 25 Cal.App.5th at
pp. 442, 447.) Rejecting the conservatee’s arguments that the medical
records were inadmissible hearsay and an expert witness improperly testified
to case-specific facts in the records that were not otherwise proven, S.A.
explained: “S.A. argues that not every entry expressly states that the person
who recorded it was the direct observer. She points, for example, to an entry
that begins ‘Per staff . . . ’ and questions whether the writer witnessed the
events. But the trial court considered these arguments, reviewed the records,

                                       12
and found the [facility] records were ‘clearly the reports of persons and staff,
licensed psychiatric technicians, . . . who are reporting [S.A.’s] observed
conduct’ and the board and care facility records were ‘obviously the
observations . . . of the people in the psychiatric program.’” (S.A., at p. 448.)
      With respect to expert testimony based upon medical records, “[a]n
expert witness may rely on hearsay in forming an opinion, and may tell the
jury ‘in general terms’ that she did so, but may not ‘relate as true case-
specific facts asserted in hearsay statements, unless they are independently
proven by competent evidence or are covered by a hearsay exception.’ ” (S.A.,
supra, 25 Cal.App.5th at p. 448, quoting People v. Sanchez, supra, 63 Cal.4th
at pp. 685-686.) Sanchez applies to conservatorship proceedings. (S.A., at
p. 448; Conservatorship of K.W. (2017) 13 Cal.App.5th 1274, 1284.)
                                        II.
                                    Analysis
      A. S.A. Has Not Demonstrated an Abuse of Discretion
         Regarding Multiple Hearsay.
      S.A. argues that exhibits 2 and 3 contained multiple hearsay that the
trial court erroneously admitted without requiring the public guardian to
establish a hearsay exception for each level.
      S.A. describes exhibit 2 as a five-page summary drafted by Ameek S.
Mundi, DO, that provides an overview of S.A. for each day she was detained
at the facility but does not state that the information was known to Dr.
Mundi personally or identify the source of the information, so that “[e]very
entry contains an unknown level of hearsay.” She contends the trial court
erred in treating statements from one staff member to another as reliable,
citing two pages of the reporter’s transcript that reflect questions based on
particular entries in exhibit 2. As to exhibit 3, S.A. points to a number of

                                        13
specific entries: She argues it is unclear whether statements attributed to
her were made directly to the social worker who wrote an assessment
appearing at page 8; some of the weekly progress reports at pages 52-57
include a section that summarizes information received from other
employees; an intake report at pages 58-59 refers to log notes from John Muir
containing statements by S.A.’s family and outpatient social worker as well
as psychiatric and social history; and it is “unclear” whether information
stated in “comment boxes” in weekly progress reports at pages 70, 74 and 75
was known personally to the comment writer.
      S.A.’s arguments fail for several reasons. First, for many of the entries
she challenges, S.A. provides citations only to exhibits 2 or 3, neither of which
was included in the record on appeal. Consequently, our review is limited to
what we can glean from discussion of the exhibits at the hearing. The
discussion reflected in the reporter’s transcript is often insufficient to permit
consideration of a given entry in context without reference to the document
itself. It is S.A.’s burden to provide an adequate record to assess error, and
failure to do so requires that the issue be resolved against her. (Hernandez v.
California Hospital Medical Center (2000) 78 Cal.App.4th 498, 502.) S.A.
thus has not satisfied her burden of affirmatively demonstrating error (ibid.)
with respect to many of the entries she challenges.
      Second, some of S.A.’s challenges are to entries that the reporter’s
transcript indicates may in fact have been redacted. For example, with
reference to pages 56, 57 and 58 of exhibit 3, the trial court agreed that an
“intake report” relating statements from “the case manager” appeared to
come from an external source—i.e., did not relate observations from staff at
Canyon Manor. Counsel for the public guardian agreed that a portion of
another note on page 58, also reflecting information obtained from another

                                       14
facility at intake, should be redacted, and the court stated it would not look
at this information. The court held that a passage on page 58 that was
ambiguous as to whether the information came directly from S.A. would be
redacted, as would a report of prior diagnoses that did not clearly come from
S.A. and another passage on page 59 that S.A.’s attorney viewed as
speculative and counsel for the public guardian did not object to redacting.
      Third, from our review of the reporter’s transcript, we see no basis for
finding the trial court abused its discretion in admitting the entries it found
to come within the scope of the business records exception.
      The foundation of S.A.’s claim is that many of the entries in the records
do not expressly state that the matter related was personally observed by the
individual who wrote the entry. S.A. argues that the trial court could not
know a source was trustworthy (§ 1271, subd. (d)) without knowing who the
source was, could not know whether multiple layers of hearsay were relayed
without knowing where the source obtained the information, and could not
determine whether an entry was made close in time to the incident (§ 1271,
subd. (b)) without knowing when the incident was witnessed.
      We are aware of no requirement that each entry in medical records
such as these specify its author or expressly state that the author observed
the recorded incident, and the decision in S.A., supra, 25 Cal.App.5th 438, is
to the contrary. S.A. rejected the argument that entries lacking an express
statement of personal observation were inadmissible because the trial court,
which had considered the conservatee’s arguments and reviewed the records,
concluded the entries were “ ‘clearly the reports of persons and staff, licensed
psychiatric technicians, . . . who are reporting [the conservatee’s] observed
conduct’ ” and “ ‘obviously the observations . . . of the people in the psychiatric
program.’ ” (Id. at p. 448.) The same conclusion is implicit here in the trial

                                        15
court’s finding that the entries were from a trustworthy source within the
facility. (See also People v. Orey (2021) 63 Cal.App.5th 529, 551-552
[trustworthiness, in context of public employee record exception (§ 1280)
“may be established by showing that a written report is based on the
observations of a public employee who has a duty to observe the events and to
report and record them accurately”].)3 To the extent the entries in exhibits 2
and 3 related S.A.’s conduct and statements—as opposed to diagnoses and
evaluations of her condition, as will be discussed—they were records written
by staff whose job it was to record observations relevant to S.A.’s treatment
in the regular course of their employment at the facility.
      We are also unaware of any requirement that individual entries specify
they were made at or near the time of the observation recorded. Part of the
required foundation for admission under section 1271 is an affidavit from the
custodian of records attesting that “[t]he records were prepared by the
personnel of the business in the ordinary course of business at or near the
time of the act, condition, or event.” (§ 1561, subd. (a)(3).) S.A. does not
claim the custodian’s declaration in this case lacked this attestation and,
having failed to include the records or accompanying declarations in the
appellate record, has not demonstrated any such error.4

      3 Both the business records exception and the public employee records
exception require that “[t]he sources of information and method and time of
preparation were such as to indicate its trustworthiness.” (§§ 1271, subd. (d),
1280, subd. (c).)
      4 S.A. notes that the custodians’ declarations do not assert the entries
were written by the person who witnessed the event described or that only
events witnessed by staff were documented. She cites only to exhibits 2 and 3
and, as we have said, she did not make the exhibits part of the record on
appeal.

                                       16
      The trial court properly relied upon S.A. to rule that entries describing
observations of “trustworthy source[s]” “within the facility” were admissible
under section 1271. This included entries relating statements made by S.A.,
which were admissible as party admissions. (§ 1220.)5 As noted above, the
trial court redacted entries relating information that appeared to come from
sources outside the facility or did not clearly appear to have come from S.A.’s
own statements.
      For instance, as indicated above, S.A. cites two pages of the reporter’s
transcript in connection with her assertion that the trial court erroneously
admitted statements from one staff member to another. At the first of these
pages, the trial court overruled S.A.’s objection to a question asking
Weinstein about an August 9 note referring to “active AH,” which Weinstein
testified stands for auditory hallucinations. S.A. argued at trial that the
reference was inadmissible without a showing of how the author of the note
learned the information and concluded there was a hallucination, and she
now contends the trial court erred in accepting the public guardian’s position
that the business records exception does not require that a record list “ ‘who
heard what when.’ ” As S.A.’s counsel acknowledged at trial, the note
continued, “believes she’s possessed by Satan,” thus implicitly explaining that
S.A. voiced the delusional belief. In overruling the objection, the trial court
stated that “[g]iven the context of the notes,” the second statement provided a
trustworthy basis for the first and “the entries as a whole appear to be from
within the facility and from a trustworthy source.”

      5  S.A. recognizes that such statements are admissible if reported by
the individual who directly heard her make them; her objection to these
entries is that they do not affirmatively demonstrate she made the
statements to the author of the entry.

                                       17
      At the second page S.A. cites, the trial court overruled her objection to a
question about an August 10 entry that stated, “Reports being possessed by
multiple persons.” S.A. objected that there was a “long sequence of entries on
different dates,” which counsel viewed as possibly including multiple layers of
hearsay because it appeared the author was summarizing others’ reports
rather than contemporaneously recording an incident. The public guardian
pointed to the declaration of the custodian of records stating these were
records of acts, conditions or events “as regularly taken and recorded in the
course of this business,” and the court overruled the objection.
      The reporter’s transcript reflects that the trial court carefully
considered each entry to which S.A. objected: The court heard, considered
and ruled on S.A.’s objections to Weinstein’s testimony based on the medical
records as they arose during the course of that testimony, then later heard,
considered and ruled on additional objections to the documents themselves.6
We find no abuse of discretion in its determination that entries in S.A.’s
medical records, by staff whose job it was to record their observations of
S.A.’s conduct, were trustworthy and made in the regular course of the
facility’s business. (S.A., supra, 25 Cal.App.5th at p. 448.)

      6 As one example of the court’s attention to hearsay issues, during its
discussion of the records with counsel, after agreeing that an entry in
exhibit 3 should be redacted because the information appeared to come from
an “external source,” the court interjected that an entry in exhibit 2 had the
“same report of the exiting vehicle” that “seem[ed] to come from an external
source” and commented, “the end result is that I have that information in
this case from [S.A.], but I want to respect the Hearsay Rule for its purposes.”

                                       18
      B. The Trial Court Did Not Abuse Its Discretion in Admitting
         Records Reflecting S.A.’s Observed Conduct.
      S.A. contends the trial court erroneously admitted entries that related
inadmissible opinions and conclusions rather than the acts, conditions or
events permitted under section 1271. Specifically, she points to entries in
exhibit 2 stating she was “ ‘unable to engage in an interview,’ ” “ ‘very
psychotic,’ ” “ ‘disorganized,’ ” “ ‘labile,’ ” “ ‘aggressive towards staff,’ ”
“ ‘responding to internal stimuli,’ ” “ ‘internally preoccupied,’ ” had “ ‘poor
insight,’ ” had “ ‘paranoid delusions,’ ” had “ ‘auditory hallucinations and
delusional thinking,’ ’’ was “ ‘showing improvement,’ ” was “ ‘anxious but
otherwise doing ok,’ ” and was “ ‘not agitated, aggressive, or threatening.’ ”
In S.A.’s view, while an entry stating that she was seen talking to someone
when she was alone in the room, or quoting something she said, would be an
admissible observation, the above remarks are inadmissible opinions and
conclusions “filtered through the mental process of the writer.” Similarly,
regarding exhibit 3, S.A. references a social worker’s report at page 8 that
“intertwines statements made by [S.A.] with opinions and conclusions”;
weekly progress reports at pages 52-57 that include sections describing the
doctor’s impressions of S.A. that day (“MSE”), relating “items the doctor
considers important” (“IMP”) and providing instructions to staff for the
coming week (“Plan”); and a report at page 66 that contains the social
worker’s conclusion regarding S.A.’s “threat risk” as well as descriptions of
the social worker’s observations.
      Again, to the extent S.A.’s challenges to the trial court’s rulings depend
on citation to pages in exhibits 2 or 3, her failure to include the exhibits in
the appellate record compels us to find she has not affirmatively
demonstrated error. For instance, we have no means of evaluating S.A.’s

                                           19
assertion that the social worker’s report at page 8 of exhibit 3 “intertwines
statements made by [S.A.] with opinions and conclusions.” S.A. does not
point to any discussion of this entry on the record that might illuminate its
details, and our review of the reporter’s transcript discovered references to
page 8 only in connection with objections to information derived from sources
outside the facility.
      Additionally, as with the multiple hearsay objections discussed above,
some of the entries S.A.’s appellate briefs challenge as opinions and
conclusions appear to have been redacted by trial court. For example, the
entry at page 66 of exhibit 3 to which S.A. objected at trial was redacted7 and
the court sustained S.A.’s objection to the “plan” portion of the entries.
      As for S.A.’s general contention that the trial court erroneously
admitted entries relating opinions and conclusions, we disagree. While
courts have observed that a psychiatric diagnosis “tend[s] to be [an] opinion[]”
based on “the reasoning or thought process of the psychiatrist rendering” it
(People v. Young, supra, 189 Cal.App.3d at p. 912; People v. Reyes, supra,
12 Cal.3d at p. 503), an observable psychiatric symptom is an “act, condition
or event” within the meaning of section 1271. S.A. views descriptions in the
records such as “psychotic,” “aggressive,” “responding to internal stimuli,”
“delusional” and having “poor insight” as conclusions and opinions because
they do not relate what the observer saw in literal terms: As earlier noted, in

      7  S.A. does not explain in her opening brief what she means by the
social worker’s “conclusion” regarding her “threat risk”; her reply brief refers
to page 66 as containing a “ ‘client unsafe behavior assessment’ ” that is then
referred to as a “risk assessment.” At trial, referring to page 66 of exhibit 3,
S.A.’s attorney objected to an entry describing S.A. “fidgeting, saying that she
wants to go into a facility where she could smoke” and stating, “ ‘This may be
a reason for her to attempt AWOL.’ ”

                                       20
S.A.’s view, to be admissible, an entry would have to state that she was seen
talking to someone when she was alone in a room rather than that she was
hallucinating or delusional, or quote something S.A. said without
characterizing it as a threat or a delusion.
      The trial court viewed the challenged entries as “observations of staff
who are not lay people” but rather “trained professionals of varying degrees.”
In the context of medical records from a psychiatric facility, the court saw
terms such as “psychotic” or “lack of insight” as “boiling down a series of
behaviors into one description . . . without being a diagnosis.” We agree. In
this context, entries stating S.A. appeared “aggressive,” “delusional,” and
“psychotic” described S.A.’s conduct and condition; they were more like
“terms of art,” as the public guardian characterized them, than reasoned
diagnoses based on consideration of multiple factors.
      S.A.’s analogy to Palmer v. Hoffman (1943) 318 U.S. 109 (Palmer) is
unpersuasive. Palmer held that a railroad employee’s accident report,
although made in the regular course of business, was not a routine record of
the business’s day-to-day operations within the meaning of a business records
exception. The Court explained that the purpose of the exception was to
lessen the time and expense required to use in litigation records that were
“considered reliable and trustworthy for major decisions in the industrial and
business world.” (Id. at p. 112.) As the Court observed in a subsequent case,
the accident report “did not qualify as a business record because, although
kept in the regular course of the railroad’s operations, it was ‘calculated for
use essentially in the court, not in the business.’ ” (Melendez-Diaz v.
Massachusetts (2009) 557 U.S. 305, 321, quoting Palmer, at p. 114.)
      S.A. contends the log notes in exhibits 2 and 3 are “more like accident
reports discussed in Palmer than systematic and routine entries” in that each

                                       21
entry “is the product of a writer making a judgment that a particular incident
or issue is significant, and is filtered through that judgment,” and the “filter
may include more than one person’s perception.” To the contrary, Palmer
supports the admissibility of the records at issue here. S.A.’s medical records
are trustworthy precisely because they document the observations of staff
whose job was to record such observations, which were relied upon in the
course of the facility’s day-to-day business of assessing and treating
psychiatric patients.
      As we have said, the trial court “has broad discretion in admitting
business records under Evidence Code section 1271” (People v. Dorsey (1974)
43 Cal.App.3d 953, 961), and “it has been held that the foundation
requirements may be inferred from the circumstances.” (Ibid.) The trial
court here distinguished between a diagnosis, which all recognized would not
be admissible as a business record, and observations made by facility staff
whose job was to keep records of S.A.’s behavior and condition for use in her
assessment and treatment. We find no abuse of discretion.
                                DISPOSITION
      The judgment is affirmed.

                                       22
                                         STEWART, P.J.

We concur.

RICHMAN, J.

MARKMAN, J. *

Conservatorship of S.A. (A164805)

     * Judge of the Alameda Superior Court assigned by the Chief Justice
pursuant to article VI, section 6 of the California Constitution.

                                    23