CC - IV.CC-B - Authorization To Reject Claim Against City From Ruth Bao Rong MaoTO: HONORABLE MAYOR
AND MEMBERS
ROSEMEAD CITY COUNCIL
FROM: NANCY VALDERRAMA, CITY CLERK, CMC l /
DATE: AUGUST 2, 2000
RE: AUTHORIZATION TO REJECT CLAIM AGAINST CITY FROM RUTH BAO
RONG MAO
The attached claim was received in this office on May 7, 2000. A copy was sent to the City's
claims adjuster, Carl Warren & Company on the same day.
Carl Warren & Company sent a notice on August 1, 2000, recommending that the aforementioned
claim be rejected by the City.
Recommendation:
It is recommended that the City Council approve the rejection of this claim and authorize a letter
of rejection be sent to the claimant.
Attch.
COtJNC IL AGENDA
av U 08 2000
ITEM No. J CC i
staf fopor
2/19
MAYOR:
.roe VASOUE-
MAYOR PRO TEM:
MARGARE7. CLARK
COUNCEMEMBERS:
ROBERTW BRUESCH
JAY T. IMPERIAL
GARY A TAYLOR
March 7, 2000
Dwight J. Kunz
Senior Account Manager
Carl Warren & Company
750 The City Drive,'Suite 400
Orange, CA 92668
1fC y~ f o()y tead
6636 E. VALLEY BOULEVARD - F.O. BOX 399
ROSEMEAD, CALIFORNIA 91770
TELEPHONE (626) 268-6671
FAX (626) 307-9218
RE: RUTH BAO-RONG MAO CLAIM
Dear Mr. Kunz:
The attached claim was received in my office today. Enclosed are Ms. Bao's bills and earnings
statement. She also included one eyeglass lens whose surface is scratched. If you want me to
forward that to you, please let me know.
Please advise us of the steps you wish to take in this matter.
Sincerely,
1,,TAIsTCY V.ALDERPAMA
City Clerk
City of Rosemead
Attachments
cc: City Attorney
•r'
FILE WITH: CLAIM Fq?j DAMAGES
RESERVE FOR FILING STAMP
CITY CLERK'S OFFICE
TO PERSON OR PROPEF ft Y
CLAIM, NO.
INSTRUCTIONS
1. Gars for death, injury to person or to personal property must be filed not later than six
months after the ooeurrenee. (Gbv. Code Sec 911.2)
2. Claims tr damages to real property mull be filed not later than 1 year after the occurrence
(Gov. Code Sec 911.2)
3. Read entire claim form before filing.
4. See page 2 for diagram upon which to locate place of accident.
5. This claim form must be signed on page 2 al bonom.
E, Anach separate sheets, if necessary, to give full details. SIGN EACH SHEET -
Date of Binh of Claimant
TO: CIT.' OF ROSEl AD 8838 E. Palley 5ivd., Rosemead 91770
( j ~CZ
Occupation of Claimant
Name of. Claimant
~~N'~-, lei r1-G'
FV Ty +
ailta•t~.r:,cJ -re-i.i~ .
~
Home Address of Claima 'rt City and S.
I`,ln 1
L (1lr~
l
c
k
r
Home Telephone Number
•
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~ > ~iL:.~ - ~ba
ni.:tl
'
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r•~e,
-V
Lti)a Iv 1-
Business Address of Claimant imam ,..,y an., Su--
) S' a Numberp
/9usiness Telabhon
Give address and telephone number to which you desire notices or communications to be sent
this claim: (GGIU✓)=L3i
rdin
Claimant's Social Secumy Na
33~
g
rega
.;...~.~.hl..~~.~: ir,c~ i~..t~u,.~~.~.~~Fr•rl1'1'7r'. ?i.c-~wfr
Y✓hen did As o; INJURY occur? I ' Names of, any city emplgees involved in I J or
Time fv,t. u,'T 3" t t1'1
Date
If claim is for Equi=le indemnity, give dale claimant served
with the complaint:
uac
Whare dU DAMAGE or INJURY occur? Describe Tully, and locate on diagram on reverse s: a is sheet . _
names and address and measurements thorn IandmaLLrYs:
i t I I 2 i,.%•:~(LpS f C1
~t~~V7✓1i~.lrv~d II`>vwyfn~Y
^..i~cl-t,'1+J~S,G~ vJn::..Zic.T I„c.IiL~-:.II:-•.L L-.1a,-~h:C S;d2.1'l.'~,'I-~f'
1
G1A~y.{.~CTZSS 4}r"LL-:.. V=J(zy 17 }
VJrI Y riv2 ,;✓z i5L t2= v~ iti v~'v )Kzd C
Describe in derail how the DAMAGE or INJURY occurred. l/Jn ic4'
~ S i ~ ~ •'n.ir'l✓
I1-✓{.,,v V ~I) e'~ I, I Vc),. C C^'.i in'~ ,71/i~'' 1't%/ ~ y
1- iu."vim `~p+~.l-'CJll.ri.- I,:_G~•✓/ .q5~ I,vi^,^~' ~ilv~~.', ~'jC 1! Y
grcva {'z.~i,z 1✓~'L✓OrcSSttlV.ll~Ely
71- 1. il.'%i Ir,^L 'v~•.{ ~?~4L ✓v'C I1V v~ 1.V0.11 ✓..Ff" rv J ✓
vs_l )
- .1 ^ 1 Lw /'t✓.n'L. I':/./.fit:^'v~ 1 'Y= f
N'hy do you claim the ciq is responsible? ~~.'i,/,',1 . v'~ a SD '•n~ ~ tli-- ^L'•~5 'i'ce dC v >L 10~.C C~.~' CI .
ivo GI 1 I ~ L~ ~+~c"` <C,. cl7 ~C h 4a cLl ~ (~Ci ~'I
TS I _ n , t - ,L L (r'~,, v~tl- ~'71'i. V.'_. /YVZ_"ti L'✓•'V ~L.hit.- -Fi~or.~l i~
Describe in detail each INJURY or DAMAGE j?; I`['lG.( V'till~"''~' ti`s `/~I 't•'~'
/ ~ , _a,;_ ; v cl K=d t.t F:,VJ✓ s rz f c c., ~,,,,t Iw
• ..w-y-z C :1-C'v~•. Inc.✓ IlvT.',J~,
v.j i• I<'1• *o'' {
~ IC 1 V'~ . bZl ti: ✓v.A. i9', I ~ Iti i.. V.nn2~.PMJ •'"~'/LJ r
• t . l . 1 rr ' ✓~,.~.d.~. LLL -{'t'L:. L:~^.% iv7 1, v:.iu~ • S V
~;J A,.t,l~, C+~,1 V'~•C S'c:. ✓v7 f✓J31^.:-✓ '_c~•Jl Linti. v l" .r ;i /
SEE PAGE 2 (OVER) C; t' ='v,;: v"" THIS CLAIM, MUSL SIGt.~'O~It't `^~ir45^~'
'n._/V✓..vt ) . -i..n /l y'<.}r ~I ~.C' i\; .(i-i .L W L {'A \1;~ = 'mil, T.•r..•w ~ j'(^~'w~ J ~ >_e~;~ ` 1,"7
^ ~ S 'L. ' tom! Z t'~i d { ,d wlc M1✓✓{ti- t, . I w~ 1 i4
{'~,'.1 tti/ y IwJV~ ~ U.:a fu' v o
7 ) v
k' tr 'r1~'l i'.n bh'=-b :.nr t LI' i ~''l.b^-•d;a'
L J r
C~k
" i t~•-,s. ~~.,....,,,,,,,T, , S o y 5,=~~ tft"l~ ~ 1%,..c;t ~..-il d;y„
The amoun: claimed, as of the date of presentation of this claim, is computed as follows: c4 --,*yv',,,; h,'~1x
Damages incurred to dale (exact): Eslimated prospective damages as far as know n:,C'..,at vt-*o
Damage to property S~ Future expenses for medical and hospital care ....5 ~ ~ - ~
Expenses for medical and hospital care S -f In) Future loss of eamings S ^
LOSS of earnings Other prospective special damages
Special damages for ........................5 Prospective general damages .5
Total estimate rospective damages ....1......S
General damages ...........................5 yµl✓~r.✓'✓(
Total damages incurred to date ..............S Z-K4.f/ i^u- ~.;-V,...7, 1 C ; l^'",Yf ~'✓tL"-'~'.~"5~°.
Tatal amoun! claimed as of date of presentation of this claim:
~Iv.C. ~ `.1't,T✓~ ~y.vi-~ w..~ /..vy~ ~a'^a-~-/C.fi,~~-c~,wn
Was damage andhur injury investigated by police? n If so, whal city?
Were paramedics or ambulance called? ln~_ If so, name city or ambulance 0.i FU7 T -`'~'~I?iCT Tim vs' 14- i e-A;r r. 9+.r1
)f injured, sate date, time, name and address of dDaor of your 8st visR J 't~ \ '-'e' /A
WITNESSES to DAMAGE or INJURY: List all persons and addresses of persons kruwm to
Narw Ajl ' /V-d- Address
Name Address
Name Address
DOLT PS and HOSPITALS:
Hospital
Dater ( ) I,II ,A
READ CAREFULLY -
For all accident claims place on following diagram names of streets, or your vehicle when you firs saw City vehicle; location of City vehicle
including North, East, South, and West; indicate place of accident try at time of accident by "A-1" and location of "yourself or your vehicle at
"X" and by showing house numbers or distances to street comers the time of the accident by "&1" and the point of impact by "X:'
If Cray Vehicle was involved, designate by letter "A" location of City NOTE: H diagrams below do not fd the situation, attach hereto a proper
Vehicle'when you first saw it, and by "B" location of yourself diagram signed by claimant.
I~
SIDEWALK
(Z/ CURB
PARKWAY
f`T
I SIDEWALK
I
1
,-t,: u
Sionaium of Claimant or person filing on
his behalf diving relationship to Claimant:
;irq l ✓`X -14
~ 4..L
C'JnB f
n 1 '
Ka
Typed Name:
~U I tJ b f-o- Ivl r~
Date:
NOTE: CLAIF.!S MUST BE FILED WITH CITY CLERK (Gov. Code Sec 915a). Presentation of a false claim is a felony (Pen. Code Sec 72.)
BIRTH DATE: 3
FRAME
r
MR. D
MRS. 0
Z
LENSES
Dltl t;j r~rn
Name:MISS M S )'~1'{ ;`yty ~
`
:
TOTAL
~
-
Address: I',,kjIvA1 L1111 rn VC k-Ve
'
DEPOSIT
n CKY_/
City: jC nC C. ~"'1Y -
BALANCE
State: Zip:
DATE DISPENSE D: -
a.
Tel. (Home):
CASHO CHECK 3 C/CARD O':
Fq
S+
Tel.
(Office):
DATE:
.
SCwa~rT~L'~R•~1~_li719 09 >21917 API)t bz+LSA•
Signature. ~ ~
~
All sales are final. Orders are automa4caPy cancelled,
~
Y
8 not pick up within three months
✓
ti 7
~i lj
LEAVE
EARNINGS AND
STATEMENT
.
S-DVEM1'CE H'p PP HD
END DATE
SIA/SUB
OPE NO
SERV SOCIAL SECURITY NO
SiA
1
C./SUB ACCT
21-25
_
EMPLOYEE"S NAM`.
I
559-49-3399 8224.
597
RLITH
MAO
BAO-RONG," 217348 0.02
01-29
_
752
TSL UNIT
'A
vIK i MC C
Dicr RESERVED
.
RM
GRACE/ 1 SALARY RATE FATE
C
BONA BALANCE
BpNp
VV
CR
LEAVE YEAR
wo
Si
M
DURS
FCP
NO
KRIS
ANSE
STEP
ISS
D
2
]OO N
072
80
OS-06, 28 , 171 ~0-01
USED
CURRENT 6AL P T CREDIT
AAI~'TSP RATE TSP ASP
LEAVE CARRY OVER
TSP 1`n DEC
TSP LM
v.
AwT STAT ADJ
6/19
BEST EASTERN ACUPUNCTUTPE & IIERB. L CLLNTIC
To `Vhom It'NIay Concern:
1D42 S. San Gabriel Blvd., San Gabriel, CA P1776 Ciz:!is Tsai L.A~.. O.M.D.
Td: (E26) ZS 7-~5]? • rzx: (626) 287-4210
Date: 1 - 7- o-o
?~Zr./h1rs./ ss V<LIt~ is under rrearment at
my office on - -)-VrT for ry In addition to further
,r--
treatment, T~rpz day(s) of bed rest are necessary.
~-en Truiy Yours,
A'2 `
S;: Ts- L.-4c. O.-I.D.
PRACTITl9,W'S STATEMENT r'
This form has been prepared to assist you in the completion of your insurance claim form and contains all the information that the
practitioner is required to provide. Fill out the personal information requested on your insurance company claim form and attach this
statement to it. Each patient, not the insurance company, is responsible for payment to this office.
Patient Age S/sa 3 - cr - 3 P
Today's Date: I] Illness (rust symptom) or c0ond0ion ronsulled you torhhi
Address U 7 g )'JCf)'rfIJ ~iTt+ f 21 / v-v P Injury (aciddern) I Z/ 7 /9
/ Dale patie~i. adb a Delm 0 Tpal dsadidly ❑ Paeie :ten,
r L / / Q 7 -c' lelum 1.
hom kin
has paliem ever fad idllro or Place of VOffice ❑ Home
simile-syminoms7
Phone Yet D N011( Service: J ther
NEW PATIENT (Office Visit) Fee
❑ 99201 Sell Limited or Minor
❑ 99203 Moderate Severity
❑ 992D4 Moderate to High Severity
ESTABLISHED PATIENT (Office Visit)
❑ 99211 Minimal
❑ 99212 Self. Limited or Minor
❑ 99213 Low to Moderate Severity
❑ 99214 Moderate to High Seventy
ACUPUNCTURE PROCEDURES
❑ 97780 One or more Needles
without Elec. Stim.
97781 With Elec. Stim. ~t
7799 Unlisted Phys. Med. Sew.
Specify
❑ 97035 Ultrasound, ea. 15 min.
❑ 97110 Therapr..ulic Prod-, ea 15 min
❑ 97112 Neuromuscular Reeducation
❑ 97124 Massage Therapy
❑ 97139 Unlisted Therapeutic Prod.
❑ 97140 Manua Therapy Techniques
(Manipulation, Myofascial release, Manual
Traction, Mobilization) 1 or more reoions,
ea. 15 min.
❑ 97802 Cupping
❑ 97803 Moxibustion
MODALITIES
❑ 97010 HoVCold Treatment
❑ 97012 Traction, Mechanical
❑ 97039 Unlisted Modality
Specify
MISCELLANEOUS
❑ 99056 Home Services
❑ 99070 Supplies/Materials
(Not included in office visit)
72 Herbs ❑ N=_dles ❑ Supp ernenis i. O '
1❑ 99090 Special Reports (UCR)
TOTAL b Fi
Old Balance
s
Today's Charges
S
TOTAL
s
Payment Received
S 1> ( r
New Balance
S
DIAGNOSIS (if not checked below):
O New Case
❑ Continued Clef
GENERAL
0 Resp. DIV.. S.O.B.
Abdominal Pan
790,0
D Rheumatoid Amimis
Amencinnea
626.0
D Shingles
Alcohol Dependence
303.9
0 Sinusha (Acne)
Allergies
995.3
0 Sinusha (Chronic)
Asthma
493.9
D Sore Throa: (Acute)
Backache. Unspecified
724.5
O Sore Throat (Chronic)
Bell's Palsy
351.0
E Stiffness of Joints
Bronchitis
490,0
0 Tendomis
Carpal Tunnel Syndrome
354,0
0 Tmni us
Common Cold
460
O TM.1 Pain
0 Tobacco Dependency
Constipation
554.0
O Vertigo
Cough
7862
JOINT PAIN
Cysthls
595.0
Demat4:is/caema
6929
O A•thralgia
Diarmea/Colilis
558,9
_ C Shoulder
Drug Dependence
304.0
D Upper Arts
Dvsmenormea
625.3
O Forearm
O Hand
Edema
752.3
D PeMl-iThigh
Fatioue/Malaise
780,7
0 Lower LegfKnee
Gastric Pain
787.3
0 Ankle/Foot
Hay Fe+er/Rhinitis
477.9
algia
O
Headache (Tension)
307,81
rachi
0 Brachial/Neurili culni5
Headache (Common Migraine)
346,1
C Lumbar Spine Pain
Pain
Headache (Pain in Head NOS)
784.0
13 Wm6aoo/Wmtalgia
HYPenenion
4019
D Sciatica
iypotension
456.0
D Sacroiliac Pain
ndigestion
536.8
0 Coccyx Pain
nfertilM
6069
C Bursns Shoulder
nsomnia
760.52
D BursitsfElbow
Menopausal Syndrome
6272
❑ BursaisfKnee
Menorrhagia
626.2
D SurshislAnkle
Myalgia-Myosms, Unspecified
729.1
SPRAIN/STRAIN
Nausea
767.0
C Shoulder/Arm
Neumis/Neuraloia
7292
C Elbow/Forearm
Nuinlion, Inadequacy
269.2
0 WrisVHand
Nutrition, Counseling
VE5.3
C HiprThioh
Obesity. Consthutional and Nutritional
276.0
D Knee/Leg
Osleos'n"I's
715.9
Ankle/Fool
-
sleoporosis
733.0
Neck (Cervical)
'S/
Otilis Media
362.9
/[i-Thoracic
'remensVUal Syndrome
6254
0 Lumbar
°rostatls
601.0
D Sacrococcygeal
Respiratory Infection
467.1
D Coccyx
NEXT APPOINTMENT:
DATE Till;
ASSIGNMENT AND RELEASE: I authorize payment of benefits be made directly to this healthcare provider and I
understand I am responsible for charges not coveretl by this assignment. I also authorize the release of any information
requested to process this claim.
CHARLIS TS.^.I, L.AC.
I.R.S. R95-3898840 - LIC. NI AC1616
1042 S. SAN GABRIEL BLVD.
SAN GABRIEL, CA 91776
PHONE (626) 287-3512
i
l
PRACTITIFP{F§R'S STATEMENT
This form has been prepared to assist you in the Completion of your insurance claim form and contains all the information that the
practitioner is required to provide. Fill out the personal information requested on your insurance company claim form and attach this
statement to it. Each patient, not the insurance company, is responsible for payment to this office. r c, r
Patient / f v Il H t Age SISM
Today's Date. i-lllnev'((rst symptom) or ate fi. ' ^ sulteo you for Ihi
Address 1 7
m )TY y V Injury (accident) r~
r.. - _ -laj C Date patbm eob m Dntc ❑ toml disepY~~Mj 7(~ Pe _ ismil -
. ~.f~, /n G r•+ l6Wrn to wOrK f
tram m,oupn "~`~V
siIhnsmur symptoms?aswir tmo woe o• Place o dffi e Home 1:1 Nei
r _
f nO-lA - Yes ~ No a/ SENt Other ,~-rr ~ontl I
NEW PATIENT (Office Visit) Fee DIAGNOSIS (if.not checked below):.'
❑ 99201 Self. Limited or Minor r
❑ 99203 Moderate Severity
❑ 99204 Moderate to High Severity
ESTABLISHED PATIENT (Office Visit)
99211 Minimal
❑ 99212 Set', Limited or Minor, '
❑ 99273 Low to Moderate Severity -
❑992ia M_ Dd- e27e - t r .
to Hiah Severity - -
ACUPUNCTUREPROCEDURES
❑ 97780 One or more Needles _ _ - - '
without Elec Stun _ GENERAL ❑ Resp DM S.O.B 7a6.o5
97781 With Dec Shm. ❑ Abdominal Pain 789.0 ❑ Rheumatoid Arthritis 714.0
-w:>+: , / ❑ Amenormea 626.0 Shingles ',rte'u 053.9
y❑ 97729 Unlisted Phys. Med. Serv. 0 Alcohol Dependence 303.9 ❑ SinusTu^ 46t.9
S p- city ❑ Allergies 9953 0 SmusfuslChronuJ 473.9
❑ 5 4 WItrasound ea. 15 min ❑ Asthma 4939 r ED Sore Throat (Anne) ^ 4 0
❑ Easiaohe, Unspecified 724.5 >?:'S4re 71soat{Chrontc) 4- 1
❑ 5711erdD2JGC Prr_ ea 15 nun. ❑ Bell's Palsy ..57 0 @ K x 719.5
11 9 ED Bronchus 4900
hteuromuswtar Fleeducadon - Vic. - !,4 > ?
❑ ,Car^ Tunnel Syndrome 354 .0 32
13 97124 Mz§SSage 71terapy I itt ❑ Common Cold 460
. r ❑ Constipation 5640. ❑'Sobadm 1-iN ~•lr.:
❑ 97139 Unlisted Therapeutic Prof . - p Verogo ° 3:-jCY- .760.4
s! . ❑ cough 786M2 ,
Spe°~'..'[ .:.❑.d pis ` 5950_. -'JOINT PAIN'-y:-
' ❑ 97140 Manual Therapy Techniques
❑ De
s/E¢ema'
692 9
❑ F
Afn loia.'
•
❑ shoulder .
•
(Manipulation, Myofascial release, Manual
rrrea/
0 Diug
-
5589
r,
❑ Upoer Arm .
Traction, Mobilization) 1 or more regions,
❑ Drug Dependedence
Dependence
❑ Dysmenormea
304.0
625.3
❑ Forearm
ea. 15 min.
❑ Edema `
Edema
782.3
❑ Hand
❑ Pel ic/rnigh -
❑ 57802 Cu
in
0
780.7
❑ Lower LegrKnee
pp
g
❑ 97803 Moxibustion
0 Gastric Pain
0 Hay Fever/Rnfnftis
767.3
477.9
0 AnklerFool
El
❑ Headache
(Tension)
307.81
Cervicalgla
❑
❑ Brachial/Neuntiszradiculitis
-
❑
0 Headache (Common Migraine)
❑ H
h
d
P
i
346.1
7
0 Thoracic Spine Pain
ea
ac
e (
a
n in Head NOS)
64.0
❑ Wmbaao/Lumbal
oia
MODALITIES
❑ Hypertension
401.9
_
❑ Sciatica +
❑ 97010 Hot/Cold Treatment
❑ Hypotension _
❑ Indigestion
458.0
536.8
❑ St l Pain
COmyx Pain
:
❑ 97012 Traction
Mechanical
❑ Infenilry
606.9.
❑ Bursnis'Shoulder
,
r
ty P
❑ 97039 Unlisted Idodali
_ .
❑ M
n a
❑ M
n
l S
d
m
.
760.52'
627
21
..t.._.
❑ 6 isrElbow. ;
e
e
opausa
yn
ro
e
.
.
El BursdisiKnee
Specify
❑ Menormagia i -
-
626.2
❑ BuisnisrAnkle
MISCELLANEOUS
0 Myaloia-Myosilis, Unspecified
729.1
SPRAIN/STRAIN
❑ Nausea _
787.0
❑ Should
❑ 99056 home Services
0 Neuiii alu
729.2
o,ea
n Elbow/Forearm
II 99070 Supplies/Materia is
❑ Nutrition, ion, inadequacy
269.2
❑ Wristband
❑ Nutrition, Counseling
V65.3
0 Hiprrhign
(Not included in office visit)
❑ Obesity, Constitutional and Nutmional
278.0
❑ Knee/Leg
❑ Herbs ❑ Needles ❑ Supplements
❑ Osieoarthritis .
'
715.9
❑ Ankle/Foot
❑ Osteoporosis
733.0
1C~ Neck(Cervisai)
❑ 59060 Special Reports (UCR)
❑ Otitis Media
352.9
AO-,Lhoraclc
❑
❑ Premenstrual Syndrome
625.4
❑ Lumbar
-
❑ Prostatis
601.0.,
' ❑ Sacrococcygeal
❑ Respiratory Infection _
4571
❑ Coccyx
TOTAL
. 'Old Balance S
Toc Jay's Ch arc=s S1. `
NEXT APPOINTMENT '
DTAL ~
~
fAOJ 1~TCAI
i
"
„J RS k953898840 LIC LAC16f
eyment Received S U! .
DATE TI7.1E
:S r 1042 S SA
ABRIGL 3LVd
N
G
f4ew Ealance S
,
~
p
,
c, j fSAN GABRIE~,,CA 917r o. fc
ASSIGNMENT AND RELEASE: I authorize payment of benefits be made directly to this healthcare provider and I t' - -Murvt Loco) Gor OD I<
understand I am responsible for charges not covered by this assignment. I also authorize the release of any information
requested to p: ocess Ins clai=.
-
9/19
Carl War en and Company
750 Th City Drive
suit 4
Ora ge, CA 92868
"ttention: Richard Marque
Next Report Due: 8/1/00
CJPIA
Rosemead
Ruth Bao-Rong Mao
2-4-00
S 107909 SWQ
Re: 0/Principal:
Member City:
Claimant:
D/Incident:
Our File No.:
Ladies and Gentlemen:
May 8, 2000
MAY 1
62000
PREVIEW: The claimant while walking on the public sidewalk,
tripped, fell and sustained injuries.
MEMBER CITY: City of Rosemead, 8838 E. Valley Blvd.,
Rosemead, CA 91770.
DATE TIME AND PLACE: This injury event allegedly occurred
on February 4, 2000, at approximately 8:00 p.m. We have yet
to establish, however, where this injury trip and fall was
to have taken place, although it occurred within the
territorial jurisdiction of the City of Rosemead.
GOVERNMENT CODE REQUIREMENTS:
1. Date Verified Claim Filed: The claim of Ruth Bao-Rong
Mao was timely filed on 3-7-00.
2. Action Taken by Public Entity: At the present time,
the City of Rosemead has taken no action.
3. Statute of Limitations: Six months from the date of
denial or two years from the date of occurrence.
OWNERSHIP /CONTROL: In her claim for damages, Ruth Bao-Rong
Mao indicates that she walked a few steps from her home at
4179 Walnut Grove Avenue in Rosemead, CA, to cross the
street at or about Valley Blvd., when she tripped and fell
CARL WARREN & CO.
CLAIMS MANAGEMENT • CLAIMS ADJUSTERS
750 The City Drive • Suite 400 • Orange, CA 92866
Mail: P.O.' Box 25180 • Santa Ana, CA 92799-5180
10/19
Page 2
S 107909 SWQ
on a sidewalk deviation. The claim documentation is
insufficient for us to complete a scene inspection and
identify the location of the alleged deviation.
Furthermore, our attempts to make contact with the claimant
have not been responded to. Once we have identified the
incident location, we will establish if it lies within the
public right-of-way of the City of Rosemead, CA. We will
have more information regarding this in our next report.
FACTS IN BRIEF: The claimant, while walking on the public
sidewalk, tripped, fell and sustained injuries.
PHOTOGRAPHS: We have yet to identify where on the public
sidewalk the claimant tripped and fell. When we have
identified the exact location, we will conduct our scene
inspection and secure photographs at that time. We will
have more information regarding this in our next report.
CITY MEMBER VERSION: Until which time we have identified
where on the public sidewalk the claimant tripped, we will
not contact the City to secure information. When we have
identified the location, however, we will secure all
appropriate investigative information from the City of
Rosemead. We will have more information regarding this in
our next report.
CLAIMANT VERSION: Ruth Bao-Rong Mao, 4179 Walnut Grove
Avenue, Rosemead, CA 91770.
For a significant period of time, we have been attempting to
make contact with the claimant in the hopes of scheduling an
appointment at which time we could secure her statement. We
are also interested in identifying where on the public-
sidewalk the deviation was that the claimant encountered.
Our attempts at contact, however, have not been responded
to. We feel that by making further contacts with the
claimant, we may only solicit a claim that she otherwise has
decided not to pursue. Unless and until which time we hear
from the claimant, we will not. make any further attempts to
communication with her. We will have more information
regarding this in our next report.
INJURIES: Ruth Bao-Rong Mao.
Per review of the claim that was filed with the City of
Rosemead, we have been informed that Ruth Bao-Rong Mao
sustained injuries in the fall. We have received some
limited medical documentation, and the documentation is as
follows:
11/19
Page 3
S 107909 SWQ
1. Monterey Park Optical Co., Inc., 230 N. Garfield
Avenue, #D-7, Monterey Park, CA 91754. Date of
visitation: 2-12-00. A billing was not submitted with
this document.
2. Best Eastern Acupuncture and Herbal Clinic, 1042S. San
Gabriel Blvd., San Gabriel, CA 91776, (626) 287-3512.
The document indicates that the claimant is receiving
treatment at this facility for neck pain and right
shoulder pain. Dates of visitation: 2-4-00 and 2-7-
00. The medical billing totals $110.00.
The claimant has also submitted an Earnings and Lease
statement from her employer, who apparently is the Dept. of
Veteran Affairs. The documentation indicates that the
claimant's salary rate is $28,111.00 per year, but the
statement does not show the year that the income was earned.
INDEX: An injury index form has been submitted to the Index
System Bureau with regards to this claimant. At the present
time, however, we have not received any responsive
information regarding previous and/or post-injury claims.
We will have more information regarding this in our next
report.
LIABILITY: We will defer our liability evaluation until we
have established exactly where this trip-and-fall was to
have taken place. We have yet to confirm that the location
of event is located within the City of Rosemead's public
right-of-way.
WORK TO BE COMPLETED:
a. Investigation:
1. Determine if the claimant pursues her claim for
damages.
2. Identify incident location.
3. Conduct scene inspection.
4. Report on Index findings.
b. Claims Remaining Open:
1. Ruth Bao-Bong Mao - LBI.
12/19
Page 4
S 107909 SWQ
COMMENTS: Our handling of this matter continues. Our next
report will follow upon receipt of additional information or
on or about August 1, 2000.
Very truly yours,
CARL WARREN & CQ.
4-C ' '
SAW:ck 5tephen A. White
cc: CJPIA
Attn: Executive Director
°cc: City of Rosemead
Attn: Nancy Valderrama
13/19
March 10, 2000
TO: City of Rosemead
ATTENTION: Nancy Valderrama, C
RE: Claim
Claimant
D/Event
Rec'd Y/Office
Our File
p
MAR 1 2005
- -S C=s=ICE
ity Clerk C!T'.`
Mao v. City of Rosemead
Ruth Bao-Rong Mao
04-Feb-00
07-Mar-00
S-107909-S WQ
We have reviewed the above captioned claim and request that you take the action indicated
below:
• TAKE NO ACTION: Defer any written response to the claimant pending our
further advice.
If you have any questions please contact the undersigned.
Very truly yours,
CARL WARREN & COMPANY
Dwight J. Kunz
cc: CJPI.A Oenc.
Attn.: Executive Director
CARL WARREN & CO.
CLAIMS MANAGEMENT-CLAIMS ADJUSTERS
750 The City Drive • Ste 400 • Orange, CA 92868
Mail: P.O. Box 25180 • Santa Ana, Ca 92799-5180
14/19
C!7~ ,
GOVERNMENTAL ENTITY PRELIMINARY REPORT
TO: Carl Warren & Company DATE: 03/23/00
~ange. e City Drive; Suite 400 CLAIMANT: Ruth Bao, Ron-, Mao
CA 92868 FILE NO: S 107909 SWQ
2-4-00 FILING DATE: 3-7-00 SIX MOS.: YES
PRINCIPAL/CITY: CJPIA/City of Rosemead
RECOMMENDED ACTION ON CLAIM: Take no action.
FACTS: The claimant while walking on the public .sidewalk tripped, fell and sustained
injuries.
POSSIBLE CO-DEFENDANTS: We will determine the identities of any potential co-
defendants when we conduct our scene inspection.
EVALUATION: We will defer our liability evaluation until we'have conducted our scene
inspection.
RESERVES TYPE OF CLAIM AMOUNT
1. Ruth Bao. Rona Mao LB] S10.000.00
COMMENTI"'ORK TO BE COMPLETED: Our further report will follow shortly.
Very truly yours,
CA =A-RREN & COMPANY
en A. White
tc: City of Rosemead Attn: Nancy Valderrama
cc: CJPIA - Attn.: Executive Director
CARL WARREN & CO.
CLAIMS MANACEMENT•CLAIMS ADJUSTERS
750 The City Drive • Ste 400 • Orange, CA 92868
Mail: P.O. Box 25180 • Santa Ana, Ca 92799-5180
Phone: (714) 740-7999 • (800) 572-5900 • Fax: (714) 740-9412
15/19
/7
li
II
L
Carl Wa en and Company
750 Th City Drive
Suite 400
Ora - e, CA 92868
tion: Richard Marque
Re: 0/Principal:
Member City:
Claimant:
D/Incident:
Our File No.:
Ladies and Gentlemen:
Next Report Due: 10/25/00
~1 July, 27, 2000
(;JT 12000
CJPIA
Rosemead
Ruth Bao-Rong Mao
2-4-00
S 107909 SWQ
PREVIEW: The claimant, while walking on the public
sidewalk, tripped, fell, and sustained injuries.
PHOTOGRAPHS: Enclosed in this report are photographs taken
of the incident location. These photographs are supplied
with captions and are self explanatory.
At an earlier date, the undersigned had the opportunity of
accompanying the claimant to the location where the injury
trip-and-fall took place. The claimant would have been
walking southbound on the west end public sidewalk of Walnut
Grove and the defect fronts 4024 Walnut Grove Avenue in the
City of Rosemead, California. We photographed the claimant
at or about the location where she would have tripped on the
sidewalk deviation. The deviation, at or about the area
where the claimant encountered it, measured.5/8.of an inch
in height. This would be considered a trivial defect. We
noted that there was patchwork on the public sidewalk in the
area of incident as asphalt patching was clearly evident.
We feel that the sidewalk condition, in all likelihood, was
caused by roots growing from a nearby parkway tree. Lastly,
there appears to be sufficient overhead lighting in the area
of occurrence.
CARL WARREN & CO.
CLAIMS MANAGEMENT- CLAIMS ADJUSTERS
750 The City Drive - Suite 400 - Orange, CA 92868
Mail: P.O. Box 25180 - Santa Ana, CA 92799-5180
Phone- 1714) 740-7999 - (800) 572-6900 - Fax: (714) 740-7992
16/19
Page 2
S 107909 SWQ
CLAIMANT VERSION: Ruth Bao-Rong Mao.
Recently, we had the opportunity of meeting with the
claimant at her home address and interviewing her regarding
how this event took place. The claimant would not provide
us with a formal statement. In summation, the claimant
indicates that she would have been walking southbound on the
west end public sidewalk of Walnut Grove when she
encountered a deviation at or about 4025 Walnut Grove in the
City of Rosemead, California. She indicates that the event
occurred at approximately 8:00 p.m. and it was dark outside.
There was insufficient overhead lighting in the area. The
claimant indicates that her foot struck the deviation
causing her to fall onto the sidewalk and sustain injuries.
During our discussions with the claimant, she essentially
indicated that this was her second claim with the City of
Rosemead. On the date of incident, the claimant would have
been wearing sandals that did not have a heel strap. She
was walking alone. Her left foot encountered the defect.
The claimant was wearing her prescription glasses. When
questioned further, the claimant indicates that she walks in
the area daily. She was, however, not aware of the
condition previous to encountering it. The claimant would
have been looking straight ahead when she tripped.
INJURIES: Ruth Bao-Rong Mao.
At an earlier date when we interviewed the claimant
regarding how this event took place, the claimant informed
us that she sustained injuries in the fall. As a result of
falling onto the sidewalk, the claimant injured her neck and
right elbow. She does, however, have health insurance
coverage available to her through Blue Cross. We. have
received a partial accounting of the claimant's medical
specials and the documentation is as follows:
1. Charlis Tsai, 1042 S. San Gabriel B1., San Gabriel, CA
91776. Business phone number is (626) 287-3512. The
claimant was seen at this facility on April 13,
April 20 and April 25, 2000. The claimant's treatment
consisted of acupuncture procedures. The diagnosis
was "tennis elbow". The medical billings total
$192.00.
The claimant also indicates that she incurred a wage loss
due to her injuries. She indicates that she missed
approximately 5 days from work and her estimated wage loss
is $400.00.
17/19
Page 3
S 107909 SWQ
Recently, we spoke to the claimant regarding her claim for
damages with the City of Rosemead. We indicated that the
deviation, at or about the area where the claimant
encountered it, measured 5/8 of an inch in height. This
would be considered a trivial defect. Since the claimant
encountered a trivial defect, she will be unable to
establish that the City of Rosemead was maintaining a
dangerous condition of public property. Based upon the
above, she was notified that no settlement offers would be
extended to her on behalf of the City of Rosemead.
INDEX: Enclosed in this report is information received from
the Index System Bureau with regards to claimant Ruth Bao-
Rong Mao. .Per review of the documentation, it appears that
this claimant has submitted a subsequent injury claim to the
City of Los Angeles regarding injuries that were incurred on
April 3, 2000. The claimant apparently injured her finger.
No other injury claims were noted.
LIABILITY: This appears to be a claim of extremely
questionable liability with regards to the City. We have
now established that the claimant was walking on a public
sidewalk when she encountered a deviation and as a result
tripped, fell, and sustained injuries. The sidewalk in
question lies within the public right-of-way of the City of
Rosemead. Furthermore, it appears that the sidewalk
condition was caused by roots growing from a nearby parkway
tree. We would surmise that this parkway tree is also owned
and maintained by the City. The deviation, however, at or
about the area where the claimant encountered it, measures
5/8 of an inch in height. This would be considered a
trivial defect. Since the claimant encountered a trivial
defect, she will be unable to establish that the City of
Rosemead was maintaining a dangerous condition of public
property. Based upon the above, this appears to be a claim
of extremely questionable liability with regards to the
City.
WORK TO BE COMPLETED:
A. Investigation:
1. Determine if the City of Rosemead rejects this claim.
B. Claims Remaining open:
1. Ruth Bao-Rong Mao - LBI.
18/19
Page 4
S 107909 SWQ
ENCLOSURES:
1. Scene photographs.
2. Medical release/wage loss authorizations.
3. Special damage documentation.
4. Index information.
COMMENTS: Our handling of this matter continues. Our next
report will follow upon receipt of additional information or
on or about October 25, 2000.
Very truly yours,
CARL WARREN & CO.
~rJ ? CtJ J
hen A. White
SAW:ck p
cc: CJPIA
Attn: Executive Director
(With copy of enclosures)
rte,
<<;; cc: City of Rosemead
Attn: Nancy Valderrama
19/19
July 31, 2000
r1l" T
" 12000
TO: City of Rosemead
ATTENTION: Nancy Valderrama, City Clerk
RE: Claim
Claimant
D/Event
Recd Y/Office
Our File
CI TI 1' CLERK'S OFF C E
Mao v. City of Rosemead
Ruth Bao-Rong Mao
2/4/00
3/7/00
S 107909 SWQ
We have reviewed the above captioned claim and request that you take the action indicated
below:
• CLAIM REJECTION: Send a standard rejection letter to the claimant.
Please provide us with a copy of the notice sent, as requested above. If you have any
questions please contact the undersigned.
Very truly yours
cc: CJPIA
Attn: Executive Director
CARL WARREN & COMPANY
2 i.C.YLGwdl D . M cwcq u el
Richard D. Marque
CARL WARREN & CO.
CLAIMS MANAGEMENT-CLAIMS ADJUSTERS
750 The City Drive • Ste 400 • Orange, CA 92868
Mail: P.O. Box 25180 • Santa Ana, Ca 92799-5180
Phone: (714) 740-7999 • (800) 572-6900 • Fax: (714) 740-9412