HomeMy WebLinkAboutClaim #718 - Araceli L. McDougal CITY OF PALM DESERT
^ �
CITY CLERK DEPARTMENT
STAFF REPORT
REQUEST: CLAIM AGAINST THE CITY(#718) BY ARACELI L. McDOUGALL IN THE
AMOUNT OF $389,347.53
SUBMITTED BY: Rachelle Klassen, City Clerk
DATE: January 10, 2013
CONTENTS: • Staff Report
• Recommendations of Claims Adjusters and Staff
• Claim No. 717
Recommendation
By Minute Motion, reject the Claim and direct the City Clerk to so notify the
Claimant.
Background
Based on a review of the subject Claim and the recommendation of the Claims Adjuster,
Risk Manager, City Attorney, and staff, it is recommended that the Claim be rejected.
Discussion of this item should be held in Closed Session pursuant to Government Code Section
54956.9(b), potential litigation.
Fiscal Analysis
City of Palm Desert participates in the self-insurance pool of the California Joint Powers Insurance
Authority (CJPIA). Action to reject the subject Claim does not have a fiscal impact on the City at
this time.
Submitted by: A ved:
R helle D. lassen, M C, City Clerk o n M. Wohlmuth, City Manager
rdk TY COUNCIL ACT((1��
� Attachments (as noted) A�'►'ROVrD ✓ ____ ���.,;���;��
izFcctvrt� _ :,6���rEz
mrFT�Nc� naTc - � a
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NOES: on�
ABSENT: _f�i onr
Al3STAl1V:�on,�
V�RIFIED BY; �
Qriginal on File with City C'lerk's O �ce
�
RECEIYED �
CtTY C�ERlC'S OFFICE
PAI.M t�E��P,1`. C,�
C�/, � 2012 D�C �0 PM 2� 34
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(::11{1, 11':1lflil�;N � COItiP�1M'
Deeember(i, 20 l2
TO: The City of Palm Desert
ATTENTION: Racllelle D. Klassen, City Clerk
RE: Claim : McDougall vs. The City of Palm Desert
Claimant . Araceli L. McDougall
D/Event . 6/6/2012
Rec'd Y/Office : 12/5/2012
Our File . 5-1814244-PMQ
We have received and reviewed the above 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,
CARL W N&CaMPANY
f �
Rich D. Marque
cc: CJPIA w/enc.
Attn.: Executive Director
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�JJ�? CITY REC�IV�D
CtERK'S UFFIC�
PALM DE,��R�, CA
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:, in� ��9<�u � ���in��-r . i `_,< <,ir>u�� � 2' 28
December 7, 2012
GOVERNMENTAL ENTITY PRELIMINARY RrPORT
TO: Cacl Wai-�-en & Company
PO F3ox 25180
Sania Ana, CA 92799-5180
Princi�al: CJPI�1 Our File: 1814244
`````�-- City: Palm Desert Date of Loss: 6-6-2012
�� � Claimant: Araceli McDougall Date Received: 12-5-2012
�==�-�-� Faets: The claimant's juvenile daughter is on probation. Acting on an anonymous tip,
��� Riverside County Sheriff Deputies and the Bureau of ATF responded to the claimant's
_,�, home, wanting to search the home. The claiinant was videoing the law enforcement action
�� �j and was arrested for resisting arrest.
''�,___ � Government Code Requirements•
a) Date Verified Claim Filed: 12-5-2012
b; Aetion by Public Entity: City to rejeci claim.
c) Statute of Limitations: 6 months fi-om date of rejection notice.
Possible Co-Defendants: Riverside County Sheriff Deputies and the Bureau of ATF.
Liabili : Riverside County SherifF Dept. has a duty to defend and indemnify the city. The
Bureau of ATF is a separate entity from the city.
Dama�es: Claim alleges false arrest and illegal search and seizure.
Claim: Reserve:
1) LPI—Araceli McDougall $10,000
Comment/Work to be Completed: 1) We have contacted the claimant and confirmed
the basic facts. We referred her to the Riverside County Office of Risk Management. 2)
Contact Sheriff's Dept. determine if there are any available police reports. 3) Conduct City
investigation as warranted
Our further report will follow shortly. �
Very Truly Yours,
CARL WARREN& CO.
Pete McNulty
cc: City of Palm Desert Attn. Rachelle Klassen CQPY TO- ��� �- � �-%ir7
cc: CJPIA - Attn.; Executive Director �� , ,��. � , ,,
C�TE �� `/ _�L!��--
AN EMP�OYEE-OWNE� GOMPANY
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T0: CJPIA (c/o CARL WARREN & CO.), CITY MANAGER, ClTY ATTOF�N�Y;
PALM DESERT POLICE DEPARTMENT, RISK MANAGER
FROM: CITY CLERK
DATE: DECEMBER 5, 2Q12
SUBJECT: CLAIM NO. 7'f� - CLAIM AGAINST THE. CITY BY
ARACELI L. McDOUGALL IN THE AMOUNT OF $389,347.53
The attached Claim Na. 718 is being transmitted to you for the foliowing;
❑ Information only.
or
� Review and recommenda�ia�to the Claims Review Committee for any action
required by the City of Palm Desert.
We would appreciate your report, if requested, by January 7, 2013, for timely response
to the Claimant.
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RACHELLE D. KLASSEN, MMC �
CITY CLERK
Attachment (as noted)
..
ta�., ,
ASSIGNED CLAIM N0.�„�^,,,e`�,�
, CLAIM AGAINST THE CYTY �OF PAL�M D�SEItT
(For Damage�s) to Person(s� or Personal Property) � ��r� R�CE1��p
. , /
�A�.M�p�E�����
Received by: ���(�� ��.. � � ��'��J��t f?�t,,;� ,��I
—r �DEC-5 qM ll:38
l -
via: U.S. Mail Interoffice Mail� Over-t�he-Counter �-�''
A CLAIM MUS BE FQ.ED WITH HE CITY CLERK� H@ CITY OF PALM UESERT Wi'fHIN SIX
MONTHS AF'fER �INICH THE INCIDENT� OR EYENT CICCURRED. B� SUI� YOUR CLAIM IS
AGAINST THE CITY OF PALM D�SERT, NOT ANOTHEIt PL18I,IC ENTITY. WHERE SPACE iS
1N5UFFI�IENT, PLEASE U5E A�7pTrIONA1 QAP�R AND ID�N1'IFY IlVFOltMA7'iON BY
PARAGRAPH NUMBBtt. COMPLETED CLAIMS MUST BE MAILED OR DP.I;YVEI2ED'�O 'CHE CITY
CLERK, CITY OF PALM DESERT, 73-510 FRED WARING DRIVE, PI�LM DES�RT,G���92260.
TO THE HONORABLE MAYOR AND CI'fY COUNCIL, City of Palm Desert, Cali�ornia:
The undersigned resp�ctfully submit(s) the following ctairn and information relative ta damage(s) to
person(s)and/or personal property:
1. CLAIMANT INFORMATIO�t: � .
NAME �-it.-!�:r L.t L. � ��t.t�;4��
ADDRESS �- —
PHONE Na. - �,...� ur BIRTH:
SOCIAL SECUR .�'Y O DRIVLR'S LfCENSE NO.
2. Name, teleph�ne number and post o�fice address to which claimant deaires �otices to be
sent, if other than above:
S�nt� t�5 •-A-d?..a�..��
�
3. �Jccurrence or event from which the clairn arises: �,�,n�r�:.�txt��.sE �►2-►z+E-ST J��K`����
�ectF-rs���.�.,'z� � c+tK.L�E2- �.sE
a. DATEe k�'t��• �2a1�b. TIMEs � A'YY� c. PLACE (exact and specific �E�'
lacation
�T 1�Y1�t�' �S t d7 C Pv L.� ,$ - - —� � -- - - — ._ . . _._ _
d. How and under what �ircwTestances d[d damage or injucy ocCur? Specify the particular
occurrence� event, act or omrnission yo laim ca�d the injuty or damage. (Use
addi,tional pape if necessary.� n �e��r�.h �.
{� ri �I.S . -
,� slS�a
'U -
2 d-3 .
� ' � • s
�' t���I rf w -cU rzc��r-�cr VYI�,�1-i���s c c� w �-rn��sporz�-�r�U XkcE
e. Wha# articulac action b the Ci �"�O -��
p y ty, or its employees, caUsed the alleged damage ar
injur ? '� �l,t `�1t.�. �Yt �r� O�NG .S �d1.£� 5'Cl U- 1�1
SE� r..� r�i�,D �2 �
� �u ,
w�
spE u� A��,�-r s��.rL�.son., �o�N-�r-��a t+�,n,s r�,.r- �s �rt-rt� pd�c�
Page 1 of 2 �,►'�-7�tz �OEN-rr f-lE.D +�s ��rw� �� ��v►P(„��� o� �u,rz,��c�. c�� Firi.�ACL►��-
�-As�� t� '� ti�t c..�2s H� A �,�4�zEt t,��2s2t3n,`l—�r'�'►rr�� D i f��A�
-fi'tm�S—�}E'� D�D N�'"T d�s�a�A. WE4`C '�C A�.x.28�p�,�� � P�� �� r-�P�-�p-
-l- i151L�0 F-�rz- ���2rn t S St nn� �-ro t�,ECp�'LO ��' w� (� w�r,s I��r2m �SS/b`�'l�
�s �aw t4s :�. s�A�rP � w� C�o�w6 -rn G�;.�. -rt+�. v i n�.o r2.�c.��:o�tib �o
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� !''' �� i �
' �GOl rL K%1" 71'�.� �'C�Y7�P"E3
4. Give a general description of the indebtedness. obligation, injury, damage, or loss incurred
so far as it may be known at the time ot presentation �f,� e��Clas�Tf t Ore w S no
injuries, state "no injuries": ryt E�2G�,�'-� �,i,.-i,,,,�o.� �A.,�;,� � �
`._�a fob �
�' � � J � ,�ws�.c.n+qwt� . ��..�r-►-�'r.� �A�'l�-•� �,icr�--
� v,-c s�u-� /yt�i�� ,5'71 �
O�NIE �{„gs�,.�b 1e.�+- ! t�ncow -rvn �-r-r� ,�-2 0�— g Y.s
5. Goryg_�°Op -} 4ex�-5� 4- 17c�o— � ; �
ive thesr'rame(s) of the City employee(s} causing the dama e or in'ury: Url n0�,.;� p.�c.���
�,St� � L T�- 3 � � S �.N.� s �
6. hlame and address of any other person(s) injured: �x.l��,Z��� f�Z�� �}.��, ,,,� .,1.���.��5
.1fa.��e._ �!' �1��I/en 1 ' - �`,� �„�
.... � �m ' �R'lY�i� l'W�'��
I NJiu2,�23 t•w CUx.pc- D(SS b c,►�T'1��' O c�F,',z��1E.�2�i ,1Cr+rr�,0o��-- D!�"�z-e.8.g l+ $r�asc��
7. Name and address of the owner of any damage�rl property: �
l�� "'f�'a W�'t�1-i Gl.-FJ3 0�� 6-A+2_.R-t".�s t�} q�,�;T� 41s7�(p�- Dr2_J i�� Lct�' -A�r� r.�r��a�,�
�+� ►4s A.�-v�!_. o�a�rL.a�`� t.�n,�r b �o�,,� N�+t,�t-r�-r�.�
h
8. Damages claimed: . . . .^ _ _ �. _ _ . — ,
a. Amount claimed as of this date: $ �, ���, c��,-�
b. Estirnated amount of future costs: � 3;�z,-7�����,/��J�
c. Total amount claimed: $�y�,��, ��
d. Basis for computation of amounts claimed (include c pies of al bills, invoices,
estimates, etc.): I'G- ~ /�.-�7z 4 Lt�v1�� SP� ( 5 �2,y A,t��
' G' � � � L'-rt I/r� S ��C r ��ES
�SGYaO AO L(�ir2�Y.tZ�dL•A�b!N, �
9. Names and addresses of all rwitnesses, hospitats, doctors, etc.e' '�� d�' Fr.e�E t��i,,..�y Q2wrL
!i •� _
� k P s +• lu-c nurse�s R�w��- I YYIOAIILOG �, /N➢GG�cl4�f220
, A- �. �on.� �s 5. �gse � -s�2 5 S �'►�
- �rrrfw � vv� �IZ 7. N�1� e r�A,rz"i►sL � cr�az�u,�
pKo�st-rlvwh��F'T t-ACE'PF3a�Pr�njr/w� l3�i 3�s�r�•�-�-�c�u,�r�C��o�, j�niO�CFF�lZ2o!
10. Any additional information, including police reports; which might be helpfu! in considerin
th's cl 'm:�UF�r�C `�tfl� S R- t-!G� !' `— Oi�'�7�f� D �JHOUS
. I�f�ow�7n�1� � S ,e A1�m l "Ta �,J f 6n
�. .oJ (3�r'�rng�t�� _ n'1�1�Av6a�2 v� �D w� d�D n►4'rlvn� NFEer�a�..s r���T�L��
WARNING:IT L5 A CRIMINAL O FENSE TO FILE A FALSE CLAIM! PENAL CODE 72; �s,,,,
INSURANCE C4DE 55b.1). ,��� ���..r ��� �� �� ��
I have read the matters and statements made in the above claim, and I know the same to be true of
my own knowledge, except as to those matters stated upon information or belief as to su�h matters
I believe the same to be true. I certify under penalty of perjury that the foregning is TRUE AND
CORRECT.
Signed this ,��day of _ /����/'►til3rJ2,-2p 12. , at L�`1j�a,h�' C�/�r✓�"--�s�%�,�r
SIGN E OF CL IMAIN � SIGNA URE OF CLAIMAIYT
Office of the City Clerk, Palm Desert, California DOG NO. DATE FILE❑
Page 2 of 2
' BOB'S AUTO BODY REPAIR Workfile ID: c5bcf4cb
68-399 PEREZ ROAD, CATHEDRAL CIIY, CA 92234 Federal ID: 452584870
Phone: (760) 324-3300
FAX: (760) 328-5046
Esti mate
�Number.
tomer: Insurance: Adjuster: Estimator: Bobby Middleton
ez-McDougall,Araceli Phone: Create Date: il/19/2012
Claim:
Loss Date:
Deductible:
r: 2005 Style: 4D P/U VIN: Mileage In:
:e: TOYO Color. Mileage Out:
iel: TUNDRA 4X2 License: Job Number: Vehicie Qut:
ie Ver Operation Description Qty Extended Type Labor Type Paint
Price$
E01 CONSOLE
E01 Remove/Replace Console assy charcoal 1 478.77T OEM 0,5 Body
E01 FRONT DOOR
E01 Remove/Replace LT Armrest gray 1 134.58T OEM 0.2 Body
E01 Remove/Install LT R&I trim panel 0.4 Body
Estimate Totals Discount� Markup# Rate# Totai Hours Total$
Parts
613.35
Labor,Body 48.00 1.1 52.80
5ubtotal 666.15
Sales Tax 53.67
Grand Totai 119.8Z
Net Total �i9.82
Estimate Version T��$
Qriginai 719.SZ
Insurance Total$: �ig.gZ
Received from Insurance$: 0.00
Balance due from Insurance$: 719.82
Customer Totai$: 0.00
Received from Customer$: O.OQ
Balance due from Customer$: 0.00
�azable Item,RPD=Related Prior Damage,AA=Appearon[e Aflowance,UPD=Unrelated Prior Damage,POR=Painqess Dent Repair,p/M=Aftermarket,Rechr=Rechroined,Reman=
nufactured,OEM=New Original Eqtdpment Manufacturer,Recor=Re-cored,LNQ=Like Kind Quality or Used,Diag=DtagnoSCc,Elec=Ektitrfcal,Mech=Mechanical,Ref=Refinfsh,SW[_
vra!
.9/2012 1:54:52 PM Page 1
• Estimate
O Number:
VehiGe: 2008 BENZ E350 4D SED 6-3.5L-FI
l2 E01 Repair 8umper cover w/o ESS,E63 w/o parktronic 1.0 Body 2.8
w/o AMG
l3 E01 Add for Clear Coat 1.1
l4 E01 Overhaul OJH bumper assy Z.g gody
l5 E01 ELECTRICAL
l6 E01 RemoveJInstall Antenna mast sedan 0.3 Body
l7 E01 Repair COLOR TINT 0.5 Body
L8 E01 Remove/Replace COVER VEHICLE FOR OVERSPRAY 1 10.00T Other 0.3 Body
t9 E01 Repair DE-NIB&POLISH 4.0 Body
?0 E01 Sublet HAZARDOUS WASTE 1 8.00 Other
21 E01 Remove/Repiace FLEX ADDI7IVE 1 12.00T Other
�2 E01 additional damage may be found once in
For repairs
Estimate Totals Discount$ Markup$ Rate$ Total Hours Total$
Parts 72.80
Sublet/Miscellaneous g,pp
Labor,Body 48.00 36.5 1,75Z.00
Labor,Refinish 48.00 39.2 1,881.60
Material,Paint 1,489.b0
Subtotal 5,204.00
Sales Tax 136.71
Grand Total 5,340J1
Net Total 5,340.71
Estimate Version Total�
Original 5,340.71
Insurance Total$: 5,340.71
Received from Insurance$: 0.00
Balance due from Insurance$: 5,340.71
Customer Total$: 0.00
Received From Customer$: 0.00
Balance due from Customer$: 0.00
'=Taxable Item,RPD=Related P�iar Oamage,AA=Appea2n[e Albwance,UPD=Unrelated Prlor Oamage,PDR=Patndess Dent Repair,A(M=Aftertnazke[,Rechr=Rechromed,Reman=
,emanufactured,OEM=New Original Equipment Manufacturer,Retor=Re-cared,LNQ=Uke pnd Quality or Used,D(ag=Diagnostic,Elec=Elechical,Me�h=Mechanicai,Ref=Refinish,Struc=
Wctural
.1/19/2012 1:29:21 PM Page 4
PayRlel�it ReCEIpt �' For NAVARRETE,ARACELI
ALBERT R ANOERSON MD Date 06/19/2012
Ail Provider Profiles
Date Payment Code Payment Description Check#
Visit# DOS Insurance Portion Patient Portion Payment Amount
06/19/2012 PP PAYMENT-PATIENT 1003 $55.00
06/19/2012 $55.00
Charge: UNAPPLIED
Current Patient Balance: ($55_00)
Insurance Pending Balance: $0.00
Unticicd Page
Page 2 oF2
DesertAdvancedlmaging-PalmDesert
72855 Fred Waring Drive
Palm Desert, CA 92260
Transaction Time: 6/20/2012 9:01 :31 AM (Arizona Standard Time)
Transaction Type: C
Transact' tu : Approve
Amount� $57.00
Name on . MCDOU LL/ARACELI L
Card Number: XXX- -
Processor Transaction ID:
Result: APPROVED
User: AAVE
Patient Name: araceli navarette
Patient #:
I agree to pay above totaf amount according to the card issuer Agreement.
X
CARDHOLDER SIGNATURE
Customer Copy
C�E�ynght E'+2012(;pnyue.,t TedinUlOgies R,1=1<�tl;ai�d tiledia Afl ri4�h(S reserved �
B4B'S AUTO BODY REPAIR workfile ID: a9di1641
68-399 PEREZ ROAD, CATHEDRAL CITY, CA 92234 Federal ID: 452584870
Phone; (760) 324-3300
FAX: (760) 328-5046
Estimate
) Number:
stomer: Insurance: Adjuster: Estimator: Bobby Middleton
pez-Mc Dougail,araceli Phone:
Create Date: 11/19/2012
Claim:
Loss Date:
Deductible:
ar: 2008 Style: 4D 5ED VIN; Mileage In:
ike: BENZ Color: Mileage Out:
�del: E350 License: )ob Number: Vehide Out:
ne Ver Operation Description Qty Extended Type Labor Type Paint
Price�
E01 FRONT BUMPER
E01 Overhaul 0/H bumper assy 4.0 Body
E01 Remove/Install R&I bumper assy 0.0 Body
E01 Repair 8umper cover w/o Spo�t wJo parktranic 0.5 Body 2.6
w/o lamp washer
E01 Add for Clear Coat 1.0
E01 FRONT IAMPS
ED1 Remove/Install RT R&I headlamp assy 0.3 Body
E01 RemoveJInstall LT R&I headlamp assy 0.3 Body
E01 HOOD&GRILLE
E01 Repair Hood(ALU) 0.5 Body 3.0
E01 Add for Clear Coat 1 z
E01 Remove/Install Vent grille black 0.4 Body
E01 Remove/[nstall Grille w/o proximity cruise standard 0.4 Body
E01 Remove/Install Emblem 0.0 Body
E01 FENDER
E01 Repair RT Fender(ALU) 0.5 Body 2.2
E01 Overlap Major Adj.Panel (0.4)
E01 Add for Clear Coat 0.4
E01 Repair LT Fender(ALU) 0.5 Body 2.2
E01 Overlap Major Adj. Panel (0.4)
E01 Add for Clear Coat 0.4
E01 RemoveJInstall RT Wheelhouse liner fi-ont w/o 4-Matic 0.3 Body
E01 Remove/Install LT Wheelhouse liner front w/o 4-Matic 0.3 Body
E01 PILIARS,ROCKER&FLOOR
E01 Remove/Install RT Rocker molding w/AMG 1.1 Body
E01 Remove/Install LT Rocker molding wJAMG 1.1 Body
E01 ROOF
T�able Item,RPD=Related Prior Damage,AA=Appearance Allowance,UPD=UnrHated Pdor Damage,PDR�Paintless Dent Repair,A/M=ARermarket,Re�hr=Rechromed,Reman= •
ur�ufactured,OEM=New Oryinal Equipment ManufacWrer,Recor=Re-cored,LKQ=Llke Klnd Quailty or Used,Diag=Diagnostic,Elec=Electricai,Mech=Med�anicai,Ref=ReFlrtish,Struc=
Kturai
119/2012 1:29:21 PM Page 1
�ap John F. Kennedy Memorial Hospital STATEMENT Page: 1 of 4
MEMORIAL BOX 830913(Use mail address below)
HOSPITAL g�rmingham,AL 35283-0913 June 18, 2012
,�,"'�" IIIII��E�:I�E�'������l��II�V��iG���;G�i�;����'��iC�,IIIII ARACELI MCDOUGALL
Patient Reference Number:
es oxo2 Hospital Code: 266
Payment Due Date: oue upon Receipt
CHANGE SERVICE REQUESTED Date(s)of Service: ob/06/2012 - 06/06/2012
#BWNHDLV Message ID: PFssTM2r
#01301381812G0019#
�����ii�iiiii�i�n��ilil��hi��inl��lullin,�„�nil��ilh��ui
ARACELIL. NAVARRETE
Thank you for choosing John F. Kennedy Mernoria!Hospita!
, . ./- �
Account 5ummary � '
TotalCharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �
. . . . . . . . . .$197.3B
Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .�12.1 ..3s ' ''
.
Paid bylnsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .so.00 �
Already Paid by Patient . . . . . . . . . . . . . . . . . �
. . . . . . . . . . . . . . . .$o.00
., , .
Amount you owe now . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$�6.o0
Detach and retum bottom portion with payment.Please make checks or money orders I�����I��������'����
payable in U.S.funds to John F.Kennedy Memorial Hospital and include your patient refarence number.
___ -
_.
-- ------- —�
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Une � 33350 t If PAYINC PYPIAST'[RC.ARD,DI�COVfR,VISAORAMERICANEXPRES>,fli.IOUTBELOW
ARACELI MCDOUGA�L � � � � ����-v��� 0 U __"� '� �
— P.SCOVtH ... VISN qMEk�nN E.CPIA.`.•- �
�A4U NthMl?i ti
ExnOA�T�µq tvo�r, i
Patient Reference Number: � I 1 � ; ! I I I � � r1% i , I
Pa ment Due Date: � � �,�� �w�•� � � � +
Y Due Upon Receipt �� .�� �F,Y�rxr
� i
Date(s)of Service: 06/06/2072 - 06/O6/2012 ( �t ;� .> �n�� ,��.. -�""�'
( � I:ARUHOI.D(f��lf(7N[e ,
` �.__... ._� ...._� � �
Phone:John P. Kennedy Memorial Hospital(se habla EspaAol) ; ouE DqTf � � �� ( A�n«ur;r vc��owE �"'
Customer Service 800-346-0775 Due U On ReCei
Monday-Friday 830am to S:OOpm �_ p pt � � $76.00
Q0342041835291000337
•
33350"TJ20FQOVT000091
, >_ �, � .. � ��� II��I'��'I����I�I����h�l'I��I"I��'�I��Ih�llllll'I�y�l���ll���
JOHN F. KENNEDY MEMORIAL HOSPITAL
FILE #57546
LOS ANGELES, CA 90074-7546
0057546 007878729 000007600 6
ME MOR1A1, ER I'F1YS1('IAN� MI;U C:RP statcmcn� ��.uc: .It1N1?2t), 'u�?
3075 1:. IMPI-:RI/�L FIWY., ti1�li 200
[3R fi1�,C'A 9?f{?I Accoimt Numbcr:
II��IIIIIIIIII�II�IIII(IIIIIII�IIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIII��IIIIIIIIIIIII�III Scrvicc llate: (,/((!II'[ I M('I)OUGAI.L
� rrssa��anz�ma:�s��sr,o�s�r Scrvice'I'Ype: Er Phytiician 5crviceti
Phonc: I-RO(1--104-1,1,27 Account Balance: � 1 Hq.�p
'1�755 349}i 17-2 Addi�ional Charges: $ .pq
Amounr Due: $ 1 K4.00 E� � ,
v"_ , ,^ � � >'
#BWNFDQV 005636 $ ..
#6163498172J6# ��,, '
ARACELI L NAVARRETE '���
URL http://
Password:
Itemized statement available upon request
;�c:,rvii��.> Lc�c�it i��n : �Ic)I1N F K�;NNL��Y Mf;MORIAL HO�Y
1'1+ <�,.�,�- r���n i i t_Lr-� �il�uvF i ���3 i ���3t���d i���i�3n��a., i t, i u 1 1 , ��t <�i,n Lac�i uLir
officr� fc,i� ,3d�lit-ic,n,il �?��iymE�>>t ��}>ti��n:; .
Ple�se .include the bottom portion ot this statement with your payment
in the e:nclosed return envelo�P. 'Po pay with credit card, please
complE�te and return the b�e.low crediY card authorization .
r� yuu have any que.;tions regarding this correspondence, please do not
hesitate to contact us at ] -800-909-6627 . We are available to assist you
B : DOAM to 4 :30PM (Pacific Stanclard T.ime) , Monday through Friday.
MEMORIAL ER PHYSIC:IANS ME;D GRP
Patient Fin<�ncial Services
1-800-409-6627
.,.� ��,,n.�: ��,��.M.> >���.�� �.��•..,,, .�. :v.,;.1�������W.:������,��a�.�.��,,
piease retain this por[ion for your records
._.....................-.._.........--complete�and return this portion with your remittance_...................................................................__...................................................._._
tEMORIAL ER PHYSICIANS MED GRP Credit Cazd Authorization
tatement Date: JUNE 20,2012 Service Location:JOHN F KENNEDY MEMORIAL HOSP
Choose 1 Credit Card Option: visa MC _AmF:xp__Discover
.ccount Number: 00003 S 15601 -- --
Card Number:
esponsibte Party: ARACELI L NA VARRETE 3 or 4 Digit CCV Code:
atient: ARACELI MCDOUGALL Expiration Date:
ervice Date: 06/06/12 Amount Paid: $
ervice Type� Fr Yhyslcian Scrvices Cazd Holder's Narae:
mount Due: $ 1 R4.00 Auihorized Signature:
mount Paid: $ ❑Please check box if address is incorrec;t or insurance infonnation
has changed,and indicate change(s}on reverse side.
Remit To: ss3s
�ra cspanol vca lado rever;;o de estc aviso. MEMC)R1AL ER PHYSICIANS MED GRP
3075 E.IMPER[AL HWY.,STE 200
� BREA,CA 92821
� r._ n rv� � E� r=: n r; i i r� t::� r:�Y��
Team Beachbody independent Coach Canceltation Form
Last nairic t--1=--��'� �' - _ _ _ __ I us� narno Y
_ _ acVL Y44 �c� 1
Cnach If)ll (if knuwnl _ _ f-rn�iil �
Du.,mc��� narnc (il app(irabl��J �r`�'
_ _ _ __
/ldclrce;s
(;�IY_____� .:_...__._..__.� _ ___..__. 5talr . ..
__..___ 1 i P_---__.___.___
Dy signing �nd submitiinc� this Cancellalion form, I am cancelling my Team [3e�chbody busmess and
��oriri�3ncntly abnndoninq niy posi(ion wilhin lhca Te�im Qear.hhody genc�iloyy. I undcrsi�nd thai hy canceling,
ih� following will occur:
• i will lose the right to ,efl Team Beachbody products.
• 1 will no tonger be eligible to earn commissions under ihc Team Beachbc�dy Co�7�pensaiion Ptan.
• I wilf permanentty lose my position iri ihe leam Beachbody genea(ogy,
• I ma not rc-enrol .
y l as a ic�am Beachbody Coa�h�g�iri uniil six�.alendar months froi7i the date
of my cancetlation.
Reason forc�nce(lation_._.���1� f�c`�"f�j�e��t It��' T _C�"'t-_,� (t Sf�l C {�"� 1=,�,ttz �z�.� C;�Y--'
----;—
, '
/ .�l/'Z �% �-9"{Ll � "�Sif`l �� f�4:''�.�r'y'�z'�7 � 5'!�rf<z<<-f7�p� /�l�` -f�--{�,i,. .t.1 �°f�'G'��r k:
I'�t_' I�(tj ��= �cf/"Ctt��/ L{�IE'l C�C( bz tti�t,'��„ /1/!r �i��-tG2r ��(j �ie�d� fll.Jz..� l�= //7!'/2��� f:-r/�r--�fC`'�
� GC.�l!( �Z'Z �C.t 1�f j //a �j. /�. i �i 'i::�....� � ��c�r� .i,�"C;l,. .�E_ �r-
Team Beach6odv Ctub Members(Check One�
❑ Although I am canceling my Coach position and my Team Bear_hbody business, I stilt want to remain a
member of the Team Beachbody Ctub. I understand that Team Beachbody wilt continue to charge my
quarter�y Club fees in the amouni of$38.87 to my credit card.
�Please cancel my Team Beachbody Ctub member-ship. I understand that untess I check this box,I will remain
l an active Team Beachbody Club Member and wi(l be responsihle for the Clu6 membership fees as noted
immedlately above.
i
Signature ---C�"d'-s'��" "�_ A Date_�� G �j f�Z- _
cancci;mq r:oac h�
P(ease stgn ancl return this�ompleted form to:
Team Beachbody, c/o Coach Cancetlations
4D0 Continenlat Blvd.,�Fth Floor
El Segundo,CA 90245
Atternativety,you may e;nail a copy of the comp(eted forms to
CoachRelationsfdTeamBeachbody.com nr tax;t to (2131 201-;225,
Please atlow up to 48 how-s for processing n' this cance(lation request. ,
_,.;,,0,1.,,,:;
. "'O1' Icam ticachhci�ty t <�acl> >iul�n�it - i�r�+,�,niu�c 1.,,�jf)��yl � � «�,� - •,� _�
. � W�
�
Personai Information II���I�pI�II�II��I��I��IN�I�
�� ��
Registration ID: 44456374
Registrant: Araceli Lopez
Registration Date: 5/31/2012 9:43 AM
Registration Type: NEW Coach Discount (Exclusive Offer For Coaches Who Have
Enrol�ed Within The Last 90 Days)
Status: Confirmed
Home Phone:
Cell Phone:
Email:
Date Of Birth:
Gender: Female
Emergency Contact Jorge Navarrete
Name:
Emergency Contact
Phone:
Current Rank: Coach
Coach ID: _
ADA: No
Fees
Fee Quantity Unit Price Amount
Fee
New Coach Discount ($165) Event Fee 1 $165.00 $165.00
Subtotal: $165.00
ota I: $165.00
Transactions
Transaction Type Date Amount Balance
Transaction Amount 5/31l2012 $165.00 $165.00
Online Credit Card Payment ("`"`***""`"**' Details 5/31/2012 ($165.00) $0.0
Current Balance: $0.00
https:!/www.regonline.comlregi ster/con f�irnlati on.aspx'?EventId=969272&Attendeeld=zF3j... 5/31/2012
• ��UW' MUC�I �V�OIll`V l illl f)C IVIi1Cll' III (�l'ill:lluuUy i �ri��uiii�. - ���.u�.�iin,��t . ..��.,�����r, ' _-�- - '- -
_ �. . � . ___.�1<>n�f49y f 0 L;ay C7�aHunc;�'�(.+r'oup fai Su�)pOYt
�����14���� . 1 aud Motivai���n
� .,,M x ��,:� � �x,, �.��,
����.. ,-.� � �� �,
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Goach+t�rk M�qhEamixs acc Eam+��3
6nterald . S?759 . 2 5�G
Ruby . E550t•� , :9"t4
Oiamond ?2�4i5 S '?u:P.�
Slardiarnond . ���Z.3h: � iti iY�
Coachntirail:':�sl . :q:,��;� „ .;.r.
�,
kc��r.nhndy rnnrhinq c.in aani��u��hiq n�innoy
In?OIU.the h�ghest paitl coach matle:$I A52,"J.E�3 while the aveiaqe Sle�r p�amond Cie�cl�body � �
coaches made$94.122 for Ihe yc:ar F.ven Ihe lowesl rank of Emerald matle a suhsfanlial amount � �
How is Ihis possiUle.sellmi��zeiase videos-likia P90X nnd iuFal ie�ilarrrn�N dunks hke `'�y
Sbakeology^ Y I �`a�'
� ,
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Learn How to Start as a Beachbody Caach Here
In the Beachbody coachinc�business.we are able tn earn a laiga mcome,ber,ause wr,use the
cuncept o1 duect marketing or mulU-level markeung to ueale a large oryan¢ation of people � �
helpin9 each otherlo succeed. In Ihe business worltl,company owners leverage ihe etlons of Jnin a Chalfenqe group todav!
theu employees li is ihe s�me with any orc�anization The president of the company makes a loi
ni money The vice preside�ts make a tivle less. Directors.managers,and so�n untd you c�et to
the average employee who is making the Ie2sL This sounds a lot hke a pyramid schem�:doesn'1 .
d? Well.rt is antl ihe;only way for saneone to rnove up m this pyrami�is ior someone�bove fhem
m rank to move out of a posdion Ihal they quahry for Now(or the gootl news In Beachbody
coaching.you don't have to wait for anyone'I The amouM of money ihAt you r.h�ose to make is i�
eMirety up to you antl fhe effort ihat you tlecide to put mto rt The nezt incredible ihing is ihat as �
you grow youi business,you wi0 Ge able to help other people succeeU as well The more people
you help to succeed,the betier ofl you become So now.wilh Beachdody coaching,yaa can pass
up the people above you. In addiuon,if someone below you passes you by,ifs a good thing Tha1
�ust mean's more money tor you too as you leverage your coach network Z�g Ziglar put it thls way,
'I'd ratber get 1 percent of 100 people's eftorl than 100 percent of 1 person's eHori". To me,tbat
reaily makes sense.
i m not he�e to tell you that Beachbody coaclung�s easy ti it were,everyone would be doinq ii
But I am here to let you know that d you are w�lling to put in 10 tu 15 houts per week of eRoA over a
period ot 2105 years,then you can become successful�n Beachbody coaching and m2ke a
substantial mcome. No,1'm not makmg a mtllion dollars per year_ I am however,consistently
mcreasing my mcome and getting closer to the time when I can say that Beachbotly coachmg is my
iull time career. You can do ihe same thinq too rf you choose. Many ot the fop financial people m
1he world Bke Warren Buffet,Donald Trump and Robert Kyosaki have praised the opportunities that
direct sales kke 9eachbody coaching can promde. Are you ready to make a change in your life?
Start Your Beachbody Coaching Business Now �g I ��
� � ' �
���
����
e8ttttg veggies?
http://titnesspluscentral.com/how-mueh-money-can-be-made-in-beachbody-coaching 12/3/2012
• -'r`-�_..1''L� f�,��,Vt t� , � � � ,,`'l 4 tC 7 • Gt_✓t L
�:. 7'ake t�NLY medicat�ion� list�c! her+�. Cu���ac� ya�ur prE�����rib����g ��ysi�iar� #t�r oki�ier rnedicatiorrs.
�e fol�c�w the direckiorMs ort ihe tabel on tl�+� �-nedicatia�� br�ttic. I ] Spanist� Lak�et
__. , ._ _ _. _. _ _ _ ___ _ _ _. _. __
gies: � NKDA ❑ PCN ❑ Sulfa L� Other(List) Weight: _ _____ Lbs.
— r �_ _._ __ _ _ _ _
_ ___ _ __ .
Medication Strength Qty Directions Indication Medication
—. __. __ _. _ _ provided
; ---
: . , � .
, r_; , ; : , _ . ,. ;D
,
� : : , , "` . Yes ❑ No
� , , ,
_.—._.�.__....._.—___ , _,_-—�----- - — --1 ---------------- ,,.
. - -----
' , r. , , ❑ Yes ❑ No
', — _ _ _ ___ _ _ ~ ,
❑ Yes ❑ No
_.___ _._..--._._.___.__.t_ __.__..._..
.. _._.____.. ._.._.._..
. ... .... .... .. ...... . .._ ____._.._'-._
. _.___... __.___. __. __-__._.__.
� � � O Yes � No
� _._.,._----- __�. .�--- '
---- -_ __- ..---_�__ __ . _
.
,
❑ Yes ❑ No
—_ . ______ --_._._.._.------ . , ;
... .�.,_ _ ;
. ------ ----- --- -------_ ___,_.
--_._------ -- ' `�
❑ Yes ❑ No
. .. ,,.;;_ . --�---- --
❑ Yes ❑ No
❑ Yes ❑ No
.,,
❑ Yes ❑ No
___.__� . __._ __--- --- -- -
, � ' �,. �J�:� , ? � � �.��; ❑ Yes ❑ No
- , ,� _ � ��
,
_� , , . „ �i� �_�< ; / , '
---- --= ' ._
--- ------------- _
irge Patient to go: Home/Shelter/8oard and are�'1MD ���lature of illness: (Diagnosis)
and Board/Group home/ �.
t to go with: Self/Parent/Spouse/ Friend/Family ""� �
nsfer to: on a legal hold/Volunt�ry Expected Course of Recovery:
vide hospital transportation. ❑ AMR 'i �`' 4
Recommendatians: Check at!that apply
�s�turn to ETS ar th�; n��rest hc�spital c�r cali 911 if your conc�ition worsens
�tions as prescribed (see above list)
up at out patient clinic at _ or private psychiatrist as listed on after care instruction form for
Medications � Individual therapy � Family therapy ❑Other
ain from using alcohol or illicit drugs ❑Other instructions
�rral to START for dual Diagnosis program
with primary care provider for following medical conditions Diet: � Regular ❑ Low Salt
❑ Low Fat ❑ Low cholesterol
❑ Calories diabetic diet
❑ Other diet (Specify):
�nissian a►1d c�rrer��ra�edi��fiora� h;��ve ����a €�:vie���:�rtr� recc�rc��1P� �°,�itl��o i37� �.��t;�rit,
�3�'��r3� tfl�(3Y[Tlzi�ii3ii f�"Cittl�c"3fTllty : �� �"�??!!t��t€i.��?z�,} C:t)tlSiCai`?'+�t� 6. ,#ti:- r�9S�;t"s`r3€`�� �)��?"�ftr'ts� ��€�°t�.Sw�4C.`t�.
rat,docurnent exp#�rtatic�t� i����i�re�s�t�s��:�}
�
— � --
Physician's Signature Printed or Stamped Name Date�me
Department of Psychiatry,Arlington Campus
A Division of -
Riverside County Regional Medical Center " .
Moreno Valley, California
Physician Discharge Order � �
and Instructions �
Ot Pink-Medical Record White-Patient RE:06/09
� �� f�-�- va�-c�
. ._:__._.._��:�_._�fi�.-t�%___'���as------���g'___—`-�-�----- -------------�----____ .--------
AIa'F�iDAVCI' O1��' It�:�,Sll)I�;N(.Y +
_.. ____ ._..._ _ . . _ __ ___.... , _. _ __ . . ._ _ _ _ _ ..._. _.__ _ __.
. ._._. .__
'i'C) WF-(OM 1'1'M�Y CON('T?ItN:
.
', _ ---�J�.-�c�r��--�_-------_------------_---_--__
, (I lonieowncr's Namc)
RL:SfDING A'I": __. _� — -
(Stre�drli:essl _ _ � ----___,_ .�.__
(CI+'�',7.11'Code) - , ('I'elephone) � .
L?F�('1_nRl:� �_����,�� /�����pQ�=/l�?/�/ � is resiciing with mc
(N�unc oF 1�:ircnUGuardian) v —
nt l.hn, aboue n�ldress f�r tlze 2071/2Q12 schuol ycrtr, rr.lorzg willz ll�e followi�zg student(s):
_---.... _ �- - -
(Name ol'Child) " (Date of Birth) (Schooi)
� '� _
D
jNaine of Child) ' (��ate of 13irth) (Schaol) �
r �
� � 4� �
(Nam�or Child) {D•ate of Birth) (School) �
I cleclarc uncicr pei}alty of periury under the 1<iws of the S��te of California thlt the foregoing is truc and correc[.
UA"T.Ell:_�/ " p-_1 o�Ojl SIGNE - --
(Homeowner's Signa[�n�e.)
Si.�,��:atzrre nf Nr�tcrry Pr,r./ilic Reqr��:red * ,�—?!�
�
(P ' ,uarriian Sf�nature) .
5t�te of Califrn�nin,
County of Riverside, SS
On /�a,��/ (d�te)before me, !/(l. �d�O.S ' _.__ ______, Notlry Public,
personal appeared_�,_�0{"6� /(�iQIlA�2���� - ---------T (signei;sj
proved to me on the b�sis of satisPactory evidence to be the persons�whose name(;vJ is/�e subscribed to the wi[hin
insp�umcnt and acknowle.dged to me that he/�ey executed the sarne in his/l3e+;Ctbeir autl�orized capacity(ic+�.),
RI1C� ChR� v)/I1LSI.�X�+�EI�1B11"51�1181UfE(,sr�on the ins[rurnent the person�a3'or the entity upon beha(f of which the person(a� .
acted,executed lhe insh�urnent.
i certify und�r PENAI_TY pF PER.TURY under the laws oF the State of California that the foregoing paragraph is[ruc and
c�rrecl
W.DOBBS WITNES5 my hand and o(ficial seal.
"' COMM.A`1791859
� ±�";. NOTARY PU9UC•CALIFORNIA�
RNERSIDE C�IMl�Y
Catxnissian E�ires fEB.24,2012
wtin,wwwv�w�wrw -
Notary's Sig�xalr�re �
• Thc schonl district may reyuire adJiliunal reasun:ible evidence dint ihe parentlguardian lives at Ihc aJdress provideJ
. Praal u(Recidcncy(cinrent Gas ur Gl�n ic Utility StatemenQ musl be pmvided I�y Ihe Nomeowner.
• Valid fur Ihe 2Q1 U1012 sci�nol Ycar onlv.
Cnpy to School Snc/Cbild We.lfarc<a AticnJancc 1)SUSI)CWA(03/11)