HomeMy WebLinkAbout2000-02-16 Agenda Packet - Board (13) TDPUD STAFF REPORT
TO: Board of Directors
FROM: Mary Chapman, Administrative Services Manager
SUBJECT: Discussion and possible action relating to the Claim for Damages submitted by Clayton
Canan
DATE. February 10;"2000
�., A b
Attached is a formal claim presented to the District by the law firm of Melvin Laub & Joe M. Laub
who filed a claim for damages on behalf of their client Clayton Canan.
Father & Son Law Firm of
MELVIN LAUB & JOE M. LAUB
PERSONAL INJURY
WORKERS COMPENSATION
February 07, 2000 c�MlBANKRUPTCY
Truckee Donner Public
Utility District
Clerk Of the Board
P .O. Box 309
Truckee, CA 96160
RE: Government Claim
Dear Sir/Madam:
We represent Clayton Canan in injuries he sustained in a bike
accident involving Truckee Donner Public Utility District .
Enclosed please find the claim required by California Government
Code Section 910 and 91_0 . 2 on behalf of Clayton Canan.
Sincerely,
THE FATHER AND SON LAW FIRM OF
MELVIN LAUB & JOE M. LAUB
JANNETTE D. REASONER
Certified Paralegal
/jdr
Enclosure : As stated
❑ ❑ 171 ❑
1148 Ski Run Blvd. 711 S.Carson St.,Suite 2 10368 Donner Pass Rd. 742 Mill St.
South Lake Tahoe Carson City Truckee Reno
California,96150 Nevada,89701 California,96161 Nevada,89502
(916)577-LAUB (702)883-LAUB (916)587-LAUB (702)323-LAUB
Fax(916)544-4920 Fax(702)893-1527 Fax(9161587-2367 Fax(702)323-3699
Feb-04-10 C4:E2Fm From-TRUDEE OONNER PUD + T-295 P 01/01 F-707
P.O. Box 309 Truckee, CA 9616DI (916i587-3896
CL.=. M POR DA2xL3GES
WARNING : While claims against the Truckee-Do-, ner Public Utility District may
be submitted on the followingform, if the Claimant has any questions
regarding his legal richts or duties, or pertaining to the manner or time of
submitting such a claim, he should consult his Dan attorney.
Name : C1c-u 1i t t2�- c,,L. Property 311 �f (�iiSi' C( b-)hY-L L
i Location: tL
Mailing ?:L 10�� �D �( t (� L
Address: S-xeet ! C. Box
I fIi (-YP ( CL I( r)-
City, State, Zip Code 3nitlLot or street address
Phone NO: 530 )L2 3
Date of claim: LUCt ">L 22 �9 iC7 Time damage occurred: O�LI5
Circumstances causingdamage : r rL�L C� J-IiC c
Bmployee(s) name (s) involved, if known:
General description of damage, injury, or loss incurred;
5'vf�zuCQ
Dollar value of claim as of date of claim, and basis of computation - attach
estimates/invo>�ce (s} , if available: � -) t n( -lti (VII
Was a complaint filed by you with the TD-PUD regarding this claim?. Oy
If yes, indicate date of filing:
Persuant to Section 910 of the Government Code of California, this claim for
damn es is respectfully submitted.
Signature of Claimant Date
NOTE: Claim must be signed by Claimant or by some person an his behalf .
(Government Code Section 910 .2)
ATTACHMENT TO GOVT. CLAIM
This claim arises out of an incident involving the
construction site located on or about west of the entrance to
Donner State Park. This area was not properly supervised
by flagmen therefore allowing two vehicles to enter the
construction area from opposite directions at the same time .
The construction zone was a hazard to anyone in the vicinity
due to exposed open trenches which were not properly marked or
covered up.
STATE OF CALIFORNIA
TRAFFIC COLLISION REPORT
Ct:P 555 P.-GM 9 jRev 2 U OPl 042 m 1 I '
NUMBEfl HIT A RUN CITY iIUOICIAL BK?PoCT LOCAL flEPoRT NUMBER
SPECIAL 40NORIONS INJUPEO FELONY
LATE—REPORTED j TRUCKEE TRUCKEE SUP_ERtOR
REPORTING DISTRICT
HEAT T1999-1624
NUMBEfl HR I RUN COUNTY
KILLED TRUCKEE 0621
NEVADA
MONTH DAY YEAR TIME CAMI NCICA OFFICER 10
COLLISION CCCURRED ON - 8-22-1999 0445 2900 3426
DONNER PASS ROAD
Z. AV F WEEK TOW AWAY PHOTOGRAPHS BY: ❑ NONE
MILEPOST INFOR..T10N
F CM T w T F s ❑ �$ ®eo DEPUTY
Q FEETIYItES OF STATE HIGHWAY REL LITCHIE
O ❑AT INTERSECTION WITH ❑ '(E$® NO
®DR:317 FEETIMILES WEST OF ENTRANCE TO DONNER STATE PARK _
pAR{y DRIVERS LICENSE NUMBER ST!`A C l`STATE
EO YEH YEAR I CANNONDALE BIKE N/A PLATE STATE
1. A5987001 li li
NA,MEA(FII/RS{T.MIDDLE LAST)
❑ CLA TON DEAN CANAN OWNERS NAME SAME AS DRIYER
STREET ADDRESS ®
nPOB 10333 OR 14950 DENTON WAY OWHERS ADDRESS SAME AB INiIVFA
CITY I STATE I LP
pTRUCKEE, CA 96162 DISPOSRKIN OF VEHICLE ON ORDERS OF: ❑ OFFICER ® DRIVER ❑ OTHER
SEX HAIR EYTTES' HEIGHT WEIGHT —19H N/A LEFT' AT SCENE -
® M BLN HML 511 1215 3-18 Pfl10R MECHANICAL DEFECTS:❑ NONE APPARENT ❑ REFER TO NARRATVE
HOME PHONE NUMBER BUSINESS PHONE NUMBER VIN NUMBER:
❑ (530) 582-1673
O
NLY
CA
INSURANCE CARRIER POLICY NUMBER ❑U„K ❑NONE ®MINOR
N/A N/A �� 1
❑MOO.❑MAJOR DROLL-OVER
OIP OF TRAVEL ON STREET OR HIGHWAY OP¢.D LIMIT CA DOT
EAST DONNER PASS ROAD 25
CAL-T TCPRSC MCMX
pAITTy ORIVEflS LICENSE NUMBER STATE CLASS SAFETY EO. VEH YEAR PANE I MODEL I COLOR LICENSE PLATE STATE
2
NAME(FIRST.MIDDLE.LAST)
❑ - OWNERS NAME U SAME AS DRIVER
STREET ADDRESS
❑ OWNER'S ADDRESS SAME AS DRIVER
CITY I STATE I LP.
❑ DISPOSITION OF VEHICLE ON ORDERS OF: OFFICER DRIVER OTHER
SEX HAIR EYES HEIGHT WEIGHT A _ H ACE
❑ PRNNi YECMANIL.LL OEFTtfS: NONE APPARENT REFER TO NARfUk—
HOME PHONE NUMBER BUSINESS PHONE NUMBER VIN NUMBER
❑ YB AMA E:
INSURANCE CAPoi'ER POLICY NUMBER ONLY
❑UNK ❑NONE []MINDR y
DIN OF TRAVEL ON BTREEf OR NtGHWAY SPEED UYR �Fp��..,�„.��R�� p'�T�h�� �,-.,,A L.d
�9"J-WSN� M9v LUYiLIIR�' W. k
pgRTY DRIVERS LICENSE NUMBER STATE CLASS SAFETY m. I QlMM1A]Rft WLATE STATE
NAME(FIRST,MIDDLE,LAST) f i
❑ OWNERS NAME AS
STREET ADDRESS
❑ OWNER'S ADDRESS ❑ SAME AS DRIVER
CITY I STATE I ZIP
❑ DSPOSITION OF VEHICLE ON ORCEIiS OF: ❑ OFFICER, ❑.DRIVER ❑ OTHER
SEX I HAIR EYES „EIGHT WEIGHT A _i H RUNE
N/A
❑ PRIOR MECHANICAL DEFECTS: NONE APPARENT REFER TO NARRATIVE'
HOME PHONE NUMBER BUSINESS PHONE„UMBER
YIN NUMBER
U ERA E RISEn E:
ONLY
INSURANCE CARRIER POLICY NUMBER
❑UNK ❑NONE MIND
Elmo.,❑MAJOR❑ROLL-0YER
DIROOF TRAVEL ON SWEET OR HIGHWAY SPEED UMR CA DOT
CAL-T TCPI➢BC YC@1X
pREPARER'S NAME' OSx GATE: REVIEWERS NAME - ` , DATE REVIEWED
DEPUTY J. LITCHIE 3426 8-22-1999 SGT. V A u>'\ �-ZZSI(`f
STATE OF CALIFORNIA
TRAFFIC COLUSION CODING PAGE 2 OF 6
CHO 555 PAGE 2 Rev B-97 OPI 0E2 LOCAL AGENCY CASE NUMBER
DATE OY 1'OWS,,M (MONTH I DAY I TEAR) nYE (tJWI XCIC A OP£ICEfl IO
8-22-1999 o44s 29M 3az6 T1999-1624
OWNER'S NAME OWNER'S ADDRESS NOnFIEO❑ YES [INO
PROPERTY G. II<<
DAMAGE DESCRIPTION OF DAMAGE
i SEATING POSITION SAFETY EQUIPMENT I EJECTED FROM
occuPANTs VEHICLE
A-NONE IN VEHICLE L-AIR BAG DEPLOYED M(C CLE BICY -HELMET
B-UNKNOWN M-AIR BAG NOT DEPLOYED DRIVER 0-NOT EJECTED
C-LAP BELT USED N-OTHER V-NO 1 -FULLY EJECTED
9 DRIVER D-LAP BELT NOT USED P-NOT REQUIRED W-YES 2-PARTIALLY EJECTED
9 2-6 PASSENGERS E-SHOULDER HARNESS USED 3-UNKNOWN
7 SUV REAR F-SHOULDER HARNESS NOT USED Cunw RESTRAINT PASSENGER
4 (� 8 REAR OCC TRUNKNAN G-LAP/SHOULDER HARNESS USED O-M VEHICLE USED X-NO
O OTHER ON UNKNOWN H-LAP/SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y-YES veEv�ENrEo�iJ1E e J Y wives CASE1
J-PASSIVE RESTRAINT USED SAN VEHICLE LINE UNKNOWN
K-PASSIVE RESTRAINT NOT USED U-NONE IN VEHICLE IMPROPER USE YES ❑ NO
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK(A) SHOULD BE EXPLAINED IN THE NARRATIVE
PRIMARY COLLISION FICTOR TpAyF1C CONTROL BEYILES 1 2 3 TYPE OF VEHICLE 1 2 .3 MOVEMENT PRECEEDING COLLISION
LIST PARTY I AT FAULT
CITED:NO A CONTROLS FlIMCTION.KG A PASSENGER CAR l SUV F� A STOPPED
1 A 281 H CVC 8 CONTROLS NOT FUNCTIONING* B PASSENGER CAR WI RAILER u B PROCEEDING STRAIGHT
B CVC C CONTROLS OBSCURED C MOTORCYCLE I SCOOTER C RAN OFF ROAD
C OTNER THAN DRIVER• �'J D NO CONTROLS PREGENIIFACTOR• D PgAUP OR PANEL TRUC% C El D MAKING RIGFR TURN
D UNKNOWN TYPE OF COLLUSION E PcWP I PANEL TRUCK WI TRAILER E MAKING LEFT TURN
E FELL ASLEEP' A NEAD-OH F TRUCK OR TRUCK--- F WpNG U I.—
YEATHEN(MARK ONETO TWO REPS) B SIDESWIPE G TRUCK I TRUCK TRACTOR Wi TRIA G BACKING
EE
A CLEAR C REAR END H SCHOOLBUS H SLOWING/STOPPING
Y CLOUDY 0 BROADSIDE i OTY£R BOB 1 PASSING OTHER VEHICLE
C RAINING E HIT OBJECT J EMERGENCY VEHICLE J CHANGING LANES
D SHOWING F OVERTURNED K HIGHWAY CMIST EOUIPYEM K PARIONG MANEUVER
E FOG I VISIBILTTY FEET El G VEHICLE I PEDESTRM L BICYCLE L E MINGTRAFFIC
F OTHER• H OTHER':FELL MTO PR M OTNER VEHICLE Y OTHER UNSAFE TURNING
M PEDESTRIAN N MNG INTO OPPOSING LANE
G WINO
LpHTBIG MOTOR VEHICLE NVOLVEB YRN 0 MOPED 0 PARK£D
A DAYLIGHT A NON-COWBgN P MERGING
e DUSK-DAWN B PEDESTRIAN 1 2 3 YARKONETDTWORfYS O TIAVELLNG WHOHG WAY
C DARK-STREET LIGHTS C OTHFA MOTOR VEHICLE A CVC CITED: R OTHER':
O DARK-NO STREET LIGHTS D MOTOR VEHK:LE ON OTHER ROADWAY a CVC CIiEB:
Lj E DARK-S`G tIGNiS NOT FUNCT. E PARICED MOTOR VEHICLE C CYC CTTEP. B/ONABRNIKEtOYNE DRUG
TWO 7MS
ROADWAY SURFACE F TRAIN E YSgN OBSCNtEYEM
A OWN G BICTLiE F NATIERRON« A HAD NOT BEEN piiNgMG
e WET El X ANIMAL 'G STOP A GO TRAFFIC B HBO-UNDER NFl.UFNCE
C SNOWY_ICY 1 FIq:008J£Ci; N ENTERING i LEAVING RAMP C ROD-NOT UNOERNFLUE;z
D SUPPEW(MUGGY,OIL HER VC.) J OT OS.IECT:GROUND I PREVIOUS COWSION 0 HBD-W._M - UNKNOWN
J UWAMILAA WTIH ROAD E UMMR DRUG INFLUENCE
ARK ONE)O>WO?EMIT
A HOLES,DEEP RVh PEOESiRWFS ACTig18 K DEFECLIVE VEIN.EQUIPMENT: F IMPAIRMENT-PHYSICAL'
B LOOSE MATFAML ON ROADWAY' ® A NO PEDEVAM INVOLVED CVC CITED: G IMPNRMEM NOT gIOWN
C OBSRNCTICN ON ROADWAW N A A L UNINVOLVED VEHICLE IN NOT APPLICABLE
INTERSECTION
D C,,I,,UG TGN-REPAIR ZONE - Y ODYR•: i SLEEPY I FATIGUED
IHTERSFCTIDN
E MOUCED ROAD WAY WIDTH D CROSSING-NOT IN CROSSWALK N NONE APPARENT
F FLOODED. E INROAD-NCWOBS SHOULDER O RUNAWAY VEHICLE
SPECIAL pPoRYATgN
G OTIB:R• F NOT N ROAD
H NO UNUSUAL CONDITIONS G APPROACHING 1 LEAVING SCHOOL BUS A XAZAROOUS MATERIAL
MISCELLANEOUS
SKETCH
aP�N T2sk I-+E.�l\
INDICATE NORTH
O'�i$y..!y YF{,1.1.'N,•d t_1 Nf'f _—__- _ _�_
Ao I Ct�ctic.>a 5-c-
Ala N riE 2., 7'ktse ZkXC ----- -----
STATE OF CALIFORNIA
NARRATIVEISIIPP FM NTAL par, r C7
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D_ NUMBER
08/22/1999 0445 2900 003426 T1999-1624
1 FACTS:
2
3 NOTIFICATION: At approx. 0850 hours I was notified of this solo bicyclist collision in the
4 area of Donner Pass Road near the Tahoe Donner Marina in the current construction zone. I
5 was advised that this collision had occurred sometime last night, during the early morning hours
6 and that the bicyclist had been treated at Tahoe Forest Hospital (TFH). I responded to the
7 injured bicyclist's residence after speaking with him over the phone at approx. 0915 hours. All
8 times, speeds and measurements in this investigation are approximate. Measurements were
9 taken by roll-o-tape, except where otherwise indicated.
10
11 SCENE: At the scene of this collision, Donner Pass Road is a two lane, east/west roadway that
12 traverses the entire length of the Town of Truckee. In this zone, the posted speed limit is 35
13 mph during normal conditions.
14 ****SPECIAL CONDITIONS: Donner Pass Road from the intersection with
15 Coldstream to Rock Street was under construction at the time of this collision. The entire
16 eastbound lane, beginning at Rock Street was closed to all traffic due to a deep open trench that
17 had been dug to facilitate water and gas pipes/lines maintenance. This trench was over 5 feet
18 deep and 3 feet wide at various areas. Cones had been placed all along the double yellow lines to
19 keep traffic from driving into the trench, and traffic was controlled at both ends by flaggers who
20 monitored vehicle traffic one direction at a time 24 hours a day.
21
22 OBSERVATIONS:
23 P-1's Cannondale Mountain Bike was located at Safeway at approx. 1400 hours where it
24 had been taken by P-l's friends (P-1 is an employee at Safeway). I inspected the bike and saw
25 that it was fitted with a mounted `Zefal" brand light. This light would have been required for
26 night-time riding per 21201(d) CVC. I pressed the on switch for the light and found it not
27 functional. I could not determine whether or not this was due to the collision/impact itself.
28 Continuing with my inspection, I noticed the bike did not have any reflectors of any kind, which
29 is also required per 21201(d) CVC. I did not observe any damage to the bike except for a
30 moderate dent to the left (front deraileur) control lever manufactured by Shimano (model XTR).
31 In addition, the bike's fork had been twisted causing the handlebars/headset to come out of
32 alignment. This type of damage is consistent with this type of collision.
33 During my measurements and inspection of the collision scene and AOI (see below), I
34 took numerous photographs of the area during daylight hours. In addition, I found the general
35 area to be well marked and adequately coned. The open trench, which is only in the eastbound
36 lane (south side) of Donner Pass Road, runs parallel to the double yellow lines painted in the
37 center of Donner Pass Road with a distance of approx. 5.6 feet between the two. The AOI (see
38 below) is the only area where the open trench deviates from this parallel course and comes
39 directly next to the double yellow lines. The trench runs next to the double yellow lines for
40 approx. 7 feet before abruptly returning to its former parallel course.
PREPARER'S NAME I.D.NUMBER DATE REVI�wEj(t'Sp°I. E
J. LITCHIE 003426 08/22/1999 Ul }A_ yi)
STATE OF CALIFORNIA
_NARRATIVE/SUPPLEMENTAL PA F f
DATE OF INCIDENT TIME NCIC NUMBER OFFICER I.D. NUMBER
08/22/1999 0445 2900 003426 T1999-1624
1 The westbound lane of Donner Pass Road was 10.8 feet from the fogline to the double
2 yellow lines (cone pattern), and 1.7 feet wide from the fogline to the roadway edge.
3
4 STATEMENTS.
5
6 Party # 1 (CANAN) was contacted at his residence and he identified himself verbally to me. I
7 saw that P-1 had moderate oozing "road rash" all over the left side of his face, as well as a large
8 cut freshly stitched on his chin. P-1 also told me his left knee was bruised and swollen. While
9 talking with P-1 I noticed dried blood on his sweater, hands, face, and pants.
10 I did not detect any odors of alcohol or other substances on P-l's breath.
11 P-1 told me he had been riding his Cannondale Mountain Bike east on Donner Pass Road
12 from his home on Denton Way at approx. 0445 hours this morning. P-1 said he had not been
13 wearing a bike helmet. P-1 told me that he was aware of the open trenches and construction on
14 Donner Pass Road after seeing the work being done for the past several days. P-I said that as he
15 approached Rock Street, he saw that there were numerous signs stating "road construction
16 ahead." P-1 said he looked for a flagger person, but didn't see anyone controlling traffic. P-1
17 said he saw a man sitting in a pick-up truck behind the "slow" signs. P-1 told me the man
is apparently didn't see P-1, so he continued east past the signs.
19 P-1 told me that as he neared the Tahoe Donner Marina, he saw headlights approaching
20 him from the east. P-1 said that since he was riding east in the westbound lane, he decided to
21 give the approaching car a wide berth. P-1 told me he swerved through the cone pattern set up
22 on the double yellow lines and continued east on the other side of the cones. As he did this, P-1
23 said he suddenly fell into an open trench that he hadn't seen and crashed. P-1 told me, "I was
24 blinded by the oncoming headlights, so I didn't see the trench."
25 P-1 told me that due to his momentum, he didn't actually fall into the trench. P-1 said he
26 fell across the pit and landed on the other side after his bike dropped into the trench. P-i told me
27 he walked without his bike to the State Park entrance where other flaggers were posted. P-1
28 told me these other men helped him into their pick-up and drove him to TFH. P-1 told me he did
29 not know any of the men's names except Bryan McMillan (530-544-7468). I have been unable
30 to contact Bryan McMillan.
31 P-1 told me he was released from TFH this morning after getting stitches in his chin.
32
33 Witness 91 (YETTER) was contacted via cell phone and identified himself as the project
34 supervisor for the construction on Donner Pass Road.
35 I explained to W-1 that a bicyclist had fallen into the open trench during the night and
36 had been injured. W-1 told me he had not been informed by any of his workers that this had
37 happened. I asked W-1 if he was aware of the open trench located near the Tahoe Donner
38 Marina that was directly next to the westbound lane of Donner Pass Road. W-1 told me that he
39 was aware of the open trench next to traffic, and had approved the cone placement next to it
40 before he had.left the job site the night before. W-1 told me this is common practice to leave
PREPARER'S NAME I.D.NUMBER DATE E 'S N
J. /LITCHIE 003426 08/22/1999 L/�
STATE OF CALIFORNIA
NARRATIVEISUPPLEMENTAL as e 6 ^Ih
DATE OF INCIDENT TIME NCIC NUMBER OFFICER S.D. NUMBER
08/22/1999 0445 2900 003426 T1999-1624
i trenches exposed during the night. W-1 told me that he felt the cones were adequate warning for
2 traffic not to cross the cone pattern. v
3
4 OPINIONS AND CONCLUSIONS
5
6 SUMMARY: P-1 (CANAINT) was riding his mountain bike east on Donner Pass Road near the
7 Tahoe Donner Marina. P-1 was lawfully riding his bicycle eastbound in the westbound lane on
8 the right most portion available to him, since the entire eastbound lane was coned off and closed
9 due to an open trench that extended from Rock Street to the State Park. An unknown vehicle
10 approached P-1 from the east, and P-1 swerved across the cone patterns onto the eastbound side
11 of Donner Pass Road. Doing this, P-1 immediately fell into an open trench located exactly on the
12 south side of the cones.
13
14 AREA OF IMPACT (A.O.I.): The AOI was determined as being approx. 317 feet west of the
15 west roadway prolongated edge of the entrance to the State Park, and approx. 8 feet south of
16 the north roadway edge of Donner Pass Road. The AOI used was placed at the point where P-1
17 crossed the cone pattern, which had been placed directly through the middle of the painted
18 double yellow line in the middle of the roadway. This was determined by P-l's statement, his
19 identification of the collision scene in person, and blood stains on the asphalt left by P-1. These
20 measurements were taken with a roll-o-tape.
21
22 CAUSE: P-l(CANAN) caused this collision by being in violation of 2818 CVC - Crossing a
23 lawfully placed flare or cone pattern.
24
25 RECOMMENDATIONS
26 No further action by this Department.
PREPARER'S NAME I.D.NUMBER DATE REND E
J. LITCF= 003426 08/22/1999 VL ( L
'Joy - attach this stateme, your insurance claim form. ( ; Alt'
personal information requested. I en term- This statement contains u the
(� C.v Cl is eGm, to supply. It is no; necessary for this of+ice to i=11 out lice I. } NAMEn 11764
-
' omr`anv Claim Corm. -1 4'
E VISIT CODE FEE ATTENDING PHYSICIAN STATEMENT �"�/,
NEW EST. SUPPLIES DATE: V
iimal ODow Collar L0120 XPAYS CODE FEE
31 99201 99211
iiled 99202 99212 O Clavi trap L3670 O Ankle Complete 73610
�rmediate 99203 99213 ( ing, its
L3969 OCervical Complete 72050
ended 99204 99214 O Crutches E0114 O Chest 2 View 71020
reprehensive 99205 99215
( j Knee Splint(non-hinged) L1830 { j Clavicle 73000
JLTATIONS O Shoulder IMM L3650 O Elbow Complete 3 View 73080
.f { j Rib Belt L0220 { ) Femur Complete 73550.
.,led 99241 99241 O Custom Fitted Back Brace L0515 O Finger 73140
rmediate 99242 99242 O Wrist Splint L3800 { ) Foot Complete 73630
ended , 99243 99243 -
nprehensive 99244 99244 O Frog Splint L3800 ( f Hand Complete 73130
nplex 99245 - 99245 O Knee Splint(hinged) L1832 O Hip.Complete 73510
:DUPES
sulizer Treatment 94640 OAnkle(gel) 99070 O Humerou emo. --73060
cutaneous I.V. 36410 { )1,Surgical Tray A4550 ) Knee Complete 73562 ,
c11V Med. 90784 O Surgical Supply ,. A4649 um ar Complete 72110
:rapeunc,IM 90782 { ) Dressings A4204 ( } OS Calcis-Heel 73650
loolic,IM 90788 ( },Nebulizer Supplies A4627 ( Rib Unilat Comp. 71100 '..
O Casting Material A4580 O Scapula - 73010
'IONS I MEDICATIONS O Infusion-Saline 500m1 J7040 Shoulder Camp. 73020
c.Penicillin 600,000 Units J2510 O
Caine J2000 ODextrose 5%SOmI J7060 ( j Shoulder Dislocation 1 View 73020
adryl 50mg J1200 O Extension Tubing A4750 O Thoracic Comp. 72070
2 1,000mg - J3420 { ) Scalp Vein ling,#23,#25), A4215', OTibia 8 Fibula Comp. 73590
rex 6mg J3030
OSterile Gloves A4927 { ) Toes 73660
slog 10mg J3301
idol 15mg J1885 O 20CC SyringelNeedle A4213 Wrist Complete 73110
:adron LA 8mg J1095 O Ace Bandage A4202 { a 71021
:ephin 250mg J0696 { ) O Forearm 73090
scat 750mg J0697 LABORATORY O Ribs Uni/Chest(New) 71101 .�
estrogen 40mg J0970
sed 1mg JZ250 ( } Strap 86403 O Skull 70260
zo1500mg J0690 _ ( it Unnalysis - 81000 ( ) Sinus Complete 70220
j-Medrol 125mg J2930 O Gulled 62270 - O Outside Radiology 76140
iterol.Sml J7625 -
mylim 20mg J7630 O ( } X-Ray Copies 96499
=hicine 1mg J0760 O ( )
npazine 10mg J0780 MISCELLANEOUS
scription-Dispensed J7140 { ) Arthrocentesis(small) 20600 TOTAL FEE—�_
O Arthrocentesis(medium) 20605
IZATIONS O Anhrocentesis(large) 20610
anus Toxoid 90703
Removal F.B.(eye) fi52n0 - PAYMENT
Sena 90724
_
R 90707 ( }Pulse-Oximetry 94760 -
rims Globulin 2mg J1470 O EKG.Resting 93000 Paid By: BALANCE DUEc�_
rgen 95115
WEDIC PROCEDURES O �,,.ta /('��.�„-1-..� / Zff 13 Cash Check ,.
Splint 29125 - '
SA/MC
Splint 29105
Splint 29515
DATE:
)er Splint 29130 ACCIDENT.
Cast 29075 O
"ast 29065 WORK RELATED: _
7asl 29405
I Removal(arm or leg) 29705 DISABILITY: FROM TO
GATEWAY URGENT CARE
DENNIS L.CHEZ,M.D.
DIPLOMAT OF THE AMERICAN
BOARD OF EMERGENCY MEDICINE
OSIS too-9: 11105 DONNER PASS,ROAD
TRU'CKEE,CA 96162
,/�, b0-0(530)582-207b FAX(530)582-2073
/ ��-✓( //�^_�.f �"-�-r/`� rs Lic.OG24790 SS#476861.,.. -
�/�
Physicians
TAHOE FOP - 'SPITAL
BILLING L IENT
P. 0. BOX _.U01 01G. R
TRUCKEE CA 96160 PATIENT NAME
FORWARDING SERVICE REQUESTED CLAYTON D CANAN
PATIENT NUMBER DISCHARGE SE=VICE OATS
031717 OS/22/94
CREDR CARD PAS\IENT LNFOnIATION CURRENT BALANCE BILLING DATE
PLASE j 960.25 09/01/99
ARD C TYPE ENE.DATE THIS Y
AGREEMENT AMOUNT PAYMENT DUE GATE
AracDNT .00 09/21/99
ACCOUNT N'L'JiH ER �'
ENTER
960.25 PAID H T
PAID
CARD BOLDER SIGNATURE HERE
CLAYTON D CANAN
TAHOE FOREST HOSPITAL P BOX 10333
BILLING DEPARTMENT TRUCKEE CA 96162
P. O. BOX 60901
TRUCKEE, CA. 96160-9001
�I,lu,l�ueu�l,{In�l,,,�,'„{I,nlOw n,�lllaun,��9u,l)
031717 2 01 0 42 0 E2
❑ PLEASE CHECK HE E AND SHOW NAMEADDRESS CORRECTION ON REVERSE SIDE
DETACH HERE TO ASSURE PROPER CREDIT PLEASE WRITE YOUR PATIENT NUMBER ON YOUR CHECK AND RETURN UPPER PORTION WITH REMITTANCES
DATE DESCRIPTION QUANTITY I AMOUNT
08/22/99 IV-SOD CHL IRRIG 250ML 1 28.00
08/22/99 SP-TRAY, SUTURE (ER) 1 78.00
08/22/99 CS-SUTURES, PLASTIC OR REGULAR 2 60.00
08/22/99 CS-SHIELD, SPLASH 1 11.50
08/22/99 CS-SPONGES, 4X4, 1OPK 2 14.00
08/22/99 ER-LEVEL 3 - 1 129.00
08/22/99 PHRM-XYLOCAINE l% 20ML INJ 1 22.00
a 08/22/99 PHRM-VICODIN TAB 6 48.00
08/22/99 ER-MID-EVAL/MGT-LEVEL 1 1 51.00
08/22/99 ER-M.D.-LAC REPAIR,INTERM 2.6-5.0 1 317.54
y 08/22/99 ER-M.D.-DEBRIDE WOUND/PREP 1 201.21
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IMPORTANT MESSAGE CLAYTON of ENT NAM
PATIENT NUMBER
FOR YOUR INFORMATION ONLY THIS IS A 031717
SUMMARY OF YOUR CHARGES. THANK YOU.
ACCOUNT SUMMARY)
PREVIOUS
.00
CHARGES 960.25
PAYMENTSr
OTHER OO
ADJUSTMENTS
CURRENT
ACCOUNT 960.25
DISCHARGE/SERVICE BALANCE
DATE 08/22/99 PAYMENT
AGRAMOEEME�N7 00 DUE DATE 09/21J99
PAY 960.25
RETAIN THIS PORTION Pn M-N o RECcJ D AFTER 611 ,-r:,qqE WILL APPEAR CNN X. TATEMENT THIS
� TAHOE FOREST HOSPITAL DISTRICT
P. O. Box 759, Truckee, California 96160 (530) 537-6011
Patient Information
Pat,",Name COS Age Sex SSN V Patient NumbeR
CANAN, CLAYTON D 03/18/74 25Y M 624�7- 03Z7T7
Mating Address C+tlistatezo local Phone
P BOX 10333 TRUCKEE, CA 96162
Physical Address(it 1,11slenl from mailing) Patient Phone Clerk
101450 DENTON (530) 582-1673 CC
Drivers License/S,ave of Issue Scat./Co.of Birth Owtusblp Reilglon County
5987001 CDL
Next of Kin Next of Kin Abla[ioniFhone Patients Maiden Name fif a➢➢licaNel
FLETCHER, JEAN IMOTHER (530) 367-2078
Patient Demographics/Hospital Stay Info.
Admit Data Admit Time Room/Slid SC PC PT MS Race Edison PSDA Admit Type Source Repeat Maphoal Record R ACC
08/22/99 04 : 57 20 01 2 S W N 081830
Responsible Party Information (if different than patient)
Resppnsitile Party Relationship to Patient Responsible Party f R Responsible Party Phone
CANAN, CLAYTON D 01 624-16-6301 (530) 582-1673
Responsible Party Address -
P BOX 10333 TRUCKEE CA 96162
Primary Employer Information (if applicable)
Employer Employee Name Rel.to Pt. Employer Phone Employer Code
SAFEWAY
Employer Addul Occupation
TRUCKEE, CA CLERK
Secondary Employer Information (if applicable)
Employer Employee Name Rel.to Pt. Employer Phone Employer Cade
Employer Address City Stare Zip Occupation
Primary Insurance/Coverage
Insurance Carrier Subscriber's Name - Rel.to Pt. Plan Code PC
SELF PAY CANAN, CLAYTON D 01
Irawance Address City/suns/Zp I
Group R lD R Authworatnin R
624166301
Secondary Insurance/Coverage (if applicable)
insurance Carrier Subscriber's Name Rel.to of. Plan Code 'C
Insurance Address cay/st2lp �I
d' �7� , S 4
Group R 10 R Awpieu,au.n R
` G
Y 2 Z
Visit Information i
Date of In,ry Mode of Transport Chief Cpmplamt 1 Injuries
/ / AUTO AMR IFACIAL LAC/AERASION
A;tendrng Physician Code Private Physician I Code Other PhYSK.an
SHIELDHOUSE, PETS 00363 DR,
.............._.__...
MODE OF ARRIVAL: a1kinbulatory O Wheelchair ❑Crutches O Gurney Q Carried O Ambulance J Other:
TEMP'. BP.1/c! PULSE& RESP 1<61 VISUAL ACUITY ❑V, VISUAL ACUITY WEIGHT JKG JACTUAL
CORRECTED/ �J No CO./ CS: CJ. JLB J STATED
J Mo eOF DISTRESS
L SS
w
N ..,�,,.`�-yti,�-[A/�,.y ..�-•-w - ✓�-;--.� -a--%�."1 ._----- J Severe
y w
A,
c7
CURRENT ECS:
PULSE O%:$p02 RA SAT L'02 via is °le
ALLERGIES: IMMUNIZATIONS CURRENT:OYes ❑No INTERPRETER
NKA TETANUS STATUS: CALLED: ARRIVED:
H TH HISTORY:
i
HISTORY&PHYSICAL E.D.TREATMENT PLAN TIME INITIAL
Lab:
Ly // I
/ [n,� Xray:
i
�, v_��3. --------------
Treatments:
Discharge n:
IMPRESSION:
PHYSICIANS
V•''L. Ufl ��L,/(//� ..tiL/ SIGNATURE
- SGGc ��U�G I1 0< <22/99 ;
25Y
REFERR TO: DISABILITY:
DIS SITION: --_ MODt -- J PVT,AUTO i - �•j F C
nOMEJ HOSPITAL J OTHER J AMBULANCE J OTHER
t�-Se000
GE CGNDI ION J FAIR J CRITICAL J DIC ATED .J 1 System
,., CSSERVATION I RESPONSES ! TX INITIALS TIME vis MEDF PAIN !MITW LSi
biD
I I
I
!
IV FLUIDS/BLOOD J Feld Start IV 14; IV Blood
TIME SOLUTION SITE - VU`NF..R.le IN, Z!
GAUGE i4-PE PO Other-----
aj URINE Blood _
�i EMESIS _ _ Ctner
RN Signature.__. ._ _.. Init.a's
RN Signature, 'n.'at5"
RN Sooature. irnla�s.
WOUND CARE ADMISSION INFORMATION DISCHARGE INSTRUCTIONS/DISPOSITION
J Saline RM Number
J H2O2 Time of Report, _. RECHECK PRIOR TO RELEASE:
J Betadme - --'--- -
J Kling Report Given To: J Other
J Fatient',ransferred to wz
J Tube Gauze
-1 Neosponn DISCHAR 5TRUCTIONS REVIEWED WITH:
J Xeroform Belongings W J Patient
J Adaptic J Famil .Friends Parent J intends
Y -J Parent J interpreter
J Sandaid
J Safe J Spouse J Guardian
J Ace
J Other_ _ _ _ To Room Via J Wheelchair J Family J Other
ORTHO CARE J Gurney rn-P�a,Ient Responsible party verbalizes understencinc of discharge
J Splint Cast Type: J Monitor 02rACLS Nurse insirucGors.
J CSM Present After Splint Applied MODE OF TRANSPORT ALSO GIVEN
J Crutches w Gait Training ADDITIONAL FORMS USED: ,yalrt
J Air Cast J Neuro Flow Sheet J Wheeicra'r J Physical Therapy
J Ace J Conscious Sedation J Carried J MD Referral
J :mmobd¢er J Thrombolytic Therapy J Pt.instructed not to drive J Off`pork School Regae_t
J Knee J Surgical Check:lst J Tax: J Xray Copies
J Shoulder J Transfer Forms
J Clavicle Strap J Blood Consent
J Sling J Admit Form J CHARGES COMPLETE
J Ice J Additional Nurses Notes J Other _ J Critical Care Flow Sheet DISCHARGE TIME 0. `7._ RN INITIALS
RN INITIALS J Other:
Tahoe Forest Hospital Emergency Department
Tahoe Drive and Pine Avenue Box 759, Truckee, CA 96160 (916) 587-6011
Aftercare Instructions
for CLAYTON CANAN, Sunday, August 22 , 1999, 7 : 07 am
IMPORTANT: We have examined and treated you today or. an can be habit forming if used for a long period of time.
emergency basis only. This is not a substitute for, or an
effort to provide, complete medical care. In most cases, you Follow these instructions:
must let your doctor check you again. Tell your doctor about - Talk to your doctor be-ore taking other medicines
any new or lasting problems. It is impossible to recognize (including over-the-counter medicines) .
and treat all iniuries or illnesses in a single Emergency - Sic or stand $lowly to avoid dizziness.
Department visit. If you had special tests such as EKG's and - Take this medicine with food or milk to avoid an upset
X-rays, we will review them again within 24 hours. We will stomach.
call you if there are any new suggestions. After leaving, - Store this medicine away from heat, moisture or direct
you should FOLLOW THE INSTRUCTIONS BELOW. light.
- Watch for signs of dependence. They include:
You were treated today by PETER SHIELDHOUSE, M.D.. - feeling that you -cannot live without this medicine-,
FACIAL LACERATION. - you need more of this medicine than before to get the
The laceration on your face needed stitches to close the same relief.
skin. That helps healing. The suture line will be reddened - Do not drink alcohol, drive or operate machinery while
at first. Over time the redness will fade. All lacerations taking this medicine. -
cause scars. Call your doctor if you have: -
- any sign of dependence'.
The `o'low'ng will affect the size of your scar - any sign of allergy.
- The size of the laceration. - increased pain nor helped by the pain medicine.
- Infection. - any new or severe symptoms.
- Location on your face.
- Exposure to sunlight. .«.««,««:...,..:.......««.««««««..«.«..«.««««.e........:.:.,
- Your own likelihood to scar. TFESE ARE YOUR FOLLOW-UP INSTRUCTIONS!
Follow these instructions: ALL COSTS INCURRED IN THE EMERGENCY DEPARTMENT IN FOLLOW-UP
- Keep your dressing clean and dry for 24 hours. . CARE ARE PATIENT RESPONSIBILITY Call as soon as possible to
- After 24 hours, wash your wound gently with soap and water make an appointment to see your private doctor in 5 days.
and pat dry. You can reach your doctor by calling their.clinic phone
- Treat the suture .line carefully without stretching it, number.-
- Avoid direct sunlight. .....«.«.«..............«........
......«..«.«...............
Call Your doctor if vouhave: AS ALWAYS YOU ARE THE MOST IMPORTANT FACTOR IN YOVR
- increased redness, swelling or pain. RECOVERY. Please follow the instructions above carefully.
- pus, drainage or red streaks from your wound. Take your medicines as prescribed. Most important, see a
- fever. doctor again as discussed. If you have problems that we have
any new or severe symptoms. not discussed, CALL OR VISIT YOUR DOCTOR RIGHT AWAY. If you
can't -each your doctor, return to the Emergency Department.
ALL COSTS INCURRED IN YOUR FOLLOW-UP CARE ARE PATIENT
RESPONSIBILIT':
"I have receiv a cocv of the 'astructicns above.
ACETAMIN
.,=..00G ..............O..................................
...,
-_
Take this medicine by mouth in the following dose:
tablets every 4-6 hours if needed for pain. Patient or Responsible Person
This is a mixture of medicines used to relieve pain. Side I AM SATISFIED WIT..4 THE CARE I HAVE RECIEVED"
effects may include: sleepiness, upset stomach or
constipation (hard stools) . Allergy would show uo as: rash YES 5L,/ NO 11
or itching, wheezing or shortness of breath. This medicine
Portions Copyrighted 1986-1999, LOGICARE Corporation, Page 1, continued...
I T E M I Z E D S T A T E M E N T
CLAIM NO. : DATE: 08/31/99
INSURANCE COMPANY:
Fred K. Maier
Laub and Laub
10368 Donner Pass Road
Truckee, CA 96161
DOCTOR:
PHONE : 916-587-5282 Phillip Ravinale, D .C.
Phillip Ravinale, D.C.
PATIENT: 10833 Donner Pass Rd #201
Clayton Canan Truckee, CA 96161
PO Box 10333 (530) 587-3776
TRUCKEE, CA 96162 IRS # 68-0417823
INSURED'S NAME : Clayton Canan CA LIC #22442
DATE OF ACCIDENT: 08/22/99
DIAGNOSIS :
847 . 0 847 . 1
728 . 85 842 (L)
844 . 8 (L)
--------------------------------------------------------------------
- DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT-
____________________________________________________________________
08/27/99 99204- Comprehensive Hist&Exam 110 . 00
08/27/99 97140- MANUAL/ MYOFASCIAL THER. 45 . 00
08/27/99 97012- Traction, Mechanical 18 . 00
08/28/99 99214- Detailed Hist, Exam,Trea 45 . 00
08/28/99 97140- MANUAL/ MYOFASCIAL THER. 45 . 00
08/28/99 97012- Traction, Mechanical 18 . 00
08/31/99 99214- Detailed Hist, Exam, Trea 45 . 00
08/31/99 97140- MANUAL/ MYOFASCIAL THER. 45 . 00
08/31/99 97012- Traction, Mechanical 18 . 00
PATIENT NO: 11143-2 TOTAL: 389 . 00
INSURANCE CARRIER - Patient Assignment Is On File For This Case
I T E M I Z E D S T A T E M E N T
CLAIM NO. : DATE : 09/15/99
INSURANCE COMPANY:
Fred K. Maier
Laub and Laub
10368 Donner Pass Road
Truckee, CA 96161
DOCTOR:
PHONE: 916-587-5282 Phillip Ravinale, D.C.
Phillip Ravinale, D.C .
PATIENT : 10833 Donner Pass Rd #201
Clayton Canan Truckee, CA 96161
PO Box 10333 (530) 587-3776
TRUCKEE, CA 96162 IRS # 68-0417823
INSURED' S NAME : Clayton Canan CA LIC #22442
DATE OF ACCIDENT: 08/22/99
DIAGNOSIS :
847 . 0 847 . 1
728 . 85 842 (L)
844 . 8 (L)
--- -----------------------------------------------------------------
- DATE - -PROCEDURE- - DESCRIPTION - -AMOUNT-
------------------------------------------------------------------
09/01/99 99214- Detailed Hist, Exam,Trea 45 . 00
09/01/99 97140- MANUAL/ MYOFASCIAL THER. 45 . 00
09/01/99 97012- Traction, Mechanical 18 . 00
09/03/99 99214- Detailed Hist, Exam, Trea 45 . 00
09/03/99 97140- MANUAL/ MYOFASCIAL THER. 45 . 00
09/03/99 97012- Traction, Mechanical 18 . 00
09/07/99 99214- Detailed Hist, Exam,Trea 45 . 00
09/07/99 97140- MANUAL/ MYOFASCIAL THER. 45 . 00
09/07/99 97012- Traction, Mechanical 18 . 00
09/10/99 99214- Detailed Hist, Exam,Trea 45 . 00
09/10/99 97140- MANUAL/ MYOFASCIAL THER. 45 . 00
09/10/99 97012- Traction, Mechanical 18 . 00
09/14/99 99214- Detailed Hist, Exam,Trea 45 . 00
09/14/99 97140- MANUAL/ MYOFASCIAL THER. 45 . 00
09/14/99 97012- Traction, Mechanical 18 . 00
PATIENT NO : 11143 -2 TOTAL: 540 . 00
INSURANCE CARRIER - Patient Assignment Is On File For This Case