Andrew Flores v. Michael J. Astrue, No. 5:2008cv01475 - Document 16 (C.D. Cal. 2009)

Court Description: MEMORANDUM OPINION AND ORDER by Magistrate Judge Alicia G. Rosenberg. IT IS HEREBY ORDERED that the Commissioner's decision is affirmed. IT IS FURTHER ORDERED that the Clerk of the Court serve copies of this Order and the Judgment herein on all parties or their counsel. **Please see order for further details** (ag)

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1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 CENTRAL DISTRICT OF CALIFORNIA 10 11 ANDREW FLORES, 12 Plaintiff, 13 v. 14 15 MICHAEL J. ASTRUE, Commissioner of Social Security, Defendant. 16 17 ) ) ) ) ) ) ) ) ) ) ) ) NO. CV 08-1475 AGR MEMORANDUM OPINION AND ORDER Andrew Flores filed this action on October 27, 2008. Pursuant to 28 U.S.C. 18 19 § 636(c), the parties consented to proceed before Magistrate Judge Rosenberg 20 on November 13 and November 25, 2008. (Dkt. Nos. 8, 9.) On May 28, 2009, 21 the parties filed a Joint Stipulation ( JS ) that addressed the disputed issues. The 22 Court has taken the matter under submission without oral argument. Having reviewed the entire file, the Court affirms the Commissioner s 23 24 decision. 25 /// 26 /// 27 /// 28 /// 1 1. 2 PROCEDURAL BACKGROUND 3 On October 22, 2004, Flores filed an application for Supplemental Security 4 Income benefits. AR 30. The application was denied initially and upon 5 reconsideration. Id. An Administrative Law Judge ( ALJ ) conducted a hearing 6 on April 6, 2007, at which Flores, a medical expert ( ME ), a vocational expert 7 ( VE ) and Flores brother, Rudolph Flores, testified. AR 81-100. On April 26, 8 2007, the ALJ issued an unfavorable decision. AR 10-20. Flores requested 9 review of the decision on August 27, 2007. AR 7. The Appeals Council 10 remanded for further proceedings on October 26, 2007. AR 41-45. On remand, 11 a supplemental hearing was held on February 5, 2008 before a different ALJ, at 12 which Flores and a VE testified. AR 101-17. On March 14, 2008, the ALJ issued 13 an unfavorable decision. AR 27-37. On August 22, 2008, the Appeals Council 14 denied Flores request for review. AR 21-24. This lawsuit followed. 15 2. 16 STANDARD OF REVIEW 17 Pursuant to 42 U.S.C. § 405(g), this Court reviews the Commissioner s 18 decision to deny benefits. The decision will be disturbed only if it is not supported 19 by substantial evidence, or if it is based upon the application of improper legal 20 standards. Moncada v. Chater, 60 F.3d 521, 523 (9th Cir. 1995); Drouin v. 21 Sullivan, 966 F.2d 1255, 1257 (9th Cir. 1992). 22 Substantial evidence means more than a mere scintilla but less than a 23 preponderance it is such relevant evidence that a reasonable mind might 24 accept as adequate to support the conclusion. Moncada, 60 F.3d at 523. In 25 determining whether substantial evidence exists to support the Commissioner s 26 decision, the Court examines the administrative record as a whole, considering 27 adverse as well as supporting evidence. Drouin, 966 F.2d at 1257. When the 28 2 1 evidence is susceptible to more than one rational interpretation, the Court must 2 defer to the Commissioner s decision. Moncada, 60 F.3d at 523. 3 3. 4 DISCUSSION 5 a. 6 A person qualifies as disabled and is eligible for benefits, only if his 7 physical or mental impairment or impairments are of such severity that he is not 8 only unable to do his previous work but cannot, considering his age, education, 9 and work experience, engage in any other kind of substantial gainful work which 10 exists in the national economy. Barnhart v. Thomas, 540 U.S. 20, 21-22, 124 S. 11 Ct. 376, 157 L. Ed. 2d 333 (2003). Disability 12 b. 13 The ALJ found that Flores has the following severe impairments: back The ALJ s Findings 14 pain and depression. AR 32. He has the residual functional capacity ( RFC ) to 15 perform medium work except that he cannot work on dangerous machinery and 16 is limited to entry level work involving routine, repetitive tasks and things rather 17 than people. AR 33. He cannot perform his past relevant work. AR 35. 18 However, there are jobs that exist in significant numbers in the national economy 19 that the claimant can perform including, for example, hand packager, industrial 20 cleaner or kitchen helper. AR 36. 21 C. 22 To determine whether a claimant s testimony regarding subjective pain or Flores Credibility 23 symptoms is credible, an ALJ must engage in a two-step analysis. Lingenfelter 24 v. Astrue, 504 F.3d 1028, 1035-36 (9th Cir. 2007). 25 At Step One, the ALJ must determine whether the claimant has presented 26 objective medical evidence of an underlying impairment which could reasonably 27 be expected to produce the pain or other symptoms alleged. The claimant, 28 however, need not show that her impairment could reasonably be expected to 3 1 cause the severity of the symptom she has alleged; she need only show that it 2 could reasonably have caused some degree of the symptom. Thus, the ALJ 3 may not reject subjective symptom testimony . . . simply because there is no 4 showing that the impairment can reasonably produce the degree of symptom 5 alleged. Id. (citations omitted); Bunnell v. Sullivan, 947 F.2d 341, 343 (9th Cir 6 1991) (en banc). The ALJ found that Flores medically determinable impairments 7 could reasonably be expected to produce some of the alleged symptoms. AR 34. 8 9 Second, if the claimant meets this first test, and there is no evidence of malingering, the ALJ can reject the claimant s testimony about the severity of her 10 symptoms only by offering specific, clear and convincing reasons for doing so. 11 Lingenfelter, 504 F.3d at 1036 (citations omitted). In making a credibility 12 determination, the ALJ must specifically identify what testimony is credible and 13 what testimony undermines the claimant s complaints. Greger v. Barnhart, 464 14 F.3d 968, 972 (9th Cir. 2006) (citation omitted). The ALJ did not find malingering. 15 [T]o discredit a claimant s testimony when a medical impairment has been 16 established, the ALJ must provide specific, cogent reasons for the disbelief. Orn 17 v. Astrue, 495 F.3d 625, 635 (9th Cir. 2007) (citations and quotation marks 18 omitted). The ALJ must cite the reasons why the claimant s testimony is 19 unpersuasive. Id. (citation and quotation marks omitted). 20 In weighing credibility, the ALJ may consider factors including: the nature, 21 location, onset, duration, frequency, radiation, and intensity of any pain; 22 precipitating and aggravating factors (e.g., movement, activity, environmental 23 conditions); type, dosage, effectiveness, and adverse side effects of any pain 24 medication; treatment, other than medication, for relief of pain; functional 25 restrictions; the claimant s daily activities; and ordinary techniques of credibility 26 27 28 4 1 evaluation. Bunnell, 947 F.2d at 346 (citing Social Security Ruling 88-13,1 2 quotation marks omitted); Burch v. Barnhart, 400 F.3d 676, 680 (9th Cir. 2005). 3 The ALJ may also consider inconsistencies or discrepancies in claimant s 4 statements; inconsistencies between claimant s statements and activities; 5 exaggerated complaints; and unexplained failure to seek treatment. Thomas v. 6 Barnhart, 278 F.3d 947, 958-59 (9th Cir. 2002); Smolen v. Chater, 80 F.3d 1273, 7 1284 (9th Cir. 1996). If the ALJ s credibility finding is supported by substantial 8 evidence in the record, we may not engage in second-guessing. Thomas, 278 9 F.3d at 959; Morgan v. Comm r of the Soc. Sec. Admin., 169 F.3d 595, 600 (9th 10 Cir. 1999). 11 Back Pain 12 The ALJ discounted Flores statements regarding his back pain for three 13 reasons: (1) inconsistency with the objective medical record; (2) no evidence of 14 any recent treatment for his back; and (3) no indication that Flores takes any pain 15 medication. AR 34. 16 Although lack of medical evidence cannot form the sole basis for 17 discounting pain testimony, it is a factor that the ALJ can consider in his credibility 18 analysis. Burch v. Barnhart, 400 F.3d 676, 681 (9th Cir. 2005) (claimant s pain 19 allegations may be discounted based on MRI and X-rays showing only mild 20 degenerative disc disease). The ALJ noted that a September 2003 MRI of 21 Flores lumbar spine showed a 4mm disc bulge but was otherwise normal. AR 22 34, 220. The ALJ s finding is supported by substantial evidence, including an 23 examining physician s opinion. AR 292 (examining physician interpreting MRI as 24 25 26 27 28 1 Social Security rulings do not have the force of law. Nevertheless, they constitute Social Security Administration interpretations of the statute it administers and of its own regulations, and are given deference unless they are plainly erroneous or inconsistent with the Act or regulations. Han v. Bowen, 882 F.2d 1453, 1457 (9th Cir. 1989). 5 1 a normal MRI for stated age ).2 See Parra v. Astrue, 481 F.3d 742, 750-51 (9th 2 Cir. 2007) (ALJ may discount claimant s testimony based on objective medical 3 evidence), cert. denied, 128 S. Ct. 1068, 169 L. Ed. 2d 808 (2008). 4 An unexplained or inadequately explained failure to seek treatment or 5 follow a prescribed course of treatment are valid considerations in determining 6 credibility. See Orn, 495 F.3d at 636; Thomas, 278 F.3d at 958-59. The ALJ s 7 finding that there is no recent treatment for back pain is supported by substantial 8 evidence. Flores does not identify any recent treatment records for his back, and 9 the Court has located none in the administrative record. In April 2004, a record of 10 a visit to an ophthalmology clinic noted mild strain in the paraspinal area but good 11 range of motion. AR 211. As the ALJ noted, there is an MRI of the back in 12 September 2003. AR 220. 13 An ALJ may discount a claimant s pain testimony based on a conservative 14 course of treatment. See Parra, 481 F.3d at 750-51. Flores testified that the only 15 pain medications he ever took were Tylenol (including Tylenol III that Flores 16 obtained without prescription from his brother). AR 108, 110-11. The ALJ s 17 finding is supported by substantial evidence. 18 Depression-Related Complaints 19 Flores contends that the ALJ did not properly credit his subjective 20 complaint of decreased concentration and hallucinations. JS 4, 8. 21 The ALJ agreed with the analysis portion of the prior ALJ s decision, 22 which discussed Flores subjective complaints and the medical evidence and 23 concluded that Flores was capable of performing non-public, simple, repetitive 24 tasks. AR 34. 25 26 Analyzing the subsequently submitted medical evidence, the ALJ found nothing that would prevent Flores from performing entry level work involving 27 28 2 Flores was 42 in 2003. AR 220. 6 1 routine, repetitive tasks and things rather than people. Id. The ALJ relied on the 2 treating psychiatrist s work capacity evaluation (mental) form and Flores work 3 history. AR 35. The ALJ found that Flores complaints to his treating physician 4 related primarily to life stressors such as financial difficulties and a strained 5 relationship with his daughters. AR 34. Flores responded well to medication and 6 his mood improved when he increased his interaction with family. Id. The ALJ gave significant weight to the Work Capacity Evaluation (Mental) 7 8 dated December 3, 2007, submitted by Flores treating psychiatrist, Dr. 9 Dittemore. AR 35, 381-82. Dr. Dittemore s assessment took into account Flores 10 subjective complaints about concentration and hallucinations. E.g., AR 344, 367, 11 371. 12 Dr. Dittemore s treating opinion is consistent with the ALJ s RFC 13 assessment that Flores is limited to entry level work involving routine, repetitive 14 tasks and things rather than people. AR 33. As the ALJ noted, Dr. Dittemore 15 assessed no limitation in Flores ability to remember work-like procedures; 16 understand and remember short and simple instructions; carry out short and 17 simple instructions; sustain an ordinary routine without special supervision; work 18 in coordination with or in proximity to others without being distracted by them; 19 make simple work-related decisions; ask simple questions or request assistance; 20 get along with co-workers without distracting them or exhibiting behavioral 21 extremes; maintain socially appropriate behavior and adhere to basic standards 22 of neatness and cleanliness; be aware of normal hazards and take appropriate 23 precautions; and set realistic goals or make plans independently of others. AR 24 381-82. Dr. Dittemore assessed Flores with moderate limitations in the ability to 25 maintain attention and concentration for extended periods; maintain a schedule, 26 regular attendance and punctuality within customary tolerances; and respond to 27 changes in the work setting. Id. The ALJ found that a moderate limitation in 28 these areas would not significantly affect Flores ability to perform work within his 7 1 RFC. AR 35; 20 C.F.R. § 416.290a(c)(4) (the last point on each scale none, 2 mild, moderate, marked and extreme represents a degree of limitation that is 3 incompatible with the ability to do any gainful activity ). In examining the treating 4 notes, the ALJ found no reason to conclude Flores is not mentally capable of 5 performing entry level work involving routine, repetitive tasks and things rather 6 than people. AR 35. 7 At the hearing, the ALJ questioned Flores about why he is unable to work. 8 AR 112. Flores responded by referring to his separation from his family, causing 9 him to hear kids voices three or four times a month, for five to ten minutes. AR 10 112-13. He also sees images of a person or animal through the side. AR 113. 11 In response to a question as to the effect of those symptoms, Flores responded, 12 I couldn t be in a hospital and see those things. You have to be alert. You have 13 to be quick. AR 114. 14 The ALJ agreed that Flores is unable to perform his past relevant work as 15 a nurse s assistant. AR 35. The ALJ s RFC assessment takes into account 16 Flores subjective complaints about concentration and hallucinations as 17 incorporated in Dr. Dittemore s evaluation.3 The ALJ also incorporated a 18 limitation that reflected Flores testimony that he can t be around people. AR 19 112. In summary, Flores has not identified subjective complaints that were not 20 accounted for in the RFC assessment. The ALJ s credibility finding is supported 21 by substantial evidence in the record. Thomas, 278 F.3d at 959; Morgan, 169 22 F.3d at 600. 23 D. 24 Flores contends that the ALJ did not properly consider certain opinions 25 26 27 28 Treating Physician Opinions in 2003 3 The ALJ did not credit Dr. Dittemore s assessment of a marked limitation in Flores ability to accept instructions and respond appropriately to criticism from supervisors. AR 35. The ALJ properly relied upon Flores own statements that he got along in an excellent manner with people at work and Flores work history, which did not indicate any problems with supervisors. AR 35, 282. 8 1 expressed in January and February 2003 by Dr. Havert and Dr. Dittemore. JS 8- 2 9, 12. 3 In February 2003, Dr. Havert diagnosed major depressive disorder, 4 recurrent, severe with psychotic features, and assessed a Global Assessment of 5 Functioning ( GAF ) score of 52. AR 206. There is no supporting record of 6 examination or treatment. Although Flores attributes his mental status 7 examination on January 8, 2003, to Dr. Havert (JS at 8), the document actually 8 reflects that it was done by Benjamin Barnes, M.A. AR 207. The mental status 9 findings indicate Flores was oriented x4, alert, coherent, had fair insight and 10 judgment, had an appropriate general appearance, and had a depressed and 11 irritable mood and affect. Id. 12 On January 14, 2003, Dr. Dittemore diagnosed major depressive disorder 13 with psychotic features; alcohol dependence, early remission; and polysubstance 14 dependence. AR 228. On January 31, 2003, Dr. Dittemore made the same 15 diagnosis and assessed a GAF of 50.4 AR 239. 16 The opinion of a treating or examining physician is given more weight than 17 the opinion of non-treating physicians. Orn, 495 F.3d at 631; Lester v. Chater, 81 18 F.3d 821, 830 (9th Cir. 1995). When a treating physician s opinion is contradicted 19 by another doctor, the ALJ may not reject this opinion without providing specific 20 and legitimate reasons supported by substantial evidence in the record. This can 21 be done by setting out a detailed and thorough summary of the facts and 22 conflicting clinical evidence, stating his interpretation thereof, and making 23 findings. Orn, 495 F.3d at 632 (citations and quotations omitted). When there 24 is conflicting medical evidence, the Secretary must determine 25 26 27 28 4 However, in a letter dated June 4, 2004, Dr. Dittemore describes Flores diagnosis as Major Depressive Disorder with Psychotic Features which are primarily in remission . . . . AR 252 (emphasis added). 9 1 credibility and resolve the conflict. Thomas, 278 F.3d at 956-57 (citation and 2 quotation marks omitted). 3 The ALJ agreed with the analysis portion of the prior ALJ s decision, 4 which discussed these two diagnoses. AR 17, 34. [T]he mere existence of an 5 impairment is insufficient proof of a disability. Matthews v. Shalala, 10 F.3d 678, 6 680 (9th Cir 1993). A claimant must show that he is precluded from engaging in 7 substantial gainful activity by reason of his impairments. Id. (citing 42 U.S.C. § 8 423(d)(1)(A)). Contrary to Flores argument (JS at 9), neither treating physician 9 opinion in 2003 (prior to the alleged onset date) addressed the issue of 10 limitations on Flores ability to work. Nor did the ALJ err in not discussing the 11 GAF scores. A GAF is not determinative of mental disability for social security 12 purposes. See 65 Fed. Reg. 50746, 50764-50765 (August 21, 2000) ( [The GAF 13 scale] does not have a direct correlation to the severity requirements in our 14 mental disorder listings. ). A failure to reference a GAF score, standing alone, 15 does not undermine the ALJ s findings. See Howard v. Comm r of Soc. Sec., 16 276 F.3d 235, 241 (6th Cir. 2002) (rejecting argument that ALJ erred in failing to 17 mention GAF score).5 18 The ALJ gave greater weight to Dr. Dittemore s Work Capacity Evaluation 19 (Mental) dated December 3, 2007. AR 35, 381-82. An ALJ may reasonably give 20 a treating physician s later opinion greater weight because it is based on a more 21 complete evaluation and treatment. See Lester, 81 F.3d at 833. An ALJ may 22 reasonably give less weight to the opinions in 2003, which were dated over one 23 and a half years prior to the alleged onset date of October 22, 2004. See 24 Burkhart v. Bowen, 856 F.2d 1335, 1340 n.1 (9th Cir. 1988). The ALJ did not err. 25 E. 26 Flores argues that the ALJ erred in failing to state explicitly that he was Dr. Dittemore s Evaluation in 2005 27 28 5 See also McFarland v. Astrue, 288 Fed. Appx. 357, 359 (9th Cir. 2008). 10 1 rejecting Dr. Dittemore s Work Capacity Evaluation (Mental) dated May 27, 2005. 2 JS at 13-16, 18. In that evaluation, Dr. Dittemore opined that Flores had slight 3 limitation in the ability to carry out short and simple instructions. AR 325. Flores 4 had moderate limitation in the ability to ask simple questions or request 5 assistance, and the ability to maintain socially appropriate behavior and adhere 6 to basic standards of neatness and cleanliness. AR 325-26. Dr. Dittemore 7 assessed marked or extreme limitations in all other categories. Id. 8 9 The ALJ stated that he gave significant weight to Dr. Dittemore s subsequent evaluation in 2007. AR 35. As discussed above, the 2007 10 evaluation is consistent with the ALJ s RFC assessment, and an ALJ may 11 reasonably give a treating physician s later opinion greater weight. See Lester, 12 81 F.3d at 833. 13 The ALJ states that he gave careful consideration to the medical evidence 14 that was before [ALJ] Gaye at the time he issued his decision (i.e., Exhibits 1-F 15 through 16-F). AR 34. Dr. Dittemore s 2005 evaluation is Exhibit 14-F, which is 16 in the group of exhibits the ALJ expressly stated he considered. AR 325-26. The 17 ALJ incorporate[d] Judge Gaye s thorough and well-reasoned analysis, and 18 cited pages 4-6 of the prior decision. AR 34. 19 The prior ALJ discounted Dr. Dittemore s 2005 evaluation for three 20 reasons: (1) Dr. Dittemore did not have Dr. Smith s report dated December 7, 21 2004; (2) Dr. Dittemore s functional limitations in the 2005 evaluation were 22 inconsistent with her letter dated June 2004 and treating records showing 23 improvement in Flores condition after the alleged onset date of October 22, 24 2004; and (3) the opinions of the medical expert and state agency physicians. 25 AR 18. The Appeals Council did not specifically assign error to the prior ALJ s 26 consideration of Dr. Dittemore s 2005 evaluation. AR 43-45. 27 There is no indication that Dr. Smith s report dated December 7, 2004 was 28 available to Dr. Dittemore. As noted by the prior ALJ, Dr. Smith found Flores not 11 1 credible in his mental status exam or interview. AR 286. Flores appeared to 2 have arrived with rehearsed talking points that he used in response to 3 questions that were not on those subjects. AR 278, 286. When Dr. Smith 4 attempted to follow up on Flores talking points, Flores could not provide any 5 details or description. AR 278-86. Dr. Smith did not believe [Flores] is impaired 6 in his ability to work from a psychiatric disorder. AR 286. An ALJ may reject a 7 treating physician s opinion based on an examining physician s opinion with 8 independent clinical findings. Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 9 1995). In addition, reports of the nonexamining advisor need not be discounted 10 and may serve as substantial evidence when they are supported by other 11 evidence in the record and are consistent with it. Id. Therefore, the ALJ did not 12 err in relying on the medical expert and state agency physicians who relied on 13 the examining physician s report. AR 91, 309-10. In summary, the state agency 14 examiners found that Flores was depressed, isolative, but quite capable of 15 adequate functioning, and his various alleged psychoses did not significantly 16 interfere with this functioning even if they existed. AR 18, 310, 305-24. 17 Specifically, the state agency examiner concluded that [Flores] could sustain 18 nonpublic simple repetitive tasks. 6 AR 18, 307. The ALJ s rejection of the 2005 19 evaluation is supported by substantial evidence. See Orn, 495 F.3d at 632 20 F. 21 Flores points to two entries in Dr. Dittemore s series of Medication Visit Side Effects Of Flores Medication 22 records, on July 14, 2005 (AR 330), and September 5, 2006 (AR 354), that 23 Flores felt dry mouth and sedation using Seroquel. The treating notes reflect 24 that Seroquel was discontinued on September 5, 2006. AR 351, 354. At the 25 remand hearing, Flores agreed he was then taking Risperdal, Wellbutrin, Celexa 26 27 28 6 The state agency examiner found marked limitations only in Flores ability to understand and remember detailed instructions, carry out detailed instructions, and interact appropriately with the general public. AR 18, 305-06. 12 1 and Depakote, but did not identify Seroquel as a current medication. AR 107. Flores does not cite to any evidence that these side effects interfere with 2 3 his ability to work. At the hearing, Flores did not identify side effects as a reason 4 he could not work. There were passing mentions of the side effects of 5 [plaintiff s] medication in some of the medical records, but there was no evidence 6 of side effects severe enough to interfere with [his] ability to work. Osenbrock v. 7 Apfel, 240 F.3d 1157, 1164 (9th Cir. 2001) (side effects such as dozing off and 8 dry mouth not severe enough); see also Miller v. Heckler, 770 F.2d 845, 849 9 (9th Cir. 1985) ( [Plaintiff] produced no clinical evidence showing that narcotics 10 use impaired his ability to work ). The ALJ did not err. 11 G. ALJ s Hypothetical Question To The Vocational Expert 12 The ALJ may rely on testimony a VE gives in response to a hypothetical 13 that contains all of the limitations that the ALJ found credible and supported by 14 substantial evidence in the record. Bayliss v. Barnhart, 427 F.3d 1211, 1217-18 15 (9th Cir. 2005). The ALJ is not required to include limitations that are not in his 16 findings. Rollins v. Massanari, 261 F.3d 853, 857 (9th Cir. 2001); Osenbrock, 17 240 F.3d at 1165. 18 Flores argues that the ALJ erred in not including the limitations contained 19 in Dr. Dittemore s 2005 evaluation or the side effects from medication in his 20 hypothetical to the vocational expert. (JS 22-23.) 21 Because the ALJ properly discounted Dr. Dittemore s 2005 evaluation, the 22 ALJ did not err. See Rollins, 261 F.3d at 857. Given there was no substantial 23 evidence that side effects limited or prevented Flores from working, the ALJ 24 properly excluded that limitation. See Osenbrock, 240 F.3d at 1164 (excluding 25 side effects from hypothetical); Greger, 464 F.3d at 973 (same). 26 /// 27 /// 28 /// 13 1 IV. 2 ORDER 3 IT IS HEREBY ORDERED that the Commissioner s decision is affirmed. 4 IT IS FURTHER ORDERED that the Clerk of the Court serve copies of this 5 Order and the Judgment herein on all parties or their counsel. 6 7 8 DATED: September 17, 2009 ALICIA G. ROSENBERG United States Magistrate Judge 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 14

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