Young v. Saul, Case No. 19-cv-01965-PJH

CourtUnited States District Courts. 9th Circuit. United States District Courts. 9th Circuit. Northern District of California
Writing for the CourtPHYLLIS J. HAMILTON United States District Judge
PartiesMARCELL YOUNG, Plaintiff, v. ANDREW SAUL, Defendant.
Docket NumberCase No. 19-cv-01965-PJH
Decision Date29 June 2020

ANDREW SAUL, Defendant.

Case No. 19-cv-01965-PJH


June 29, 2020


Re: Dkt. Nos. 16, 17

Pursuant to 42 U.S.C. § 405(g), plaintiff Marcell Young ("plaintiff") seeks judicial review of the Commissioner of Social Security's ("Commissioner" or "defendant") final decision denying his claims for disability benefits and Supplemental Security Income ("SSI"). This action is before the court on the parties' motions for summary judgment. Having considered the parties' motions, the pertinent legal authorities, and having reviewed the administrative record, the court GRANTS plaintiff's motion and hereby REMANDS this action to defendant's assigned administrative law judge for further proceedings in accordance with this order.


A. Procedural History

On May 18, 2015, plaintiff filed two applications—one for Title II disability benefits and one for Title XVI SSI benefits—both alleging disability as of May 14, 2015. Administrative Record ("AR") 235-47, Dkt. 13. Defendant denied plaintiff's Title II and Title XVI claims at the initial level on October 18, 2015 and October 20, 2015 respectively (id. at 100-01) and at the reconsideration level as to both claims on May 26, 2016. Id. at

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132-33. Following a timely request for a hearing, Administrative Law Judge Arthur Zeidman (the "ALJ") held a hearing on plaintiff's claims on December 13, 2017. Id. at 17. At the hearing plaintiff and a vocational expert, Susan Moranda, testified. Id. at 67-69.

On April 2, 2018, the ALJ issued his decision on plaintiff's application and concluded that plaintiff was not disabled within the meaning of the applicable Social Security laws and regulations. Id. at 17-30. Plaintiff filed a request for review of the decision with the Social Security Appeals Council, which denied review on February 13, 2019. Id. at 233-34.

B. Summary of Plaintiff's Medical and Employment History

Plaintiff is a 27-year-old resident of Alameda County. As a child, plaintiff was diagnosed with borderline intellectual functioning and received SSI due to his impaired intellectual functioning. Id. at 283. Plaintiff was enrolled in special education classes throughout his schooling years as his borderline intellectual functioning manifested in low basic reading ability, auditory processing deficiencies, and frequent truancy. Id. at 708. In 2009, when he was 15 years old, plaintiff was involuntarily committed to inpatient mental health treatment at Mills-Peninsula Health Services because he was threatening family members and punched a hole in the wall. Id. at 924. Plaintiff was also twice arrested and placed in the juvenile justice system. During that time, he graduated high school and received his diploma from a residential facility in Nevada in March 2011. Id. at 326. In November 2011, plaintiff (then 18 years old) was seen by Dr. Cecilia Hardey, Ph.D. for a re-evaluation of his SSI benefits. Dr. Hardey administered the Wechsler Adult Intelligence Scale-IV ("WAIS-IV") test resulting in a full scale IQ of 71. Id. at 757. Plaintiff's scores generally placed him in the borderline range of intellectual functioning, which Dr. Hardey diagnosed plaintiff as having. Id. at 757. However, plaintiff's Social Security Administration ("SSA") disability examiner assessed that plaintiff no longer was disabled. Id. at 81, 774-75.

From 2011 to 2012, plaintiff worked for brief periods of time in various positions earning near minimum wage for unskilled work. Id. at 269-71, 314-17, 412. Plaintiff

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found longer term employment with the U.S. Postal Service as an assistant mail handler from December 2012 to January 1, 2015. Id. at 611, 619, 623. According to plaintiff's mother, during this period in time, plaintiff was able to live on his own, manage his own money, and had a girlfriend. Id. at 636.

Plaintiff states that beginning in early 2015 he began experiencing auditory hallucinations and paranoia causing him to leave his apartment and end his employment with the postal service. Id. at 891-901, 635-39. Plaintiff's mother discovered plaintiff to be homeless and brought him to the Sausal Creek Outpatient Stabilization Clinic ("Sausal Creek") for treatment. Id. at 891-901, 635-39. At his intake on May 15, 2015, plaintiff was diagnosed with schizophrenia and prescribed Zyprexa, a drug used to treat mental disorders. Id. at 891, 895. Plaintiff continued to seek treatment at Sausal Creek where he was seen by various providers. Id. at 891-901. Sausal Creek providers assessed plaintiff's global assessment function ("GAF") scores1 to be 49 (May 26, 2015 by Dr. Paul Nichfarm, M.D.), 51 (October 9, 2015),2 and 55 (November 17, 2015 by Dr. James Reichmuth, M.D.). Id. at 904, 909, 914.

In September 2015, plaintiff was evaluated by Dr. Shephali Gupta, Psy.D. on a referral from the SSA. She administered the WAIS-IV test and found plaintiff's full scale IQ to be 81. Id. at 806. Dr. Gupta diagnosed plaintiff with psychotic disorder (not specified), assessed a GAF of 60, and found mild or mild-to-moderate work limitations. Id. at 808. On October 8, 2015, plaintiff visited the Highland Wellness Clinic and was seen by Dr. Andrew Lash, M.D., who diagnosed plaintiff with psychosis and provided plaintiff with a Zyprexa refill script. Id. at 850-55. Dr. Lash noted that plaintiff said he had "[n]o voices, no visual hallucinations" and he "[s]leeps well." Id. at 850. On October

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18, 2015, the SSA referred plaintiff's case to Dr. Paul Klein, Psy.D., who evaluated plaintiff's medical record, including Dr. Gupta's medical opinion, and opined that plaintiff was mildly impaired in some work-related abilities. Id. at 87. The same month, plaintiff was arrested for vandalism and received a mental status health examination at Santa Rita Correctional Facility on October 29, 2015. The evaluation by Leonicia Castro, MFT concluded that plaintiff appeared "in the early stages of a psychotic break" and had "poor insight and judgment, poor understanding of his mental illness." Id. at 888.

From November 2015 until February 2016, plaintiff received treatment at Bay Area Community Services ("BACS"), including medication and case management and therapy with BACS. Id. at 810-918, 974-1047. BACS's non-physician clinicians noted various degrees of severity of plaintiff's condition. For example, one unlicensed worker noted that plaintiff was in a "good" mood and "engaged well" with her. Id. at 984. Yet, in December 2015, plaintiff's Zyprexa prescription was increased from 5mg to 7.5mg after plaintiff reported continuing auditory hallucinations. Id. at 978, 1002. In February 2016, Dr. Fred Phillips, M.D., noted that plaintiff "has problems with concentration due to aud[itory] hallucinations. Hallucinations are persecutory but not presently bothersome." Id. at 979.

BACS referred plaintiff to the Felton Institute's Prevention and Recovery in Early Psychosis ("PREP") program in February 2016. During his time at PREP, three successive therapists managed plaintiff's care: Christina Shinn, MFT, from April 2016 until approximately late June or mid-July 2016 (id. at 1335-36, 1288); Louije Kim, MFT, from July 2016 until late March or early April 2017 (id. at 1252, 1366, 1390-91); and Teresa Shepard, LMFT through the remainder of 2017. Id. at 1390-91, 1433-34. Each of plaintiff's PREP therapists (Shinn, Kim, and Shepard) met with plaintiff, either in person or by phone, on a weekly basis. See generally id. at 1149-445 (encounter notes produced by PREP) During plaintiff's entire duration at PREP, K. Lu Gilligan, N.P., a psychiatric nurse practitioner, met with plaintiff on a bi-weekly or monthly basis to evaluate his symptoms, manage his care, and adjust his prescriptions. See, e.g., id. at

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In May 2016, a psychiatrist hired by the SSA, Dr. Norman Zukowsky, Ph.D., conducted a reconsideration of Dr. Klein's opinion. He examined plaintiff's medical record, including Dr. Gupta's opinion, and determined that plaintiff had moderate limitations in ability to maintain attention and concentration for extended periods. He opined that plaintiff could "make basic decisions independently, as well as avoid common hazards" and that plaintiff "can adapt adequately to typical workplace stresses and changes." Id. at 114.

Plaintiff's intake assessment with PREP did not occur until June 16, 2016. At the intake, plaintiff's mother related to Shinn that plaintiff still talked to himself, isolated himself, and rejected family interaction. Id. at 1151. Shinn also noted that plaintiff had "punched his brother without provocation several months ago." Id. at 1152. Shinn determined that plaintiff was eligible for PREP services and diagnosed him with schizophrenia, paranoid type. Id. at 1154. Plaintiff had several encounters with his PREP therapist as well as structured group therapists around this time and, on June 28, 2016, Shinn again assessed plaintiff as having schizophrenia and an unspecified intellectual disability.3 Id. at 1404. She also assigned plaintiff a GAF of 45. Id. at 1405.

On August 19, 2016, Kim reported that plaintiff participated in a therapy session but "appeared bored at points, evidenced by wandering gaze and speaking minimally when prompted." Id. at 1366. He "appeared unaffected by praise and encouragement; he neither smiled nor verbally responded to praise, though he would nod in agreement occasionally." Id. On September 12th, Kim noted that plaintiff "was wide-eyed and staring into space. He was internally preoccupied and endorsed hearing multiple voices throughout session." Id. at 1363. Plaintiff was "undertalkative, replied to prompts using single words or sentences. Affect was blunted." Id. Plaintiff reported that "his voices

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were at a '7' out of 10 in severity and that he would like to go to the hospital if they reach a '10.'" Id. That same day...

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