CITY OF RIALTO
OPPERIALO
LIABILITY
2024 MAY - 3 AXI1: 09
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY CITY CLLAN RECENE.
1. Claims for death, injury to person, or to personal property must be filed not later than six (6) months after the occurrence (Gov. Code §911.2).
2. Claims for damages to real property must be filed not later than one (1) year after the occurrence (Gov. Code §911.2).
RETURN TO:
3. READ ENTIRE CLAIM FOR BEFORE FILING Rialto City Clerk's Office
4. ATTACH SEPARATE SHEETS, IF NECESSARY, TO GIVE FULL DETAILS Mail: 150 S. Palm Ave., Rialto, CA 92376 Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Stephanie Cantoran
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TELEPHONE NO.
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO.
ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above):
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: January 29, 2024 TIME: 7:18 NAM OPM
2. PLACE OF ACCIDENT (OCCURRENCE) BE SPECIFIC - Describe fully and (if applicable) locate on diagram on reverse side of this sheet.
Where appropriate, give street names and addresses, measurements and landmarks.
E Foothill Blvd and N Meridian Ave in San Bernardino
3. HOW DID DAMAGE OR INJURY OCCUR?
Claimant was on Meridian Avenue northbound, at the intersection with Foothill Blvd. when an on-duty emergency vehicle that was traveling Eastbound on Foothill Blvd. with its siren and lights on, entered the same intersection on a red light and crashed into a Mazda, causing the Mazda to spin out of control and hit Claimant's
4. WERE POLICE AT THE SCENE? • YES NO WERE PARAMEDICS AT THE SCENE? YES • NO
5. WHAT PARTICULAR ACT OR OMISSION DO YOU CLAIM CAUSED THE INJURY OR DAMAGES? Give the name of the city/town employee causing the injury or damage, if known.
As. Brianna Reyes was driving her on-duty vehicle and entered the intersection against the solid red light. Thi aused an impact with the Mazda that resulted in a second impact to Claimant's vehicle
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $ Over $10,000 and NOT a limited civil case HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Property Damage Estimate Amount: $_11,696.41 Item/Date: Ongoing medical treatment Amount: $_ $ 4,848 TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ Over $10,000 and Not a limited civil case ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Item/Date: Future Treatment Costs Amount: $ Over $10,000 and Not a limited civil case Item/Date: Loss of earnings or earning capacity Amount: $_Over $10,000 and Not a limited civil case TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $ Over $10,000 and Not a limited civil case
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: _ N/A NAME:
ADDRESS: ADDRESS:
TELEPHONE: ( ) TELEPHONE: (
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: Arrowhead Regional Medical Center NAME _Central Urgent Medical Care ADDRESS: 400 N Pepper Ave., Colton, CA 92324 ADDRESS: 9695 Baseline Rd Rancho Cucamonga, CA 91730 -
TELEPHONE: (909) 580-1000 TELEPHONE: (909) 941-0920
DATE: TIME: DATE: TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate place of accident by "X" and by showing house numbers or distances to street corners.
If a city/town vehicle was involved, designate by letter "A" location of the City/Town vehicle when you first saw it, and by "B" location of yourself or your vehicle hen you first saw City/Town vehicle; location of City/Town vehicle at time of accident by "A-1" and location of yourself or your vehicle at the time of the ccident by "B-1" and the point of impact by "X"
→ NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
SIDEWALK
HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS T THOSE MATTERS WHICH ARE HEREIN STATED UPON MY INFORMATION AND BELIEF; AND AS TO THOSE MATTERS I BELIEVE THEM TO BE TRUE I CERTIFY (OR DECLARE) UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
SIGNATURE OF CLAIMANT OR AGENT
Elizabeth Ponce De Leon, Esq. May 2, 2024
TYPE OR PRINT NAME DATE
Attorney
RELATIONSHIP TO CLAIMANT
NOTE: PRESENTATION OF A FALSE CLAIM IS A FELONY (CA PENAL CODE 72) RETURN CLAIM TO: RIALTO CITY CLERK'S OFFICE - 150 S. PALM AVE., RIALTO, CA 92376 N. MERIDIAN AVE.
1st Impact
FOOTHILL BLVD. Mazda
→ * 202% MAY -3
V1
Officer CITY OF RIALTO
CITY CILAA RECCIVED
Claimant
2nd Impact
N
MEDICAL PROVIDER
PROVIDER AMOUNT
Arrowhead Regional Medical Center
Pending
(909)580-1000
Central Urgent Medical Care
$648.00
$4,200.00
Los Angeles, CA 9001:
424) 258-0124
Onsyte Imaging - San Bernardino
19360 Rinaldi St # 530 Pending
Porter Ranch, CA 91326
(888) 466-7983
Cedar Pointe Group
6700 Indiana Ave. Ste. 110 Ongoing Treatment
Riverside, CA 92506
(951)394-7545
TY CLErA ECEIVED 2024 MAY -3 ANIl: 09 CITY OF RIALTO
ALPHA CARE MEDICAL GROUP
MPM32
HEALTH INSURANCE CLAIM FORM 1600 Corporate Center Di. Suite Monterey Park, CA 91754 CARRIER
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 1 MEN CARE MEDICAID "TRICARE "GROUP FECA OTHER 16 INSURED'S ID. NUMBER (For Program in tem 1)
X (ICH)
14. INSUREDS NAME (Last Name, First Name, Middle Intie) CANTORAN, STEPHANIE 11:19:2001 F (X] CANTORAN, STEPHANIE
5. PATIENT'S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED [7. INSURED'S ADDRESS (No. StreeT Self X Spouse
CITY ¡ STATE ¡ 8. RESERVED FOR NUCC USE T STATE
SAN BERNARDINO CA SAN BERNARDINO CA
ZIP CODE "TELEPHONE (Include Area Cote) ZIP CODE™ TELEPHONE (incide Area Code) 92410 92410
9. OTHER INSURED'S NAME (Last, Fist, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: T51. INSURED'S POLICY GROUP OR FECA NUMBER
8. OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSUREO'S DATE OF BIRTH MM
X| NO 11:19:2001 M.
B. RESERVED FOR NUGG USE b. AUTO ACCIDENT? D. OTHER CLAIM ID (Designated by NücG) PLACE (State)
YES NO
C. RESERVED FOR NUCC USE c. OTHER ACCIDENT? -E. INSURANCE PLAN NAME OR PROGRAM NAME
YES XI NO MOLINA
: d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designaled by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN? YES L NO If yes, complete items 9, 9a and 9d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. [13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE T
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE 1 authorize the release of any medical or ather information authorize payment of medical benefite to the undersigned necessary to process this clsim, I also request payment of govemment benalits either to myself or 1o the party who physician or euppler for services desorbed below. accopts assignment below.
SIGNED SIGNATURE ON FILE DATE 06/28/2021 SIGNED SIGNATURE ON FILE
14. DATE OF CURRENT LNESS. INJURY, oF PREGNANCY T15. Other Date 16. DATES PATIENT UNABLE TO WORK IN CURRENT SECUPATION (LMP) DD YY MM
¡QUAL! FROM TO
QUAL
:17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 117a.] 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM
h7bl FROM
NPI
19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 120, OUTSIDETAB? S CHARGES
YES X NO
21. DIÄGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate A to service line helow (24E)) ICD indO 22. RESUEMISSION CODE ORIGINAL REF. NO.
23. PRIOR AUTHORIZATION NUMBER
E. L F. L
24. A DATE(S) OF SERVICE B. C. D. PROCEDURES, SERVICES, OR SUPPLIES E.
From To PLACE OF (Explain Unusual Circumslancas) DIAGNOSIS DAYS EPSOT ID.
OR RENDERING
DD YY MM DD YY SERVICE EMG 'GPT/HCPCS MODIFIER POINTER SCHARGES Fanly QUAL PROVIDER ID.# UNITS Pier
2|01:30: 24 101:30: 241 20 99214 125. 1 ABCD 202. 00. 11 NPE
PHYSICIAN OR SUPPLIER INFORMATION
з 01: 30: 24 101:301 24 | 20 $9088 ABCD 30.001 | NPI
4/01:301 24 |01:30: 24| 20 99401 25 ; _D 50,09 1 1
= 01:30: 24 | 01:30: 24 96372 | ABCD 86.09 2 1
NDC Qual: N4 NDC Code: 06332316202 NDC Charge: 50.00 NDC Qty: 1 NDC Meas: ML 6|01:30: 24 101:30: 241 20 J1885 L ABCD 1 280.00 1 1
NPI
25 FEETA TAX TO NUMBER 728. PATIENTS ACCOUNT'NO. IT ACCEPT RESEMENTE T28. TOTAL CHARGE 25. AMOUNT PAID 130. Rsid Ter NUCC use (For govt. claims, see back)
YE$ X NO $648.00 $0.00
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32. SERVICE FACILITY LÖCĂTION FORMATION *33, BILLING PROVIDER INFO & PH# 1626) 791 9004
INCLUDING DEGREES OR CREDENTIALS
(I certify that the statements on the reverse
apply to this bill and are made a part thereof.) Central Urgent Medical Care Central Urgent Medical Care 9695 Baseline Road Ро Box 41032
Nguyen, MD, Thuy T Rancho Cucamonga, -CA. 91733-131 Pasadena, CA 91114 SIGNED 01/31/2024 DATE
NUCC Instruction Manual available at: www.nucc.org APPROVED OMB-0938-1197 FORM 1500(02-12) Page: 1 of 1
Central Urgent Central Urgent Medical Care
Medical Care 9695 Baseline Rd.
Rancho Cucamonga CA, 91730
Ph: 909-941-0920 Fx: 909-941-0940
STEPHANIE CANTORAN
Patient ID: 108597984 DOB Sex: F Account No.:
Encounter ID: 295206674 Encounter Date: 01/30/2024
Encounter Type: Office Visit
SUBJECTIVE:
History Of Present 22 year old female presented with neck and front chest pain sip accident yesterday. Pt states that she went to the liness: ER and was not given any medication.
Allergies: No known allergies
Current Medications: Currently not taking medications
OBJECTIVE:
Vital Signs: Height: 61.00 in
Weight: 231.30 Ibs
BMI: 43.70
Blood Pressure: 104/70 mmHg
Temperature: 98.20 F
Pulse: 91 beats/min
Resp. Rate: 16
Last Menstrual Period: 12/20/2023
SpO2 (%): 98.00
Custom Vital Signs Field: GA
Physical Exam:
Ears, Nose, Mouth, and Throat: Symmetrical facial movement. Sclera white, Mucosa is pink, no lesions, Mout and Oropharynx: no exudate or redness noted. Ear canal: no redness or bulging Gastrointestinal (Abdomen): soft, non tender, non distended, normoactive bowel sounds, no organomegaly ASSESSMENT: - 9
Diagnosis: ICD-10 Codes:
1)E669; Obesity, unspecified CF RIALTO
2)V892XXA; Person injured in unspecified motor-vehicle accident, traffic, initial encounter 3)M542; Cervicalgia|
4)Z719; Counseling, unspecified
PLAN:
Procedures: 1) 99204; New Patient EXPANDED
Medications: Cyclobenzaprine HCI 10 MG Oral Tablet; Take 1 tablet orally daily; Oty: 10; Refills: 0 Ibuprofen 600 MG Oral Tablet; Take 1 tablet orally 2 times a day Take as needed; Oty: 14; Refills: 0 predniSONE 20 MG Oral Tablet; Take 1 tablet orally daily; Qty: 5; Refills: 0 Patient Instructions: Take medication as rxed. Follow up with pop/cuc. Push fluid as tolerated. Go to the ER if the sxs fails to improve or worsens. Pt verbalized understanding.
[Electronically Signed] - Date: 1/30/2024 6:43:58 PM Date: _ [Physician Extender]: Catherine Ajala-Staats, NP, FNP, DNP [Provider]: Catherine Ajala-Staats, NP, FNP, DNP 4/29/24, 11:47 AM Luminary - Medical Invoice3 (Jezelle) - Google Sheets Luminary Health
LUMINARY 1086 S Fairfax Ave
Health Los Angeles, California 90019 DATE: April 29, 2024 (424) 258-3318
INVOICE#: 52267703662
ill To: Cantoran, Stephanie Patient: Cantoran, Stephanie :/o Dayan Houman Professional Law Corporatior Date of Injury: 1/29/2024 6330 S San Vicente Blvd, Suite 40D
Los Angeles, California 90048 Remit to:
Luminary Health
Tax ID #
1086 S Fairfax Ave
Los Angeles, California 90019
Physician Due Date
Michael Ghods, MD Lien
Dt of Service Description Total Fee Paid Ad] Balance (PR) 2/25/2024 Initial visit $1,500.00 $1,500.00
3/19/2024 Folfow up visit $1,350.00 $1,350.00
4/10/2024 Follow up visit $1,350.00 $1,350.00
2021:
CITY CF
-ir.
- ri
CILAX AMI: 10 RIALTO
TOTAL $ 4,200.00
Visit 1 Visit 2 Visit 3
CPT 99205 99214 99214
Thank you!
https://docs.google.com/spreadsheets/d/1v3HSWj9A4E7iWbFjQAjwb6EuVXyb2lJvQ_ExN7sxCM/edit#gid=365577426 1/1 Re: Stephanie Cantoran
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
Patient name: Stephanie Cantoran
DOB:
Date of examination: 02/25/2024
Date of injury: 1/29/2024
Stephanie Cantoran was seen on 02/25/2024. The following treatment plan was formulated based on my medical evaluation and the history provided by the patient.
The patient provided the following medical history to the best of their recollection.
HISTORY OF PRESENT ILLNESS
Injury history:
The patient is a 22-year-old female who presents for evaluation of injuries sustained secondary to a motor vehicle collision that occurred on 1/29/2024.
Prior to the incident, the patient was in a normal state of health. RIALTO Present treatment to date:
The patient reports being seen for evaluation of these symptoms at the emergency room. The date of evaluation was 1/29/2024. X-ray of chest was performed. The patient was prescribed
Present complaints:
The patient reports neck pain described as intermittent, not radiating, aching, and 4 out of 10 (moderate). The patient reports exacerbation of the symptoms with rotational movement of the neck. The patient avoids lifting anything heavy due to fear of worsening symptoms. The pain does not interfere with sleep.
The patient denies elbow or wrist pain.
The patient reports no change in motor function in the upper extremities. The patient reports no change in sensory function of the bilateral upper extremities. There are no contusions of the bilateral upper arms, forearms, or hands. niTr
Re: Stephanie Cantoran DOB
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
The patient denies headaches.
The patient denies current nausea, denies vomiting.
The patient denies middle back, lower back, or hip pain.
The patient denies knee or ankle pain.
The patient reports no change in motor function in the lower extremities. The patient reports no change in sensory function of the bilateral lower extremities. There are no contusions of the bilateral thighs, lower legs, or feet.
The patient denies change in urinary continence, denies change in fecal continence.
The patient denies saddle anesthesia.
The patient denies chest or rib pain.
The patient reports anxiety, denies decreased concentration, reports being more easily TY irritated, reports depressed mood (when compared to before the incident), and denies OF over vigilance. The patient reports no flashbacks. There have been no distressing c dreams since the incident. There have been no sleep disturbances.
RIALTO
MEDICAL HISTORY AMI: 10
Past medical history: The patient reports none.
Past surgical history: The patient reports none.
Medications: Estarylla
Allergies: Mangos
Social history: Does not smoke tobacco,
REVIEW OF SYSTEMS
Constitutional/General: No weight loss, fever or chills.
Ears/Eyes/Nose/Throat: No sneezing, congestion, runny nose or sore throat. ---
Re: Stephanie Cantoran
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
Skin: No rash or itching.
Cardiovascular: No edema.
Respiratory: No cough or sputum.
Gastrointestinal: No anorexia, diarrhea, constipation, abdominal pain.
Genitourinary: No burning on urination or blood in the urine.
Neurological: No syncope, paralysis, ataxia.
Hematologic: No bleeding.
Psychiatric: No hallucinations.
Endocrine: No diaphoresis, cold or heat intolerance. No polyuria or polydipsia....: 2024 MAY -9 CITY OF Allergy/Immunology: No hives, eczema or rhinitis.
RIALTO
PHYSICAL EXAMINATION AMII: 10
Stephanie Cantoran is a well-developed, well-nourished 22-year-old female in no apparent distress, whose stated height is 5'1 ft and stated weight is 230 pounds. The patient is right-hand dominant.
The patient is awake, alert and oriented to self, place, and time.
The patient's musculoskeletal examination is described in detail below.
Cervical spine:
On examination patient has tenderness to palpation at the cervical paraspinal, trapezius, and levator scapulae musculature up and down, bilaterally. Motor strength of the cervical musculature is guarded, secondary to pain. Patient's cervical range of motion is limited with flexion, extension, and rotation, secondary to pain.
B'H
Re: Stephanie Cantoran
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
Motor examination of the bilateral upper extremities is 5/5 and symmetric. Sensation is symmetric and intact to light touch in the bilateral upper extremities.
Thoracic spine:
Patient had no tenderness to palpation of the thoracic paraspinal musculature.
Range of motion was intact.
Lumbar spine:
Patient had no tenderness to palpation of the lumbar paraspinal musculature.
Range of motion was intact.
ASSESSMENT & DIAGNOSIS
Stephanie Cantoran is a 22-year-old female presenting following a motor vehicle CITY OF collision. After taking a history from the patient, including the mechanism of injury and current symptoms, and having examined the patient, I have arrived at the following diagnoses listed below. • RIALTO
S16.1XXA STRAIN OF MUSCLE, FASCIA AND TENDON AT NECK LEVEL, I 11:10 F43.0 ACUTE STRESS REACTION
CPT 99205 OFFICE/OUTPATIENT VISIT NEW (MOD 95, LOC 02)
Based on the information provided to me and my objective findings it appears that the patient's complaints are likely related to the 1/29/2024 incident.
TREATMENT PLAN & DISCUSSION
The above diagnoses were discussed with the patient and conservative therapy was recommended, with close follow up. Emergency precautions were given to the patient in case the symptoms changed or suddenly worsened.
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
The patient was advised to begin physical therapy or a chiropractic regiment 3-4 times per week for 4-6 weeks in efforts to reduce pain and/or spasm as well as improve range of motion.
Ibuprofen 600 mg one tablet every 6 hours as needed (indication: pain) for 3 weeks was recommended to the patient. Patient was directed to use hot compress as needed.
Patient was advised to avoid heavy lifting and strenuous exercise.
The patient will follow up with me in approximately 4 weeks for re-evaluation and, in the meantime, on an as needed basis.
At this time I do not recommend musculoskeletal imaging given the temporal proximity of the symptoms to a known precipitant. Depending on the development of the patients symptoms over the next 4-12 weeks of conservative care, recommendations for further imaging and/or referral to pain management or surgical specialist may be made.
The above treatment plan was discussed with the patient who demonstrated understanding and intention to comply. 2024
CITY
If you have any further questions, please do not hesitate to contact me at my office. •320 - oF
Kathy Chau PA Lic# 63524 assisted in the examination and preparation of this report.
RIALTO
Electronically Signed: DAVID GHODS, DO 11:10
General Medicine
Date: 02/25/2024
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
Patient name: Stephanie Cantoran
DOB: 11/19/2001
Date of examination: 03/19/2024
Date of injury: 1/29/2024
Stephanie Cantoran was seen on 03/19/2024. The following treatment plan was formulated based on my medical evaluation and the history provided by the patient.
The patient provided the following medical history to the best of their recollection.
HISTORY OF PRESENT ILLNESS
Injury history:
The patient is a 22-year-old female who presents for evaluation of injuries sustained CITY secondary to a motor vehicle collision that occurred on 1/29/2024.
Prior to the incident, the patient was in a normal state of health.
Present treatment to date:
The patient reports being seen for evaluation of these symptoms at the emergency room. The date of evaluation was 1/29/2024. X-ray of chest was performed. The patient was prescribed. The patient reports that they are receiving therapy with a chiropractor or physical therapist and avoiding rigorous exercise.
Present complaints:
The patient reports neck pain described as intermittent, radiating to the left upper arm, aching, and 4 out of 10 (moderate). The patient reports exacerbation of the symptoms with rotational movement of the neck. The patient avoids lifting anything heavy due to fear of worsening symptoms. The pain does not interfere with sleep.
The patient denies elbow or wrist pain.
The patient reports no change in motor function in the upper extremities. The patient reports no change in sensory function of the bilateral upper extremities. There are no contusions of the bilateral upper arms, forearms, or hands.
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
The patient denies headaches.
The patient denies current nausea, denies vomiting.
The patient denies middle back, lower back, or hip pain.
The patient denies knee or ankle pain.
The patient reports no change in motor function in the lower extremities. The patient reports no change in sensory function of the bilateral lower extremities. There are no contusions of the bilateral thighs, lower legs, or feet.
The patient denies change in urinary continence, denies change in fecal continence.
The patient denies saddle anesthesia.
The patient denies chest or rib pain.
The patient reports anxiety, denies decreased concentration, reports being more easily. irritated, reports depressed mood (when compared to before the incident), and denies over vigilance. The patient reports no flashbacks. There have been no distressing ALTO dreams since the incident. There have been no sleep disturbances. : 11
PHYSICAL EXAMINATION
Stephanie Cantoran is a well-developed, well-nourished 22-year-old female in no apparent distress, whose stated height is 5'1 ft and stated weight is 230 pounds. The patient is right-hand dominant.
The patient is awake, alert and oriented to self, place, and time.
The patient's musculoskeletal examination is described in detail below.
Cervical spine:
On examination patient has tenderness to palpation at the cervical paraspinal, trapezius, and levator scapulae musculature up and down, bilaterally. Motor strength of
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
the cervical musculature is guarded, secondary to pain. Patient's cervical range of motion is limited with flexion, extension, and rotation, secondary to pain.
Motor examination of the bilateral upper extremities is 5/5 and symmetric. Pain is reproducible with passive abduction of the right upper extremity at 110 degrees. Pain is reproducible with passive abduction of the left upper extremity at 110 degrees.
Sensation is symmetric and intact to light touch in the bilateral upper extremities.
Thoracic spine:
Patient had no tenderness to palpation of the thoracic paraspinal musculature.
Range of motion was intact.
Lumbar spine:
207h
Patient had no tenderness to palpation of the lumbar paraspinal musculature.
CITY OF
Range of motion was intact.
Bilateral upper extremity:
There is no erythema or discoloration of the skin. There is no edema. 10 Shoulder range of motion limited as above. There is no tenderness to palpation over the acromioclavicular joint or long head of the biceps. There is no painful cross body adduction. Lift off test is negative. Empty can test is negative. There is no tenderness to palpation over the humerus. No anatomical snuff box tenderness. Grip strength is
ASSESSMENT & DIAGNOSIS
Stephanie Cantoran is a 22-year-old female presenting following a motor vehicle collision. After taking a history from the patient, including the mechanism of injury and current symptoms, and having examined the patient, I have arrived at the following diagnoses listed below.
S16. 1XXD STRAIN OF MUSCLE, FASCIA AND TENDON AT NECK LEVEL
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
M54.12 RADICULOPATHY, CERVICAL REGION
F43.10 POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED
CPT 99214 OFFICE/OUTPATIENT VISIT EST (MOD 95, LOC 02)
Based on the information provided to me and my objective findings it appears that the patient's complaints are likely related to the 1/29/2024 incident.
TREATMENT PLAN & DISCUSSION
The above diagnoses were discussed with the patient. Emergency precautions were given to the patient in case the symptoms changed or suddenly worsened.
The patient was advised to continue his physical therapy or chiropractic regiment in efforts to strengthen the muscles surrounding the injury and improve range of motion.
Ibuprofen 600 mg one tablet every 6 hours as needed (indication: pain) for 3 weeks was recommended to the patient. Patient was directed to continue use of hot compress as needed. Patient was advised to avoid heavy lifting and strenuous exercise.
The patient will follow up with me in approximately 4 weeks for re-evaluation and, in the meantime, on an as needed basis.
The patient's symptoms have persisted past the time of expected recovery. Therefore, I recommend MRI of the cervical spine.
At this time I will refer the patient to psychological services as the patient is exhibiting clinically significant symptoms of post traumatic stress disorder.
The above treatment plan was discussed with the patient who demonstrated understanding and intention to comply.
If you have any further questions, please do not hesitate to contact me at my office.
Kathy Chau PA Lic# 63524 assisted in the examination and preparation of this report.
Electronically Signed: DAVID GHODS, DO
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
General Medicine
Date: 03/19/2024
2024 MAY - 3 AMII: 10 CITY OF RIALTO
LUMINARY
Health
1086S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
Patient name: Stephanie Cantoran
DOB: 11/19/2001
Date of examination: 04/10/2024
Date of injury: 1/29/2024
Stephanie Cantoran was seen on 04/10/2024. The following treatment plan was formulated based on my medical evaluation and the history provided by the patient.
The patient provided the following medical history to the best of their recollection. 202%
HISTORY OF PRESENT ILLNESS
Injury history:
LTO
The patient is a 22-year-old female who presents for evaluation of injuries sustained 10 secondary to a motor vehicle collision that occurred on 1/29/2024.
Prior to the incident, the patient was in a normal state of health.
Present treatment to date:
The patient reports being seen for evaluation of these symptoms at the emergency room. The date of evaluation was 1/29/2024. X-ray of chest was performed. The patient was prescribed. The patient reports that they are receiving therapy with a chiropractor or physical therapist and avoiding rigorous exercise.
Present complaints:
The patient reports neck pain described as intermittent, radiating to the left upper arm, aching, and 6 out of 10 (moderate). With movement, the pain becomes more sharp. The patient reports exacerbation of the symptoms with rotational movement of the neck. The patient avoids lifting anything heavy due to fear of worsening symptoms. The pain does not interfere with sleep.
The patient denies elbow or wrist pain.
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
The patient reports no change in motor function in the upper extremities. The patient reports no change in sensory function of the bilateral upper extremities. There are no contusions of the bilateral upper arms, forearms, or hands.
The patient denies headaches.
The patient denies current nausea, denies vomiting.
The patient denies middle back, lower back, or hip pain.
The patient denies knee or ankle pain.
2024
The patient reports no change in motor function in the lower extremities. The patient CITY OF reports no change in sensory function of the bilateral lower extremities. There are no ...4 contusions of the bilateral thighs, lower legs, or feet.
The patient denies change in urinary continence, denies change in fecal continence. AMI: 10 RIALTO The patient denies saddle anesthesia.
The patient denies chest or rib pain.
The patient reports anxiety, denies decreased concentration, reports being more easily irritated, reports depressed mood (when compared to before the incident), and denies over vigilance. The patient reports no flashbacks. There have been no distressing dreams since the incident. There have been no sleep disturbances.
PHYSICAL EXAMINATION
Stephanie Cantoran is a well-developed, well-nourished 22-year-old female in no apparent distress, whose stated height is 5'1 ft and stated weight is 230 pounds. The patient is right-hand dominant.
The patient is awake, alert and oriented to self, place, and time.
The patient's musculoskeletal examination is described in detail below.
Cervical spine:
LUMINARY
Health
1086S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
On examination patient has no tenderness to palpation at the cervical paraspinal, trapezius, or levator scapulae musculature. Motor strength of the cervical musculature is guarded, secondary to pain. Patient's cervical range of motion is limited with flexion, extension, and rotation, secondary to pain.
Motor examination of the bilateral upper extremities is 5/5 and symmetric. Pain is not reproducible with passive abduction of the upper extremities..... Sensation is symmetric and intact to light touch in the bilateral upper extremities.
Thoracic spine:
Patient had no tenderness to palpation of the thoracic paraspinal musculature.
Range of motion was intact.
2024 MAY - 3
Lumbar spine:
CITY OF RIALIS
Patient had no tenderness to palpation of the lumbar paraspinal musculature.
Range of motion was intact. ASH: 10
Bilateral upper extremity:
There is no erythema or discoloration of the skin. The patient's upper arm, forearm, and hands are symmetric and there is no edema.
Range of motion at the bilateral shoulder is intact. There is no tenderness to palpation over the acromioclavicular joint or long head of the biceps. There is no painful cross body adduction. Lift off and empty can tests are negative.
Range of motion at the bilateral elbow is intact. There is no tenderness to palpation over the olecranon process, lateral epicondyle, or medial epicondyle.
Range of motion at the bilateral wrist is intact. There is no tenderness to palpation over the distal end of the radius, ulnar head, or ulnar styloid process.
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
There is no tenderness to palpation over the humerus. There is no tenderness to palpation over the shaft of the radius or ulna. There was no tenderness to palpation of the bones of the bilateral hands. No anatomical snuff box tenderness. There is no tenderness to palpation over the MCP, PIP, or DIP.
Grip strength is intact.
ASSESSMENT & DIAGNOSIS
Stephanie Cantoran is a 22-year-old female presenting following a motor vehicle collision. After taking a history from the patient, including the mechanism of injury and current symptoms, and having examined the patient, I have arrived at the following diagnoses listed below.
S16. 1XXD STRAIN OF MUSCLE, FASCIA AND TENDON AT NECK LEVEL e.- 2024 MAY - 9 CITY OF M54.12 RADICULOPATHY, CERVICAL REGION
F43.10 POST-TRAUMATIC STRESS DISORDER, UNSPECIFIED
M99.71 CONN TISS AND DISC STENOSIS OF INTVRT FORAMIN OF CER RIALTO M48.02 SPINAL STENOSIS, CERVICAL REGION AN1 : 11
CPT 99214 OFFICE/OUTPATIENT VISIT EST (MOD 95, LOC 02)
Based on the information provided to me and my objective findings it appears that the patient's complaints are likely related to the 1/29/2024 incident.
TREATMENT PLAN & DISCUSSION
The above diagnoses were discussed with the patient. Emergency precautions were given to the patient in case the symptoms changed or suddenly worsened.
The patient was advised to continue his physical therapy or chiropractic regiment in efforts to strengthen the muscles surrounding the injury and improve range of motion.
Ibuprofen 600 mg one tablet every 6 hours as needed (indication: pain) for 3 weeks was recommended to the patient. Patient was directed to continue use of hot compress as needed. Patient was advised to avoid heavy lifting and strenuous exercise.
LUMINARY
Health
1086 S Fairfax Ave
Los Angeles, California 90019
Tel: (424) 326-1361
The patient will follow up with me in approximately 4 weeks for re-evaluation and, in the meantime, on an as needed basis.
At this time I will refer the patient to psychological services as the patient is exhibiting clinically significant symptoms of post traumatic stress disorder.
At this time I will refer the patient to pain management specialist as the patient is exhibiting persistent symptoms of pain.
The above treatment plan was discussed with the patient who demonstrated understanding and intention to comply.
If you have any further questions, please do not hesitate to contact me at my office.
Anthony Rizzuto Jr., PA-C assisted in the examination and preparation of this report.
Electronically Signed: DAVID GHODS, DO
General Medicine
Date: 04/10/2024
STATE OF CALIFORNIA
DEPARTMENT OF CALIFORNIA HIGHWAY PATROL
TRAFFIC COLLISION REPORT
CHP 555 Page 1 (Rev. 4-11) OPI 060 Page 1 ol 4
ENECIAL CONCITIONS CITY AUSCIA, DISTRICT LOC
TRISNICERA
3 ¡ SAN BERNARDINO
HNCH AALED ¡ COLENTY REPORTIN DISTRICY SEAT OAF OF WEER TOW AWAY On-Duty Emergency Vehicle 0 SAN BERNARDINO
8 OT W T F 8 [XI YES
COLLIBIO OOCURRED ÓN ĐAY YEAR TIME (2430) NCIC # OFFICER LD E FOOTHILL BLVD 01/29/2024 0718 3610 50772
MILEPOST SHEORMATION TOPS COGROINATES" PHOTOGRAFHS BY []NONE FEFTAALES OF J LATITLOE 34.106766955144Dwpruce - «117.352898848464 Christian Phillips
X]AT INTERSECTON VITH • STATE HWY REL
N MERIDIAN AVE
UR. FEETMLES OF [XI YEO
DR VERS LICANSE NUMBER STATE OLABS AR BAG VEN. YEAR MAKEMODELICOLOR EXPLORER LICENGE MASMOCH STArE PARTY
FORD
01 CA L G 2018 BLACK
1410339 CA
ORNER MANE, (FARST. AADOLE, LAST)
BRIANNA REYES-ON DUTY EMERGENCY VEHICLE DWNERS NANE
ISAME AS DAIVER
STREET ADDRESS CITY OF RIALTO
428 N WILLOW AVE OMNER'S ADDRESS LISAME AS DRINER
CITVBTAYE(2
VEH 150 S RIALTO AVE RIALTO CA 92376
RIALTO CA 92376 BISPOSTION GE VENEE ON ORDERS OF. DRIVER
IXOFFICER (OTHER
BEK EYES WEIGHT RACE TOWED OWNERS REQUEST
F BRO BRO 5 7 150 PRIOR MECHANICAL DETECTO (REFER TO NARRATIVE
XI NONE APPARENT
HOME PHICHNE BUSESS PHOWE VEH-CLE IDENTIFICATION NUMBEN 1FM6K8ARXJGC17586
(909)820-2550 VENICLE TYPE DENCRIBE VEHICLE DAHAGE SHADE IN DAMAOED AREA INSURANCE CARSUER POUCY NUMBER *lUNK. D HONE IMINNOR
CITY OF RIALTO 48
(X) мо0. • MAJCH ROLL OVER
ĐIR LE ON STREEY ON HIDHNAY SPEED LAKT
TRAVEL CA DOT
E WEST FOOTHILL AVE ( X2
50 CAL 7 "CPIPSC
DRIER'S LICENSE NUMBER SYATE KLAS$ AIR BAG BAFE TY COLW. VEH YEAR MAKE/MODBLCOLOR SPORT TRUCKLICENNE MIMBER STATE PARTY
MAZDA
02 CA G 2008
MAROON CA
DRVER KANE PIRST, MODLE LAST)
[X] DINA MACHAN COLO OMMERS NAME IX) SAME AS DRIVER
BTREET ADDRESS DINA MACHAN COLO
KRINER'S ADORESA XI SAME AS DRIVER
CITY/STATE/ZIP
FONTANA CA 92335 DISPOBITION OF VEHICLE ON CROERS OF IXTOFFKER EORVER TOTNER SEX THAS lEVES REGHT (WEICHT RACE TOWED OWNERS REQUEST
F BRO BLK 5* 3 145 H PROR MECHANICAL DEFECTS LX/ NONE APPARENT REFER TO NARRATIVE
OTHER HOME PHONE BUSIHE SS PHONE VEHICLE IDENTIFICATION HUNBER JM3TB28V680125204
VENCLE IYPE DESCRBE VEMICLE DANAGE SIADE IN DRAAGRD AREA INSURANCE CARRIER POUCY NUWGER LJUNK. • LINONE _ MNOR
LOYA CASUALTY 07 2 *
MOD XİNAOR L]BOLLOVER
TON SIREET OR HAINAY TSPEEO UMIT
TRAVEL CA
NORTH MERIDIAN AVE 25 **
CAL! СМІрВС МОИХ
DRIVER'S UCENSE NUMBER CLASS NIR BAC SAFETY EQUIP VEN VEAR IMAKE/MODELCOLOR CIVIC LICENSE M SURER STATE PARTY
HONDA
03 CA E 2022
RED SKOZ035 .CA
DREVER NAME (FIST, MOOLE LASTI
X STEPHANIE CANTORAN OWNER S NAME [X SAME AS DRIVER
STREET AODAEAS STEPHANIE CANTORAN
DWHER'S AGOREAS [X) SAME AS DRIVER
CITY ASTATE/ZW 243 N MERIDIAN AVE 271 SAN BERNARDINO 92410 SAN BERNARDINO 92410 DISPOSITRON OF VEHICLE ON ORDERS CF [X OFFICER ILORVER TOTHER
SEX MAR EVES EIGHT WEKAHT HACE TOWED OWNERS REQUEST
F BRO BRO 5- 2 230 H PRIOR MECHANICAL DEFECTS: XINONE APPARENT .)RETER TO NAARATIVE
OTHER HOME PHONE SUSNESS PHONE
VENCLE IENTIICATOY NUMBER. 2HGFE2F50NH509715
VERICLE TYPE DESCRIBE VEHICLE DASHUE SHADE IN CANADÉD AREA INSTRANCE CAPRER 'UNK •]NONE [X] MINOR
GEICO MOD MAJOR ROLL-OVER
HR OI TON STREET OR HIGHWAY TEPEED LANT
MAVE CA DOT
N NORTH MERIDIAN AVE 40 CAL-Г
Topaper
PRÉPARER'S HAME DESPATCH NOTIFEO REVEWERS NAMÉ GATE REVIEWED Mata 50772 KI YES LINO NUA Acosta, Daniel 02/06/2024
An Internat d Agency 2015 CH$ 555 2522 80%
STATE OF CALIFORNIA
DEPARTMENT OF CALIPORNIA HIGHWAY PATROI
TRAFFIC COLLISION CODING
CHP 555 Page 2 (Rev. 4-11) OPI 060
of 4
DATE OF COLLBION INO DAY YEARY TRAE (2400) OFFICER : O
01/29/2024 0718 3610 50772 2024-00011760
OWNER'S HAME OWNER S ADORESS
NOTIFIED
PROPERTY /YES L NO
DAMAGE TDESCAPTION OF BANGE
SEATING POSITION SAFETY EQUIPMENT AIR BAG INATTENTION CODES OCCUPANTA CHILD RESTRAINI B - UNKNOWN A.. CELLPHONE HANDHELD ¡A- NONE IN VEHICLE Q - IN VEHICLE USED 4 • AIR BAG DEPLOYED 8 - CELLPHONE HANDBFREE 8- UNKNOWN R - IN VEHICLE NOT USED M: AIR BAG NOT DEPLOYED C • ELECTRONIC EQUIPMENT IC - LAP BELT USED 5. IN VEHICLE USE UNKNOWN N• OTHER D- RADIO/CD O - LAP BELT NOT USED T- IN VEHICLE IMPROPER USE P - NOT REQUIRED 5. RACKING
1. DRIVER E - SHOULDER HARNESS USED U. NONE IN VEHICLE
123 2 TO # •PASSENGERS EJECTED FROM VEHICLE F - EATING
F: SHCAJDER HARNESS NOT USED G - CHILDREN
45 8 7 • STATION WAGON REAR G• LAPISHOULDER HARNESS USED MLC BICYCLE MELHET 0 - NOT EJECTED H- ANIMALS & - REAR OCC. TRK. OR YAN IM. LAPISHOULDER HARNESS NOT USED 1. FULLY EJECTED
DRIVER PASSENGER I- PERSONAL HYGIENE
$- POSITION UNKNOWN J. PASSIVE RESTRAINT USED V. NO X - NO 2 - PARTIALLY EJECTED $- READING 7 0- OTHER K-PASSIVE RESTRAINT NOT USED 3- UNKNOWN
W+ YES Y. YES K-OTHER
P - NOT REQUIRED
ITEMS MARKED BELOW FOLLOWED BY AN ASTERISK (') SHOULD BE EXPLAINED IN THE NARRATIVE.
PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES SPECIAL INFORMATION MOVEMENT PRECEDING LIST NUMBER (I) OF PARTY AT FAULT 01 02 03 01 0203
COLLION
01 A XIA CONTROLS FUNCTIONING A HAZARDOUS MATERIAL A STOPPED 21453(A) VC-) 2 мо B CONTROLS NOT FUNCTIONING" B CELL PHONE HANDHELD IN USE XIX X B PROCEEDING STRAIGHT B OTHER IMPROPER DRIVING* C CONTROLS OBSCURED C CELL PHONE HANDSFREE IN USE C RAN OFF 8OAD.
D NO CONTROLS PRESENT / FACTOR" CELL. PHONE NOT IN USE D MAKING RIGHT TURN C OTHER THAN DRIVER* TYPE OF COLLATION E SCHOOL, BUS RELATED E MAKING LEFT TURN D UNKNOWN* A HEAD-ON F ZA PY MOTOR TRUCK COMED LE MAKING U TURN B SIDE SWIPE 32 FT TRAILER COMBO G BACKINO
© REAR END H SLOWING / STOPPINO
WEATHER (MARK 1 TO 2 ITEMS) XID BROADSIDE PASSING OTHER VENICLE XIA CLEAR E HIT OBJECT J 4 CHANGING LANES
CLOUDY F OVERTURNED IK K. PARKING MANEUVER
C RAIHING IG VEHICLE / PEDESTRIAN L L ENTERING TRAFFIC
D SNOWING H OTHERE M OTHER ONSAFE/TURNING
E FOG /VISIBALTY FT. N XING INTO OPPOSING LANE
F OTHER': MOTOR VEHICLE INVOLVED WITH O PARKED
G WIND A NON - COLLIBION P MERGING:
LIGHTING PEDESTRIAN Q TRAVELING WROND WAY
XIA DAYLKHT C OTHER MOTOR VEHICLE OTHER ASSOCIATED FACTOR(S) TR OTHER, — B DUSK - DAWN D MOTOR VEHICLE ON OTHER ROADWAY 01.02/03 (MARK 1 TO 2 ITEMS)
C DARK - STREET LIGHTS E PARKED MOTOR VEHIOLE DECTIN YELATION
D DARK - NO STREET LIGHTS F TRAIN
- NO
E DARK-STREET LIGHTS NOT G BICYCLE VC SIROTIOM FIOLATION FUNCTOMING H ANIMAL: 23152(A) VC-M
SOBRIETY - URUG
ROADWAY SURFACE VC SECTION VOLTON
8is 01, 02,03 PHYSICAL
XIA DRY I FIXED OBJECT BIND (MARK + TO 2 ITEMS)
B WET X HAD NOT BEEN DRINKING
SNCWY - ICY J OTHER OBJECT. E VISION OBSCUREMENT: HBD - UNDER THE INFLUENCE D SLIPPERY (MUDDY, DILY. ETC) F INATTENTION: C HBD - NOT UNDER INFLUENCE* ROADWAY CONDITIONS G STOP & GO THAFFIC HB0 - INPAIRMENT UNKNOWN* (MARK 1 TO 2 ITEMS) PEDESTRIAN'S ACTIONS H ENTERING / LEAVING RAMP E UNDER DRUG FLUENCE" HOLES, DEEP RUT X. A NO PEDESTRIANG INVOLVED_ PREVIOUS COLLISION EMPAIRMENT -PHYSCAL:
B LOOSE MATERIAL ON ROADWAY B CROSSING IN GROSSWALK - J UNFAMILIAR WITH ROAD G MPAIRMENT NOT KNOWN OBSTRUCTIH ON ROADWAY" AT INTERSECTION K DEFECTIVE VEH. EQUIP. стеб M NOT APPLICABLE D CONSTRUCTION - REPAIR ZONE C CROSSING IN CROSSWALK -NOT 1 SLEEPY / FATIQUED'
REDUCED ROADWAY WITH AT INTERGECTION
F FLOODED' CROSSING. NOT IN CROSSWALK L UNINVOLVED VEHICLE "G OTHER". E IN ROAD • INCLUDES SHOULDER M OTHER*
XIH NO UMUSUAL CONDITIONS F NOT IN ROAD X IN NONE APPARENT APPROACHING / LEAVING SCHOOL BUS O RUNAWAY VEHİCLE
MISCELLANEOUS
AOl 1: 21 feet north of the south curbline
prolongation of Foothill Bivd and 21.6 feet west
4 4891(342 Art
of the east curbline prolongation of North
Meridian Avenue.
AOl 2: 14 feet north of the south curbline
prolongation of Foothili Bid and 18 feet west
of the east curb of North Meridian Avenue.
An intamationaily Accredited Agancy 2015 CHP 555 2024 008: 4 20F4
STATE OF GALIFORNIA
INJURED / WITNESS / PASSENGERS Page 3
CHP 555 Page 3 (Rov. 11-06) OPI 065
DAY TIME (2450) CAFICERID MAMBER
GATE OF COLLISICH MO YEAR!
01/29/2024 0718 3610 50772 2024-00011760
EXTENT OF INJURY (**" ONE) INJURED WAS "X" ONE:
PARTY BEAT SAFETY
WITHERS PASSENGER ADE BEX NUMDER POR. BAQ LECTED
ONLY #ATAL SEVERE OTHER VIABLE COMPLAINT E0U.
ONLY DRIVER PASS PED BICYCLIST OTHER
HARI! WUURY BURY OF PABA
28 01 M E
BRIANNA REYES 09/10/1995 TELEPHONE
NAME 10 0 8 / ADDRESS
128 N WILLOW AVE RIALTO 92378 _(909)820-2550
INAIRED OMY) TRAISPORTED BY TAKEN TO
AMR ARMC
DESCREE PURES
COMPLAINT OF PAIN TO THE CHEST
VICTH OF VIOLENT CRIME NOTINED
22 F 03 1 G 0
TELEPHONE
NAME 1O. D. B /ADORESS STEPHANIE CANTORAN 11/12/2001
SAN BERNARDINO_ 02410
INURED ONLY TRANSPONIEO AN TAKEN TO
AMR ARMC
DESCREE INARIES
COMPAINT OF PAIN TO THE CHEST
(AURED OM Y) TRANSPORTED BY TAKEN TO
AMR.
DESCRIBE BLURES
VICTM OF VIOLENT CRON SE NOT FAL
TELEPOR
NAME ID O. B / ADDRESS
(NARED ONLYI TRANSPORTED BY: TAKEN tO
DESCRIBE INSURE'S
VICTAL ON VIOLENT CRIME NOTIED
TELEPHONE
TAKEN TO
MILED ONEY! TRANSPCRTED BY
DESCRIBE INJURES
VICTBE OF VALENT CRIME NOTIFIED
TELEPHONE
MALE I0 0 8 1 ADORESS
MANECD ONLY! TRANSPCRTED BY TAKEN TO
DESCRIBE TURES
VICTIM OF MOLENT CAME HOTRED
NO DAY YEAR REVEWER'S NAAE DAY YEAR
PREPARER'S NAME iD NUMBER
60772 01/29/2024 Acosta, Daniel 02/06/2024
Mata
553 b08 *
015 Cp 255 2024.00011760 Pace 3 OF
STATE OF CALFORNIA
NARRATIVE/SUPPLEMENTAL
CHP 556 (Rev 7-90) OPI 042 Page 4 8 4
DATE OF INCIDENTIOCCURRENCE TIME 12400) INCIC NUMBEN OFTICER ID, NUMBER NUMHER 01/29/2024 0718 3610 50772
2024-00011760
"**ONE T** ONE TYPE SUPPLEMENTAL PX" APPLICABLE)
[X Narrative X Collision report [BA update • Fatal L) Hit and run update Supplemental Doter: • Hazordous materials • school bus Dother:
CIFICOUNTRUUDICIAL DISTRICT SAN BERNARDINO SAN BERNARDINO REPORTING DISTRICTBEAT ¡ CITATION NUMBER [LOCATIONISUBUECT STATE HISHWAY RELATED
E FOOTHILL BLVD /N MERIDIAN AVE X) Yes •No
SEE INVESTIGATIVE NARRATIVE FOR ADDITIONAL INFORMATION.
CITY CLERK RECEIVED 2024 MAY -9 AMII: CITY OF RIALTO
PREPARER'S NAVE AND IS NUMBER TOATE "RE VEWERS NAVE" DATE Mata 50772 01/29/2024 Acosta, Daniel 02/06/2024
Use previous editions until depleted. * OSP 58 18960
2019 CHP 905 2024 0011762 Pane 4 pr a
CERTIFIED MAIL
$9.170
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MAIL FR0042024 062S0001443277
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com®
9414 7112 0620 4185 4988 84
Rialto City Clerk's Office
*YUSA CMF - 134 01/22* * 1-UP Laser Form* 150 S Palm Ave Rialte CA 92376-6406
VITO A NO