CITY CLERK'S DATE STAMP
CITY OF RIALTO
LIABILITY
CITY CITY OF RIALTO
CLAIM FOR DAMAGES
PRE JUM 22 PR 1: 19
TO PERSON OR PROPERTY
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 9237( Address: 290 W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
ADAM L. CARDE SANCEN
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: - 4/16/2026 TIME: 10:02 KAM O PM
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.
Rialts, Frisbre parky Skerepurk
3. HOW DID DAMAGE OR INJURY OCCUR?
Floor war ovey slick In con acon to waky substances present Slipped and fell and broke My arm.
4. WERE POLICE AT THE SCENE? DYESONO WEREPARAMEDICS AT THE SCENE? AYESONO
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.
Not enough stans of horards of waxy floors and overly Slick Floor i beleave cement war fire treated during construction
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage $60,000 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Broken Aron Amount: $ 60,000
Item/Date: Amount: $
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM: $ 60,000 ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN:
Amount: $
Item/Date:
Amount: $
Item/Date:
TOTAL ESTIMATED AMOUNT PROSPECTIVE DAMAGES: $
7. WITNESSES TO DAMAGE OR INJURY List all persons known to have information (attach additional pages, if necessary) NAME: Anthony Bara NAME: - Anthony Bara
ADDRESS: ADDRESS:
Rialto CA 82376
TELEPHONE:..- TELEPHONE:
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
Haga Jeffrey DO/Andrew Wong Mo NAME: Peter ELstily MD
NAME: —
ADDRESS:..*** ADDRESS:.
colton CA 92324
TELEPHONE: TELEPHONE: seve
DATE: TIME:
DATE: TIME:
9. PLEASE READ THE FOLLOWING CAREFULLY:
For all vehicle accident ciaims, 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/towni vehicle was involved, designate by letter "A location of the City/Town vehicle wher you first-saw it, and by 'B" location of yourself or your vehicle when 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 accident 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 22 OF
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 HOSE 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. "440V2
SIGNATURE OF CLAIMANT OR AGENT
Adam L. Carde Sancen
TYPE OR PRINT NAME DATE
Me, myselF, F
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 Laboratory Test Results (continued)
Procedure
Component i Value
Comment: Units
Marijuana Results for medical purposes only. Date/Time
Screen, Urine Negative <50 ng/mL
Fentanyl Screen, Negative <5 ng/ml Comment: Results for medical purposes only.
Urine
Comment:
Urinalysis WITH reflex to Culture (Normal) Specimen: Urine, Clean Catch Results for medical purposes only. • Color, Urine Collected: 04/16/26 1408
Clarity, Urine Yellow
Clear --Updated: 04/16/26 1509
pH, Urine
6.5 Leukocytes Negative
Esterase
Nitrite, Urine Negative
Protein, Urine Negative
Glucose, Urine Negative
Bilirubin, Urine Negative
Ketones, Urine Negative
Blood, Urine Negative 2029 JUN22 PX: 19
Specific Gravity: CITY OF RIALTO
UA 1.010
Imaging Results
Procedure
Component
CT humerus left wo contrast Value
Units
Narrative: Date/Time
CT HUMERUS LEFT WO CONTRAST Collected: 04/16/26 1543
. Updated: 04/16/26 1556
INDICATION: Fracture, humerus, trauma.
COMPARISON: None.
adjustment of the mA and/or kV according to patient size, or use of iterative reconstruction techniques. is CTDI mGy. CT scan was performed using one of the dose lowering techniques: Automated exposure control, TECHNIQUE: Without IV contrast, multiplanar images were obtained. Total DLP is DLP mGy cm and CTDI volume Impression:
FINDINGS/IMPRESSION:
• There is an acute, comminuted, laterally displaced fracture of the proximal humerus diaphysis. The humeral head maintains appropriate articulation with the glenoid. There is no bony erosion. There is hematoma medial to fracture site. There is no soft tissue gas.
Interpreted by Resident: Geoffrey Wilkinson, MD on 4/16/2026 15:50 ECG 12 lead - In process 1 have personally reviewed and concurred with the contents of this report.
This restiehas hot been signed Information miahube incompletel XR chest 1 view Collected: 04/16/26 1227 Updated: 04/16/26 1229
Narrative:
INDICATION: pain 2/2 trauma. COMPARISON: 4/4/2025. Collected: 04/16/26 1127 Updated: 04/16/26 1156
The cardiomediastinal silhouette is within normal limits: The osseous structures and soft tissues are unremarkable. TECHNIQUE: XR CHEST 1 VIEW. FINDINGS: There is no focal consolidation, pneumothorax or pleural effusion. - Carde Sancen, Adam
Printed at 4/16/2026 4:18 PM •
Docusign Envelope ID: 9F3C4B83-B3D5-459C-BDE6-6ABCE25578B..RENCE/INCIDENT REPORT (Not part of Medical Record)
CLIENT INFORMATION Last Name Carde-Sancen
First Name Adam
Chart No. 2063055 Gender: 2 Male Female • Unknown Age 28 Birthdate:
Reporting Clinic/Contract Agency DBH DOORS Date last seen by Staff 04/16/2026 Name of Clinic/Contractor Family Notified: Telephone Letter X/ None Name of Program Delivering Services DBH-DOORS Family Contact Name Client Address/Phone
INCIDENT (Please check all that apply) Disturbance/Destruction of Property** • Dangerous Behavior - Self L Dangerous Behavior - Others L Victimized • Sexual Behavior X Medical/Injury** • Death* Date Deceased L Other
LOCATION OF INCIDENT Within Clinic • Surrounding Clinic (grounds, parking lot,) • Residential • Client Residence, Independent Living X Other (Please specify) Program event (outdoors) Located at Frisbie Park 1901 N Acacia Ave, Rialto 92376 EXPLANATION OF INCIDENT* incude names of witmesses DATE OF INCIDENT: 04/16/2026 TIME: 10:02 AM Mr. Carde-sancen was at the park with his case manager Mr. Baca, awaiting the arrival of other participants for scheduled outdoor wellness groups (Mind/Mood and Relapse Prevention). During this waiting period, Mr. Carde-sancen was using his skateboard within the parks skate area. While skatboarding he fell and landed on his shoulder. Mr. Carde-sancen reported pain affecting from that area.
WITNESSES: Anthony Baca, SWII
ACTION TAKEN (Please check all that apply) Counseling, reassuring, removal of client • First Aid • Consulting with Physician (Phone or office visit) X Called Paramedics • Staff escort out of building - Police called L Other Report (CFS, APS, Licensing)
• Other (Please Specify)
EXPLANATION OF ACTION TAKEN*
Anthony Baca, SWII contacted emergency services (911), and an ambulance was dispatched to the scene:
Mr. Carde-sancen was transported by ambulance to ARMC for further medical evaluation and treatment, Mr. Baca accompanied Mr. Carde-sancen to the hospital in his separate county vehicle.
SUPERVISORS COMMENTS Indude, ag: Family Roopones, Dale of Lad Savio, Lad Made corn a (8. 4, Grave Die ), dia.). Cant complance is (snaporalen, chil car, do) i spropale Mr. Carde-sancen was admitted to the DOORS program on 10/29/25, attends treatment groups, case management, individual therapy, medication management. On 10/29/25 the he was placed at JC Wallace House.
Initial case management support began on the date of admission 10/29/25. The last psychiatry appointment took place on 3/31/26, and is currently med compliant on all prescribed medications. Mr. Carde-sancen has been programming well and has not had any disciplinary concerns to date.
Signed by:
Signature of Supervisor
NOTIFICATI®N (cheer lated, include date and method of notification ie, phone, fax, email in the space provided) X Director Joshua Dugas- Acting Director X Program Manager Melanie Porges X Assistant Director Marina E/Jennifer A. • Department Safety Coordinator X Deputy Director Dr. Alyce Belford-Saldana DABP I Medical Director Dr. Christopher Schreur X Chief Compliance Officer Erica Ochoa 4/23/2026 • Program Coordinator AUTHOR INFORMATION (Who completed form) Date 04/16/2026 Title Mental Health Clinic Supervisor Printed Name Hannan Dababneh, LCSW, CS
Slaned by:
Signature
E7352300300249
*Add additional sheet as needed Follow-up outcome should be reported to the Office of Compliance **Office of compliance shall determine if report required to Department of Risk Management QM053 (04/22) Quality Management Page 1 of 1
Adam L.Crte Ji. •..
SN BERNARDINO CA 923
- 18 JUN 2026 PM6 L
USA * FOREVER *
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1505 C.: FIFRALT
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S2376-640650