CITY CLERK'S DATE STAMP
CITY OF RIALTO
CITY OF RIALTO
LIABILITY
2026 SEP -3 PM12:29
CLAIM FOR DAMAGES
TO PERSON OR PROPERTY RECEIVED
CITY CLERX
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: 290W. Rialto Ave., Rialto, CA 92376
CLAIMANT INFORMATION:
Veronica Cina
FULL NAME DATE OF BIRTH
HOME ADDRESS INCLUDING CITY, STATE & ZIP HOME TÉLEPHONE NO.
See Attached (909 ) 890-1000
BUSINESS ADDRESS INCLUDING CITY, STATE & ZIP BUSINESS TELEPHONE NO ADDRESS AT WHICH CLAIMANT DESIRES TO RECEIVE William D. Shapiro Law, Inc. 893 E. Brier Dr.
NOTICES OR COMMUNICATIONS REGARDING THIS CLAIM
(if different from home address provided above): San Bernardino, CA 92408
1. WHEN DID DAMAGE OR INJURY OCCUR? DATE: 5/26/2026 TIME: 3:30-4:30
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.
See Attached.
3. HOW DID DAMAGE OR INJURY OCCUR?
See Attached.
4. WERE POLICE AT THE SCENE? • YES DINO WERE PARAMEDICS AT THE SCENE? DYES ONO
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.
See Attached.
6. GIVE TOTAL AMOUNT OF CLAIM Include estimate of amount of any prospective injury or damage §Exceeds $10,000 HOW WAS THE ABOVE AMOUNT COMPUTED? Be specific, list doctor bills, repair estimates, etc. Please attach 2 estimates.
DAMAGES INCURRED TO DATE:
Item/Date: Amount: $_
Item/Date: Amount: $
CITY
TOTAL AMOUNT CLAIMED AS OF PRESENTATION OF THIS CLAIM:
OF RIALTO
ESTIMATED PROSPECTIVE DAMAGES, AS FAR AS KNOWN: "3
2026 SEPs-
Item/Date:
EIVEL P412: 29
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) See Attached. NAME:
NAME:
ADDRESS: ADDRESS:
TELEPHONE: () TELEPHONE: | 1
8. IF INJURED, PROVIDE NAME, CONTACT INFORMATION AND DATE/TIME DOCTORS) OR HOSPITAL(S) VISITED:
NAME: See Attached NAME:
ADDRESS: ADDRESS:
TELEPHONE: L TELEPHONE: | )
DATE: TIME: DATE: TIME: •AM • PM
9. PLEASE READ THE FOLLOWING CAREFULLY:
-or all vehicle accident claims, place on the following diagram, the names of streets, including NORTH, EAST, SOUTH AND WEST directions. Indicate plac f accident by "X" and by showing house numbers or distances to street corner 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 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 • NOTE: IF THE DIAGRAM BELOW DOES NOT FIT THE SITUATION, PLEASE ATTACH A PROPER DIAGRAM SIGNED BY THE CLAIMANT.
CURB
PARKWAY
7 SIDEWALK
¡ HAVE READ THE FOREGOING CLAIM AND KNOW THE CONTENTS THEREOF; AND CERTIFY THAT THE SAME IS TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO 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
Brian D. Shapiro 9/1/2026
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 • •
LAW OFFICES OF
WILLIAM D. SHAPIRO LAW INC.
nand Countis 1020 Norie Coss Street
93 East Brier Driv
an Bernardino, California 9240 Santa Ana, California 92701 909) 890-100 (714) 602-6990
All mail
WILLIAM D. SHAPIRO, ESQ.* www.wshapiro.com
BRIAN D. SHAPIRO, ESQ. t: (909) 890-1000
MATTHEW D. SHAPIRO, ESQ f: (909) 890-1001
*Certified Specialist e: [email protected]
civil Trial Advocacy [email protected]
Vational Board of Trial Advocac [email protected]
September 1, 2026
City of Rialto
Attn: City Clerks Office
150 S. Palm Ave.
Rialto, CA 92376
Phone: (909) 820-2519
GOVERNMENT CLAIM FOR DAMAGES
Cal. Gov. Code §§ 810 et seq., 910 et seq.
(a) The name and post office address of the claimant.
Claimant: Veronica Cina
Claimant's Address:
sen The post-office address to which the person presenting the claim desires notices to be Send all notices to: William D. Shapiro Law, Inc.
893 E. Brier Drive, San Bernardino, California 92408
Phone: (909) 890-1000; Fax: (909) 890-1001
[email protected], [email protected], [email protected], [email protected], [email protected].
(c) The date, place, and other circumstances of the occurrence or transaction which gave rise to the claim asserted.
Date of Incident: May 26, 2026, approximately 4:00 a.m.
Location of Incident: 380 N. Linden Ave., #2803, Rialto, California 92376 Claimant lives at the Club Royale Apartments located at 380 N. Lindon, Ave., Rialto, CA 92376.
Rialto Fire Department responded twice to Claimant's residence in the early hours of May 26, 2026. Claimants' family first called 911 at 3:16 a.m. after finding Claimant suffering what they believed was seizure like activity. Rialto Fire Department arrived at the apartment at 3:32 a.m., assessed Claimant, determined no emergency transport or services were needed, then referred her to local urgent care if symptoms continued. Rialto Fire Department left approximately 10 minutes after arrival. (3:42am) Notably, Rialto's report for this first call document "Normal Findings" of left shoulder (Attachment 1).
About 30 minutes later, at 4:06 a.m.., Claimant experienced similar symptoms and her family once again called 911. The same Rialto Fire Department crew came back after this second call, and arrived back at the apartment at 4:18 a.m. At this second visit, Rialto Fire Department decided to transport Claimant to the hospital. Rialto Fire Department members paramedic Samantha Bugarin and EMT Chris Uyar secured Claimant onto a gurney and began wheeling her towards the ambulance, which was parked in the main parking lot out front.
With Claimant strapped to the gurney, Bugarin and Uyar guided the gurney towards their ambulance and off an angled curb (shown). The angle of the curb caused the gurney to tip to the left, causing Claimant to fall to the ground a suffer serious injuries to her left shoulder. The Report for this second visit confirms the incident occurred (Attachment 2), however it was falsely reported that Claimant's "chief complaint of left arm pain" and that "no apparent injuries related to the fall." This is not true.
Gross Negligence
This was not a momentary misstep or an unavoidable accident. The crew failed to take even basic precautions before attempting to move an occupied gurney over an angled curb.
They did not slow down. They did not stop and assess the curb. They did not tilt the gurney back onto its rear wheels, lower it, stabilize it, reposition themselves, or otherwise support it before negotiating the drop. They did not pause to communicate or coordinate the maneuver. Instead, they continued forward at a normal walking pace with Claimant strapped to the gurney.
The danger was open and obvious. Yet the crew proceeded directly toward the curb without taking the ordinary precautions necessary to safely move a loaded gurney over a change in elevation. As the front left wheel went over the edge, the gurney became unstable and tipped to the left, taking Claimant with it. On their way to pushing Claimant off the curb, the crew passed a lit blue handicap ramp that would have provided a smooth and safe way into the parking lot.
At the time, only a single crew member was positioned behind the gurney pushing it forward.
The crew's failure to slow, stabilize, communicate, reposition, or otherwise protect Claimant before attempting the curb descent constituted an extreme departure from the care required under the circumstances and demonstrated a lack of even scant care for Claimant's safety.
The actions of Rialto Fire Department members paramedic Samantha Bugarin and EMT Chris Uyar constituted gross negligence, and as such, exposes the City of Rialto to liability under Government Code §§ 815.2 and 820 and Health & Safety Code § 1799.108. (d) A general description of the indebtedness, obligation, injury, damage, or loss incurred so far as it may be known at the time of presentation of the claim.
Claimant suffered physical injuries, pain, and emotional distress as a result of the incident, including a closed posterior dislocation of the left shoulder, left humeral head fracture, and persistent instability. Claimant's treatment is ongoing and remains under evaluation.
Currently, Claimant's past and future losses include, but are not limited to:
• Physical injuries resulting in ongoing pain
3 Emotional distress
Past and future medical expenses
Loss of normal activities
• Current / long-term / permanent effects, still under evaluation (e) The name or names of the public employee or employees causing the injury, damage, or loss, if known.
Rialto Fire Department employees paramedic Samantha Bugarin and EMT Chris Uyar (based on the report).
City of Rialto
Attn: City Clerk's Office
150 S. Palm Ave.
Rialto, CA 92376
https://www.rialtoca.gov/856/Claims-Management
(f) The amount claimed.
Because this claim exceeds $10,000, Claimant states no dollar amount, as section 910(t) requires. Proof at trial will establish the damages, which Claimant believes will substantially exceed $35,000 — the threshold for an unlimited civil case.
ADDITIONAL REQUESTS
Preservation of Evidence.
Claimant demands that the City preserve all evidence tied to this incident: CAD/dispatch records and run reports for both the first and second 911 responses on May 26, 2026; gurney/equipment maintenance and inspection records; crew assignment and personnel records for both responses; any incident reports, employee statements, or internal reviews regarding the gurney incident; and any photo or video footage (including body-worn camera, if applicable) from the responding units or nearby City-owned cameras.
Request for Response.
The City must investigate this claim promptly and respond within the statutory period. Claiman invites the City to discuss a good-faith settlement before litigation WILLIAM D. SHAPIRO LAW, INC.
By:
William D. Shapiro, Esq.
Brian D. Shapiro, Esq.
Matthew D. Shapiro, Esq.
Attorneys for Claimant Veronica Cina
4 ATTACHMENT 1
1st Rialto Fire Report
•
Patient Name: Cina, Veronica EM5 Agency Name: Rialto Fire Department Complete ePCR w/attachments
Patient Information
Name: Cina, Veronica Age: D.O.B.:
Gender: Female Race: Hispanic or Latino
Address:
Weight: 90.7 kgEstimate
Is Patient No Alternate Home
Homeless?: Residence:
SSN#:
Patient's Phone Number Type
Mobile
Patient Notes:
Call Type/Location/Disposition
Call Type: Unconscious/Fainting/Near-Fainting
Resp. Made: Emergent (Immediate Response) Primary Role of the ALS Ground Transport Transporting
Agency:
Response: Emergency Response (Primary Response Arca)
Location: Private Residence/Apartment Transferred To Where workhonz:
Agency ID
Incident Address: 380 N LINDEN AVE
Rialto City, CA 92376
Unle Disposition: Patient Contact Made Patient Assess and Refer Crew Disposition: Back in Service, No Transport No Transpo Evaluation/Care: Care/Support Services ispositio
Required
Perusalese fer Released colonies Level of Care ALS - Paramedic Provided per
Protocol:
Dispatch Reason: Unconscious/Fainting/Near-Fainting EMD Performed: Yes, With Pre-Arrival Instructions EMD Card Number: 31004 Intal CAD Dispatch UNG-Da
Response Times and Mileage
PSAP: 05/26/202603:16:17 Incident Number: 26-126906
Disp. Notified: 05/26/202603:16:17 Call Sign: MA201
Unit Disp.: 05/26/2026 03:17:57 Veh. #: MA201
At Patient: 05/26/2026 03:32:46
Receiving Hospital
Contacted
Date/Time:
Base Hospital Base Hospital
Contacted: Contact Date:
Unit Personnel
evel of
Crew Member ertification Role
Bugarin, Paramedic Primary Patient Caregiver-At Scene; Primary Patient Caregiver-Transport; Other, Patient Caregiver-Transport; Other, Patient Caregiver-At Samantha Scene
Uyar, Christapher EMT-Basic Other, Patient Caregiver-At Scene; Other, Patient Caregiver-Transport; Driver/Pilot-Response: Driver/Pilot-Transport Provider impression
Primary impression: No Medical Complaint Secondary No Medical Complaint Impression:
Patient Condition
Complaint Type Complaint Duration
Chief (Primary) Nothing 10 Minutes
Symptaronsof 05/26/2025032296
Primary Symptom: No Complaint - Adult Possible Injury: No Alcohol/Drug Use: None Reported Other Symptoms: No Complaint - Adult Unit Notified: 05/26/2026 03:17:57 Patient Name: Cina, Veronica Call #: 26-126906 Incident#: 26-126906 Patient Care Report Number: d68deffe18b74bFS9eb1efbd095ca20c Date Printed: 06/10/202615:05 Page 1 of 4 Patient Name: Cina, Veronica EMS Agency Name: Rialto Fire Department Chingcnytaine Global/eneral Barriers to Pakient None Noted Care:
Antonic Longlan: General/Global
mital Patine Lower Acuity (Green)
Final Patient Acuity: Lower Acuity (Green)
Narrative
assessed referred to local urgent care or primary care doctor if needed.
Past Medical History
Patient Medications
Medication
Not Applicable
other medilisted:
Medication Allergies
Medication Allergies
Not Applicable
Medical History: Not Applicable
Pregnancy: No
Is the patis hota
overdase?
Assessment Exam
Date/Time of Assessment
03:36:10
Assessment Summary
05/26/2026 03:36:10
Detailed Findings
Location Description Details
Elaterat: Reactive
Reactive
Right: Reactive
Shoulder
Abdomen
Hip
Upper Leg
Knee
Lower Leg
Ankle
Foot
Upper Arm
Elbow
Forearm
Unit Notified: 05/26/2026 03:17:57 Call 8: 26-126906
Incident ft: 26-126906 Date Printed: 06/10/2026 15:05 Page 2 of 4 Patient Name: Cina, Veronica EMS Agency Name: Rialto Fire Department Wrist
Hand
Back/Spine
Lung
Chest
Normal Findings
skin: Mental Status; Neurological; Head; Face; Eye (): Neck; Shoulder (Shoulder-Left, Shoulder-Right): Heart; Abdomen ( Generalized, Left Lower Quadrant, Left Upper Quadrant, Periumbilical, Right Lower Quadrant, Right Upper Quadrant, Epigastric); Pelvis; Hip (Hip-Left, Hip-Right) :
Upper Leg ( Leg-Upper-Left, Leg-Upper-Right); Knee (Knee-Lefi, Knee-Right); Lower Leg (Leg-Lower-Left, Leg-Lower-Right); Ankle (Ankle-Left, Ankle-Right.); Foot (Foot-Dorsal-Left, Foot-Dorsal-Right, Foot-Plantar-Left. Foot-Plantar-Right, Toe-1st (Big)-Left, Toe-1st (Big)-Right, Toe-2nd-Left, Toe-Znd-Right, Toe-3rd-Left, Toe-3rd-Right, Toe-4th-Left, Toe-4th-Right, Toe-5th (Smallest) -Left, Toe-5th (Smallest)-Right) :
Jpper Arm (Arm-Upper-Left, Arm-Upper-Right) ; Elbow (Elbow-Left, Elbaw-Right); Forearm (Forearm-Left, Forearm-Right.); Wrist (Wrist-Left, Wrist-Right) and Fine Find-Right, Finger-3rd (Middle) Left, Finger-3rd (Middle)-Right, Finger-4th (Ring)-Left, Finger-4th (Ring)-Right, Finger-5th (Smallest)- eft, Finger-5th (Smallest)-Right, Hand-Dorsal-Left, Hand-Dorsal-Right, Hand-Palm-Left, Hand-Palm-Right, Thumb-Left, Thumb-Right) lack/Spine (Back-General, Cervical-Left, Cervical-Midline, Cervical Right, Lumbar-Left, Lumbar-Midline, Lumbar-Right, Sacral-Left, Sacral-Midline, Sacral-Right, ThoracicLe Thoracic-Midline, Thoracic-Right) ;
Lung (Left, Right, Bilateral); Chest (Left - Anterior, Left - Posterior, Right - Anterior, Right - Posterior, General - Anterior, General - Posterior, Left - Side, Right - Side):
Not Done
Cows Assessment:
Interventions
Ventilator Measurements
Blood Products
Vitals
Vitals
Master on Bed Prature ahma pole Method Hear Polity coz
i9/ CuffAlomated
72a1 curturomised
Date/Time BP Location Mean Arterial Pressure Temperature Temperature Method Pain Scale Score Pain Scale Type Blood Glucose Level 03:33:46 Right Arm 96
03:36:26 Left Arm 93
Date/Time Vital Signs Taken Cardiac Rhythm / Electrocardiography (ECG) ECG TYPe Method of ECG Interpretation 03:33:46 Sinus Rhythm; Sinus Tachycardia 4 Lead
GCS
Total Glasgow Score Qualifier
Time Coma Score Eye Mator Verbal
03:33:46 15 4- Opens Eyes 6 - Obeys commands (>2Years) interesan legitimate ate and eating spontaneously (All Age Appropriate response to
Groups) stimulation
03:36:26 15 Obeys commands (>2Year Co sins to ve les ne rinted nerves elim tealin and elation ppropriate response
stimulation
Cardiac Arrest
Therapeutic No
Hypothermia
Initlated:
Other Agencies On Scene
Other Assnsies On Scens
Other Agensies On Scene
Unit Notified: 05/26/2026 03:17:57 Patient Name: Cina, Veronica Call#: 26-126906 incident #: 26-126905 Patient Care Report Number. d63deffe18b74bfs9eb1efbd095caz0c Date Printed: 06/10/2026 15:05 Page 3 of 4 Patient Name: Cina, Veronica EM5 Agency Name: Rialto Fire Department Trauma Detail
Vork-Related N
Iness/Injury
Billing Information
Work Related?: No
ET3 Alternative Alternative Disposition Not Offered
Disposition Offer
and Result:
AL5 Assessment
Performed By::
Reason for
interfacility
Transfer/Medical
Transport:
Outcome
Date/Time of Emergency
Emergency Department Chief
Department Complaint:
Admission:
Emergency Department Procedures
Emergency First ED Systolic
Department Blood Pressure:
Recorded Cause of
Injury:
Emergency Emergency
Department Department
Diagnosis: Disposition:
Date/Time of Hospital Diagnosis:
Hospital Admission:
Hospital Procedures
Total Ventiays: Total ICU Length of
Stay:
ste/Time Hospital Disposition:
spital Dischar
Outcome atscharge:
Signatures
Type of Person Signing: EMS Primary Care Provider (for this event) Signature Reason: EMS Provider
Paragraph Text:
Status: Signed
Signature Graphic:
Printed Name: Samantha Bugarin
Date/Time Signature Locked:
Signature Date: 05/26/2026 03:37:01
MCL
Number of Patients Single
at Scene:
tient Name: Cina, Veron Call#: 26-126906
unitie: 25765026031757 Date Printed: 06/10/202615:05
tient Care Report Number: d68deffe 1674bF59eb 1efbd095ca2
ATTACHMENT 2
2nd Rialto Fire Report
•
Patient Name: Cina, Veronica EMS Agency Name: Rialto Fire Department Complete ePCR w/attachments
Patrent Information
Name: Cina, Veronica Age: D.0.B:
Address: Gender: Female Race: Hispanic orLatino,
Weight: 90.7 kgEstimate
Is Patient No Alternate Home
Homeless?: Residence:
SSN#:
Patient's Phone Number Type
Patient Notes:
Call Type/Location/Disposition
Primary Role Ofit ALS Ground Transport
Transgening Riato Fire Department (S62-07901
Response oly Mongorgeone lin Response hel Transport Mode: Non-Emergent Destination: Arrowhead Regional Medical Cente
:00 North Pepper Ave
Colton, CA 92324
Location: Private Residence/Apartment Transferred To Where was the LZ Agency ID: Location?
Dest. Dekerm: Closest Facility
Incident Address: 380 N LINDEN AVE
2803฿
Rialto City, CA 92376
Unit Disposition: Patient Contact Made Patlent Patient Evaluated an Crew Disposition: initiated anc ransport Transport by This El valuation/Care: Care Provide Continued Primary sposition: Unit (This Crew On Care
Reason fo Level of Care ALS- Paramedic Transport Delay: None/No Delay efusal/Releasi Provided per
Protocol:
Dispatch Reason: Convulsions/Seizure EMD Performed: Yes, With Pre-Arrival instructions EMD Card Number: 12004 initial CAD Dispatch 5Z-C4
Code:
Response Times and Mileage
PSAP: 05/26/2026 04:06:59 Incident Number: 26-126918
Disp. Notified: 05/26/202604:06:59 Call Sign: MAZ01 To Dest: 4.0 Unit Disp: 05/26/202604:11:03 Veh. #: MA201
Enraute: 05/26/202604:12:00
At Scene: 05/26/202604:18:55 Scene Odom: 0
At Patient: 05/26/202604:18:58 Dest. Odom: 4
Depart: 05/26/2026 04:35:00
Arrive Dest: 05/26/2026 04:50:00
Destination PT 05/26/2026 04:59:2 EMS Transport Ground Ambulance ransfer of Care Method:
In Service: 05/26/202604:59:31
Receiving Hospital
Contacted
Date/Time:
Base Hospital Base Hospital
Contacted: Contact Date:
Unit Personnel
Level catton
Uyar, Christopher EMT-Basic
Presider marasion
Unit Notified: 05/25/202604:11:03 Patient Name: Cina, Veronica Incident#: 26-126918 Patlent Care Report Number: d75912e65F80494a8d70115914f69b7e Page 1 of 5 Patient Name: Cina, Veronica EMS Agency Name: Rialto Fire Department Primary impression: Nan-Traumatic Body Pain Secondary Non-Traumatic Body Pair npression
Patient Condition
Complaint Type Complaint ratio
Chief (Primary) Left shoulder pain 15 Minute
Symptorneof 05726/2026040358
Possible Injury: No
Preter enge ten rented Other Symptoms: Pain, Extremity
Chingtoysant Musculoskeletal/skin Barlers to Patient None Noted Chief Complaint Extremity-Uppe
natomic Location
Initial Patlent Lower Acuity (Green)
Aculty:
Final Patient Aculty: Lower Acuity (Green)
Narrative
Jarrative: Medic Ambulance 201 and Medic Squad 203 responded to a 49-year-old female patient with a chief complaint of left arm pain. Upon arrival, the patient was foun ying in bed and appeared to be in mild discomfort. Family members on scene reported concern that patient may have experienced a seizure. They stated that th atient had been asleep when they observed involuntary arm movements. The patient was able to ambulate to gurney and was placed in position of comfort. Al afety restraints were secured prior to movement, While transporting the patient fram residence to ambulance, paramedic Samantha Bugarin and EMT Chris Uya were maneuvering the gurney off a curb when the gurney became unbalanced and tipped over onto its left side. Following the incident, the patient remained + conscious and alert with no loss of consciousness. The patient denied any new complaints of head, neck, or back pain. The patient landed on her left side and j immediately removed from the gurney for assessment. A trauma evaluation was performed, revealing no apparent injuries related to the fall. The patient was then repositioned onto the gurney and moved into the ambulance for reassessment of vital signs and re-evaluation. The patient reported continued left shoulder pain rated at 8 out of 10, consisting with her pre-existing complaint. All pulse, motor, and sensory were intact prior to and after incident. The patient denied any increase in pain or development of new symptoms following the incident. The patient was transported to Arrowhead Regional Medical Center without further incident. Upon arrival report was given to we staff. All times are approximate no further contact was made with patient.
Past Medical History
Patient Medications
Medication
Not Applicable
Other medications
not listed:
Medication Allergies
Medication Allergies
Not Applicable
Medical History: Not Applicable
Other Past Medical Pinch nerve in neck Pregnancy: No
History: Chronic back pain
Is the patient on a No
5150 hold?:
Is this patient a
suspected opiate
overdose?:
Assessment Exam
Date/Time of Assessment
04:58:25
Assessment Summary
05/26/202604:58:25
Detailed Findings
Location Description Details
Eye
Bilateral: Reactive
Left: Reactive
Right Reactive
Shoulder eft. Pain
Abdomen
Hip
Upper Leg
Unit Notlfied: 05/26/2026 04:11:03 Patient Name: Cina, Veronica Call : 26-126918 incident #: 26-126918 Patlent Care Report Number: d75912e65f80494a8d70115914[b9b7e Date Printed: 05/10/2026 15:02 Page 2 of 5 Patient Name: Cina, Veronica EMS Agency Name: Rialto Fire Department Knee
Lower Leg
Ankle
Foot
Upper Arm
Elbow
Forearm
Lung
Chest
Normal Findings
Skin; Mental Status: Neurological; Head; Face; Eye (): Neck; Heart:
Abdomen ( Generalized, Left Lower Quadrant, Left Upper Quadrant, Periumbilical, Right Lower Quadrant, Right Upper Quadrant, Epigastric) : Pelvis; Hip (Hip-Left, Hip-Right) ; Jpper Leg (Leg-Upper-Left, Leg-Upper-Right); Knee (Knee-Left, Knee-Right): Lower Leg (Leg-Lower-Left, Leg-Lower-Right); Ankle (Ankle-Left, Ankle-Right ):
oot (Foot-Dorsal-Left, Foot-Dorsal-Right, Foot-Plantar-Left, Foot-Plantar-Right, Toe-ist (Big)-Left Toe-1st (Big)-Right, Toe-Znd-Left, Toe-2nd-Right, Toe-3rd-Left, Toe-3rd-Right Toe-4th-Left, Toe-4th-Right, Toe-Sth (Smallest)-Left, Toe-Sth (Smallest)-Right):
Upper Arm (Arm-Upper-Left, Arm-Upper-Right): Elbow (Elbow-Left, Elbow-Right); Forearm (Forearm-Left, Forearm-Right); Wrist (Wrist-Left, Wrist-Right ) ; Hand (Finger-2nd (Index)-Left, Finger-2nd (Index)-Right, Finger-3rd (Middle) Left, Finger-3rd (Middle)-Right, Finger-4th (Ring)-Left, Finger-4th (Ring)-Right, Finger-5th (Smallest) Left, Finger-Sth (Smallest)-Right, Hand-Dorsal-Left, Hand-Dorsal-Right, Hand-Palm-Left, Hand-Palm-Right, Thumb-Left, Thumb-Right):
Back/Spine (Back-General, Cervical-Left, Cervical-Midline, Cervical-Right, Lumbar-Left, Lumbar-Midline, Lumbar-Right, Sacral-Left, Sacral-Midline, Sacral-Right, Thoracic-Left.
Thoracic-Midline, Thoracic-Right);
Lung (Left, Right, Bilateral); Chest (Left -Anterior, Left - Posterior, Right - Anterior, Right - Posterior, General -Anterior, General - Posterior, Left - Side, Right-Side) :
Not Done
COWS Assessment
Interventions
Procedures
Procedure Performed Prior to this rocedu
Units EMS Care Location Equipment Attempts Respanse Success Commen 04:40:15 Bugarin, Glucose measurement, unchange
blood (procedure)
Ventilator Measurements
Blood Products
Vitals
Time PTA CAN" Mashed effled Preasure EMorE spo3 quat Coz D41452No Alert 18/ Curtautomated
15/ Cuttabionaired Lutomated Norma 78
BP Location Mean Arterial Pressure Temperature Temperature Method pain seato score Pain Scale Type Blood Glucose Levet 04:44:52 Numeric (0-10)
04:50:51
Unit Motified: 05/26/202604:11:03 Patient Name: Cina, Veronica Call : 26-126918 Incident: 26-126918 Patient Care Report Number: d75912e65f80194a8d70115914fb9b7e Date Printed: 06/10/202615:02 Page 3 of 5 Pattent Name: Cina, Veronica EMS Agency Nama: Rialto Fire Department PORSI
Date/Time Vital Signs Taken Provoked Region Pain Scale Score Duraton Duration Units PORST Narrative 04:04:52 Muscle Use
Date/Time Vital Signs Taken Cardiac Rhythm / Electrocardiography (ECG) ECG Type Method of ECG Interpretation 04:44:52 Sinus Rhythm 4 Lead
GCS
Total Glasgow
Time Coma Score Eye Motor Verbal Score Quatifier
04:44:52 15 4 - Opens Eyes
spontaneausly (All Age iterventions such as intubation and sedati Groups)
04:50:51 15 4 - Opens Eyes -propriate response years: so oursels ble sie, oriented Interests eimate water it elation spontaneously (All Age
Groups) stimulation
Cardine Arrest
Cardiac Arrest: No
Therapeutic No
Hypothermia
Initiated:
Other Agencles On Scene
Other Agensiss On Ssene
Other Agencies On Scene
Trauma Detail
Work-Related No
Illness/Injury:
Billing Information
Payment: Insurance Work Related?: No
ET3 Alternative Alternative Disposition Not Offered
Disposition Offer
and Result:
A store ey
Reason for
Interfacility
Transfer/Medical
Transport:
Outcome
Departmen chief
Complaint
Emergency. Department Procedures
First ED Systolic
Blood Pressure:
Injury:
Emergency Emergency
Department Department
Diagnosis: Disposition:
ate/Time Hospital Diagnosis:
spital Admissic
Hospital Procedures
Total Ventilate: Total u Lengthat
Hospital oftarget Hospital Disposition:
Outcome as harget
Signatures
Type of Person Signing: Healthcare Provider
Signature Reason: Transfer of Patient Care
Unit Notified: 05/26/202604:11:03 Patient Name: Cina, Veronica Call : 26-126918 Incident#: 26-126918 Patient CarRaport umber: 059255809428701591456967e Date Printed: 06/10/2026 15:02 Page 4 of 5 Patient Name: Cina, Veronica EMS Agency Name: Rialto Fire Department Paragraph Text:
Status: Signed
Signature Graphie:
Printed Name: Aaron Rn
Date/Time Signature Locked: 05/26/2026 04:49:15
Signature Date: 05/26/2026 04:49:05
Type of Person Signing: EMS Primary Care Provider (for this event) Signature Reason: EMS Provider
Paragraph Text:
Status: Signed
Signature Graphic:
Printed Name: Samantha Bugarin
Date/Time Signature Lacked:
Signature Date: 05/25/2026 04:52:18
Type of Person Signing: Patient
Signature Reason: HIPAA acknowledgement/Release; Permission to Transport; Permission to Treat; Release for Billing Paragraph Text:
Status: Not Signed - Due to Distress Level
Signature Graphic:
Printed Name: Veronica Cina
Date/Time Signature Locked:
Signature Date: 05/26/2026 04:59:22
MCLE
Number of Patients Single
at Scene:
Valuables
Patient Belongings: None
Unit Notified: 05/26/202608:11:03 Patient Name: Cina, Veronica Call w: 26-126918 Incident #: 26-126918 Patient Care Report umber: 401591497e Date Printed: 05/10/2026 15.02
CERTIFIED MAIL®
William D. Shapiro Law, Inc.
893 E. Brit Drive US POSTAGE PITNEY BOWES
San Beardino, CA 92408 FIRST-CLASS
ZIP 92408 $ 011.560
9589 0710 5270 3949 1768 71 02 7H
0006113 SEP 02 2026
City of Rialto 2026 SEP - 3 PMI2: 29 OF RIALTO
Attn: City Clerk's Office
150 S. Palm Avenue
Rialto, CA 92376
.=......