UD-100
ATTORNEY OR PARTY WITHOUT ATTORNEY fWame, S(a(e Bar number, and address):

FOR COURT USE ONLY

_Dennis P. McPherson, Esq., SBN 128879
UBALDI & McPHERSON
455 University Avenue, Suite 360
Sacramento, CA 95825
TELEPHONENO.: (916) 2 6 5 - 4 5 5 5

F'lLEO
FAX NO. (Optional):

SlUpenor Court Of CaSiforr

(916) 265-4568

E-MAIL ADDRESS (Optional):
A"n0RNEY FOR (Name).

Plaintiff MERCY SAN JUAN MEDICAL CENTER

Cfi/2G/2e1£

SUPERIOR COURT OF CALIFORNIA, COUNTY OF S A C R A M E N T O
STREET ADDRESS:
MAILING ADDRESS

720 Ninth Street
Sacramento, CA 95814

J Depujly

C.asa Humhar:

CITY AND ZIP CODE:

:;4-2015-00180986

BRANCH NAME

PLAINTIFF: MERCY SAN JUAN MEDICAL CENTER
DEFENDANT: TYLER STOLZ by and through her Conservator Dennis Sowels
rx~] DOES 1 TO 10
COMPLAINT
m

COMPLAINT •

Jurisdiction
I

— UNLAWFUL

CASE NUMBER:

DETAINER*

AMENDED COMPLAINT (Amendment

Number):,

(check all that apply):

I ACTION IS A LIIMITED CIVIL CASE
Amount (demanded
I
I does not exceed $10,000

I
I exceeds $10,000 but does not exceed $25,000
I X I ACTION IS AN UNLIMITED CIVIL CASE (amount demanded exceeds $25,000)
I
I ACTION IS RECLASSIFIED by this amended complaint or cross-complaint (check all tliat apply):
\
\ from unlawful detainer to general unlimited civil (possession not in issue)
I
I from limited to unlimited
I
I from unlawful detainer to general limited civil (possession not in issue)
from unlimited to limited
1. PLAINTIFF (name each): M E R C Y S A N J U A N M E D I C A L C E N T E R
alleges causes of action against DEFENDANT (name each): T Y L E R S T O L Z , a c o n s e r v e d p e r s o n , by her public

guardian Dennis Sowels
2. a. Plaintiff is

(1) I
(2) I
(3)

I an indiviidual over the age of 18 years.
I a public agency.
other fspec//y;,-

(4) I
I a partnership.
(5) I X I a corporation.

b. I X I Plaintiff has complied with the fictitious business name laws and is doing business under the fictitious name of (specify):

Dignity Health, a California non-profit public benefit corporation dba Mercy San Juan Medical Center
Defendant named above is in possession of the premises located at (street address, apt. no., city, zip code, and county):

Defendant is a hold-over patient at Mercy San Juan located at 6501 Coyle Avenue, Carmichael California
(Sacramento County) who no longer requires hospital care
Plaintiffs interest in the premises is
I X I as owner I
I other (specify):
The true names and capacities of defendants sued as Does are unknown to plaintiff.
a. On or about (date): A u g u s t 2 0 1 4
defendant (name each): T Y L E R S T O L Z , a c o n s e r v e d p e r s o n

(1) agreed to rent the premises as a
I
I month-to-month tenancy
I
I other tenancy (specify):
(2) agreed to pay rent of $
payable I
I monthly I
I other (specify frequency):
(3) agreed to pay rent on the
first ofthe month [ Y ] other day (specify): B e c a m e a patient at Mercy San J u a n
This I
I written
I X I oral agreement was made with
(1) I X I plaintiff,
(3) I
! plaintiff s predecessor in interest.
(2) 1 I plaintiffs agent,
(4) IZZl other (specify):
*NOTE: Do not use this form for evictions after sale (Code Civ. Proc, § 1161a).
Pago 1 ot 3
Form Approved for Optional Use
Judicial Council of California
UD-100  Rev, July 1, 20051

COMPLAINT—UNLAWFUL DETAINER

SoliLufqns"

Civil Code, § 1940 et seq.
Code of Civil Procedure §§ 425.12, 1166

 _ PLAINTIFF (Name):

MERCY SAN JUAN MEDICAL CENTER

CASE NUMBER:

DEFENDANT (Name): TYLER STOLZ by and through her Conservator Dennis
Sowels
6. c. I

I The defendants not named in item 6a are
(1) I
I subtenants.
(2) I
I assignees.
(3) I Z Z other fspec/^j.-

d. I

I The agreement was later changed as follows (specify):

e. I

I A copy of the written agreement, including any addenda or attachments that form the basis of this complaint, is attached
and labeled Exhibit 1. (Required for residential property, unless item 6f is checked. See Code Civ. Proc, § 1166.)
I (For residential property) A copy of the written agreement is not attached because Cspec//y reasonj;
(1) I
I the written agreement is not in the possession of the landlord or the landlord's employees or agents.
(2) I
I this action is solely for nonpayment of rent (Code Civ. Proc, § 1161(2)).

f

I

7. Z Z a. Defendant (name each): T Y L E R S T O L Z

was served the following notice on the same date and in the same manner:
(1) I
I 3-day notice to pay rent or quit
(4) I
I 3-day notice to perform covenants or quit
(2) [ x Z 30-day notice to quit
(5) Z Z 3-day notice to quit
(3) ZZ 60-day notice to quit
(6) ZZ
Other (specify):
b. (1) On (date): M a y 8, 2 0 1 5
the period stated in the notice expired at the end of the day.
• (2) Defendants failed to comply with the requirements of the notice by that date,

c. All facts stated in the notice are true.
d. I
I The notice included an election of forfeiture.
e. I x I A copy of the notice is attached and labeled Exhibit 2, (Required for residential property. See Code Civ. Proc,
§1166.)
f I X I One or more defendants were served (1) with a different notice, (2) on a different date, or (3) in a different
manner, as stated in Attachment 8c. (Check item 8c and attach a statement providing the information required by
items 7a-e and 8 for each defendant.)
8. a. I X I The notice in item 7a was served on the defendant named in item 7a as follows:
(1) I X I by personally handing a copy to defendant on (date): May 8, 2 0 1 5
(2) I
I by leaving a copy with ^name or description):
a person of suitable age and discretion, on (date):
at defendant's
I
I residence I
I business AND mailing a copy to defendant at defendanfs place of residence on
(date):
because defendant cannot be found at defendanfs residence or usual
place of business.
(3) I
I by posting a copy on the premises on (date):
I
I AND giving a copy to a person found
residing at the premises AND mailing a copy to defendant at the premises on
(date):
(a) I
I because defendanfs residence and usual place of business cannot be ascertained OR
(b) I
I because no person of suitable age or discretion can be found there,
(4) I
I (Not for 3-day notice; see Civil Code, § 1946 before using) by sending a copy by certified or registered mail
addressed to defendant on (date):
(5) i
I (Not for residential tenancies; see Civil Code, § 1953 before using) in the manner specified in a written
commercial lease between the parties.
b. ZZ (Name):
was served on behalf of all defendants who signed a joint written rental agreement,
cm

Information about service of notice on the defendants alleged in item 7f is stated in Attachment 8c.

d-1 X I Proof of service ofthe notice in item 7a is attached and labeled Exhibit 3.

UD-100 IRev July 1.2005)

C O M P L A I N T — U N L A W F U L

D E T A I N E R

Page2of3

 _ PLAINTIFF (Warns;,' MERCY SAN JUAN MEDICAL CENTER

CASE NUMefH;

DEFENDANT fwemej,' TYLER STOLZ by and through her Conservator Dennis
Sowels
S- ,^........1 Plaintiff damsnds possession from each defendanl because of expiration of a fixed-terin lease.
10.
At the time the 3-day notice to pay rent or quit was served, the amount of rent due was $
11.
i Thefalrrentalvalueof the premises is J
per day.
12. i ] Defendanfs continued possession is malicious, and plaintiff is entitled to statutory damages under Code of Civil Procedure
section 1174(b). (Stste specifis facts supporting a claim up to $600 in Attachment 12.)
13. [.....'..'] A written agreement between the parties provides for attorney fees,
14.1.,.,.,] Defendanfs tenancy Is subject to the local rent ijontrol or eviction control ordinance of (city or county, title ofordinenae,
$nd dgtB af passage):

Plaintiff has met all applicable requirements of the ordinances.
15. Lx..J Other allegations are stated in Attachment 15,
16. Plainliff accepts the Jurisdictional limit, if any, ofthe court,
17. PLAINTIFF REQueSTS
damages at the rate stated in item 11 from
a. possession ofthe premises.
f.
(date):
for each day that
b. costs incurred in this proceeding:
c. IZVJ past-due rent of $
defendants remain in possession through entry of judgment,
d. K l . ! reasonable attorney fees.
g.
statutory damages up to $600 for the conduct alleged in
e. I... J forfeiture of the agreement,
item 12,
h.
other (specify):

18. [ x H Numbar of pages attached (specify); SL
UNLAWFUL DETAINER ASSISTANT (Bus, & Prof. Codo, §§ 6400-6415)
19. (ComjO/efB/n cssea.^ An unlawful detainer assistant LiG did not i I did for compensation give advice or assistance
with this form, (If plaintiff ties received any help or advice for pay from an unlawful detainer assistant, stataj:
c. Telephone No.:
d. County of registration;
e. Registration No.:
f. Expires on (date):

a, Assistanfs name:
b. Street address, city, and zip code:

Date:
^

Dennis P. McPherson. Esq.. SBN 128879
(TYPE OR PRINT NAME]

(SIGNATURE OF PLAIhfTIFF OR ATTORNEY)

VERIFICATION
(Use a different verification fonn If the verification Is by an attomey or for a corporation or partnership,)
I am the plaintiff In this proceeding and have read this complaint, I declare under penally of perjury under tha laws of the State of
California that the foregoing is true and correct,
Date:

P.Vii\
U0-100 R»v July 1,2006)

60

39tfd

V}i<r)^

iSlQNATURE OF PLAII^TIFF)

COMPLAINT—UNLAWFUL DETAINER

NoiiwyisiNiwQ'i? rsw

ITTSiES9T6

It?:6T

i002/TT/60

 PETITIONER/PLAINTIFF: jyiERCY SAN JUAN MEDICAL CENTER
RESPONDENT/DEFENDANT: TYLER STOLZ b y and t h r o u g h h e r

CASE NUMBER:

Conser

ATTACHMENT 8c
Patient Tyler Stolz is believed to be a conserved person by and through the Solano County Public
Guardian, Dennis Sowel. On May 8, 2015 Tyler Stolz was personally served with a 30 day notice.
On May 7, 2015 Deputy County Counsel Julie Barga, as counsel for Dennis Sowels, agreed to accept by
mail, the 30 day notice to quit. The 30 day notice to quit was sent by e-nnail to Julie Barga on May 7,
2015.

Soli^Qns'
Lus

 THIRTY (30) DAY NOTICE TO VACATE

DATE: May 8, 2015
TO:

TYLER STOLZ, by and through her
Conservator, Dennis Sowels

RE:

Address of Residency: Mercy San Juan
Medical Center, 6501 Coyle Avenue,
Carmichael, California 95608

NOTICE IS HEREBY GIVEN that thirty (30) days from service of this
Notice upon you, your tenancy and residency as a patient at Mercy
San Juan Medical Center wili terminate. You have been found to
meet discharge criteria by your physicians and therefore you are
required to vacate Mercy San Juan Medical Center on or before
June 9, 2015. If you have not vacated Mercy San Juan Medical
Center on or before June 9, 2015, Mercy San Juan Medical Center
will thereafter institute unlawful detainer proceedings and seek all
other as necessary affirmative relief to terminate your residency.

Dennis P. McPherson, Attorney for
Mercy San Juan Medical Center

 PETITIONER/PUMNTIFF: MERCY SAN JUAN MEDICAL CENTER
RESPONDENT/DEFENDANT: TYLER STOLZ by and t h r o u g h h e r

CASE NUMBER:

Conser

ATTACHMENT 15
Tyler Stolz was admitted as a patient to Mercy San Juan in August 2014. At that time the patient had
medical conditions which necessitated hospital care. At that time and continuously up to the present, the
patient is conserved through the Solano County Public Guardian Dennis Sowels. The patient is also
eligible for and receives services through the North Bay Regional Center.
For the last several months, dating back to at least December 2014, defendant has no longer required
inpatient hospital care and has been eligible for discharge. Defendant has multiple medical,
psychological and developmental conditions which although they do not require hospitalization, nontheless
represent dangers to defendant and possibly to others if she were discharged to the community.
Because the defendant is conserved through the public guardian and receives services through NBRC,
plaintiff has sought the cooperation and assistance of these persons/entities to secure a proper placement
so the patient can be discharged. Public guardian Dennis Sowels and North Bay Regional Center has
withheld cooperation and assistance, has not provided placement options, and has not acted in the best
interests of defendant to secure placement.
Defendant has violent outbursts and has previously harmed hospital staff. A security officer is posted to
the patient's room 24/7.
There is no family which will agree to accept placement of defendant into their home.
Defendant should not be a patient if hospital care is no longer required. Plaintiff cannot merely discharge
defendant to the community at large because there is no safe place for the patient to go.

Solutions-

 PROOF OF SERVICE
I, the undersigned, declare that I served the Notice(s) below indicated:
THIRTY (30) DAY NOTICE TO VACATE

The above described Notice(s) were served on the following named parties in the manner set forth below:
NAME;
ADDRESS:
IX I

TYLER STOLZ
MERCY SAN JUAN MEDICAL CENTER. 6501 COYLE AVE, ROOM 8524, CARMICHAEL, CA 95608

1. PERSONAL SERVICE

By delivering a copy of the Notice(s) to each of the above personally:
(1) on; 05/08/2015
(2) at 2:10 PM

At the time of service. I was at least 18 years of age. I declare under penalty of perjury that the foregoing is true and connect.
Person who served papers
a. Name:
Mike Singh
b. Address:
201410th SL, Sacramento, CA 9S818
c. Telephone number.
916-449-8390
d. The fee for service was: $ 89.50
e. I am:
(1) I
I not a registered Calilbmia process server.
(2) I

lexempt from registration under Business and Profiessions Code section 22350(0).

(3) I X

I registered Califomia process server

I X

(i) I
I owner I
I employee I X 1 independent contractor.
(ii) n n Registration No,: 2000-002

For
ABC Legal Services, Inc.
Registration* 6779

(iii) I X I County:

County:

Sacramento

Los Angeles

 l declare under penalty of perjury under the lavre of the State of Califomia that the foregoing is true and comect.
or

I

 l am a California sheriff or marshal and I certify that the foregoing is true and correct.

Date:
Mike Singh
(NAME OF PERSON WHO SERVED PAPERS/SHERIFF OB MARSHAL)

PROOF OF SERVICE
•REF: 372-1224

Tracking #: 0007007017

 Dennis McPherson
From:
Sent:
To:
Subject:
Attachments:

Dennis McPherson
Thursday, May 07, 2015 2:46 PM
'Barga, Julie A.'
RE: Tyler Stolz Mercy San Juan
Stolz 30 day.pdf

Ms. Barga,
I have attached the 30 notice to vacate which you have graciously agreed to accept service on behalf of Dennis Sov^rels,
conservator of Tyler Stolz. We are also hand serving the 30 day notice on the patient at Mercy San Juan today or
tomorrow.
Thank you for agreeing to accept service on behalf of Mr. Sowels.
truly yours, Dennis McPherson

If you have any questions please give me a call. Very

From: Barga, Julie A. [mailto:JABarga(aSolanoCounty.com]
Sent: Thursday, May 07, 2015 2:40 PM
To: Dennis McPherson
Subject: RE: Tyler Stolz Mercy San Juan
Mr. IVlcPherson,
I will accept service on behalf of Mr. Sowels.
Mr. Sowels was able to talk to the administrator at Garfield. Unfortunately, they will not accept her so placement there
is not an option.
I have not heard back from the regional center so I plan to file a motion with the Court, asking the Court to issue an OSC
to the regional center. I wiil serve you with a copy if you like?

JuCie (Barga
Deputy County Counsel
Solano County Counsel
675 Texas Street, Suite 6600
Fairfield, CA 94533
707.784,6140
707.784.6862
iabarqa(Sjsolanocountv.com

.Attorney-Client Privileged This document being emailed is intended only for the use of the individual or entity lo which il is
addressed and contains or may contain informalion that is privileged, confidential and exempt from disclosure under applicable law.
Ifyou are not the intended recipient, please nolif}' us immediately.

From: Dennis McPherson rmailto:dpm@umllp.coml
Sent: Thursday, May 07, 2015 12:25 PM

 CONDITIONS OF ADMISSION
(For Use for Inpatients Outpatients and Emergoicy Department Patients)
Terms Used in this Form
"Hospital" means: Mercy San Juan Medical Center
"Patient" means the person identified in tbe registration block.
"Patient's legal representative" can be the Patient's parent, guardian, conservator, or any other person
authorized to sign this docmnent for the Patient's, such as an agent under an advanced directive.
"You" or "Your" refers lo the person signing this docuraenl and can be the Patient or the Patient's legal
representative.
"We" or "us" or "our" refers to the Hospital.
"Insurance compaoy" means a HMO, health plan, indemnity plan, goverrunent plan or insurance company.
"Full charges" means the Hospital's published rates (called the chargemaster), prior to any discounts or
reductions.
By signing this form, you agree to all ofthe following provisions:
1. Consent to Medical and Surgical Procedures
You consent to the procedures that may be perfonned during this Hospital stay or provided as an outpatient.
These may include emergency treatment or services, laboratory procedures. X-ray examinations, medical or
surgical treatment or procedures, anesthesia, or other hospital services provided to the Patient under the general
and special instructions of the doctor. Some treatment or services may be provided through telcmedicine. You
agree that the Hospital and doctors may access and use your non-hospital pharmacy records in connection with
this Hospital stay or visit. You understand that the practice of medicme and surgery is not an exact science.
You understand that diagnosis and treatment may involverisksof injury or even death. You acknowledge that
We make no guarantees to You about the resuh of examination or treatment in this Hospital. If the Patient
delivers an infant(s) at this Hospital, You agree that these same Conditions of Admission apply to the infant(s).
2. Consent to Electronic Recording
You consent to our use of photography, audio or video recording or other electronic imaging as required for
diagnosis or treatment ofthe Patient and for other intemal Hospital purposes. We will not use the Patient's
image for marketing or fundraising unless we get Your separate authorization in writing. Wc may take the
Patient's picture to confirm and protect his/her identity.
3. General Dnty Nursing Care
The Hospital provides only general nursing care and services ordered by the doctor(s). If You want a private
duty nurse and the doctor agrees, You agree to make fhe arrangements at the Patient's expense. The Hospital is
not responsible for not providing a private duty nurse. You release the Hospital from any and all liability from
the use ofa private duty nurse or the fact that the Hospital does not provide this additional care.
4. Participation of Residents and Health Care Students
We may participate in programs to teach resident doctors, medical students, student nurses, and/or other heahh
care students. These persons may observe or participate in the Patient's care under the supervision of doctors,
nurses and other professionals on the Hospital's staff.
5. Legal Relationship between Hospital and Doctors Patient/Legal Representative Initials:
Doctors and surgeons providing services to the Patient, including the radiologist, pathologist, emergency
doctors, hospitaRst, anesthesiologist, intensive care doctors and others, are not employees or agents ofthe
Hospital. They have been granted the privilege of using the hospital for the care and treatment of their
patients, but they are not employees. You will receive a separate bill from the doctors for their services.

# Digfiity Health.

Mercy San Juan Medical Center

C O N O m O N S O F ADMISSION
AND T R E A T M E N T
Page 1 of 4

Nt- 107085334
STOLZ, TYLER
m
10082822
DOB: 10/22/1990

DOS: m2r20U
SEX: F

 You understand that the Patient is under the care and supervision ofthe attcndbg doctor. The Hospital and its
staff are responsible for carrying out the doctor's instructions. Your doctor or surgeon is responsible for
obtaining Your informed consent, when required, for medical or surgical treatment, special diagnostic or
therapeutic procedures, or Hospital services provided to You under your doctor's general and special
instructions.
6. Release of Information
You will be given a Notice of Privacy Practices that explains how the hospital may use information about the
Patient. The Notice of Privacy Practices is available on the Hospital's website under Patient Privacy Notice.
The Notice of Privacy Practices explains that we will obtain Your writien authorization to release information
about the Patient, unless We are allowed or required by law lo disclose the information without authorization.
7. Personal Belongings
You should leave personal items at home. The Hospital has a Greproof safe for the safekeeping of money and
valuables. The Hospital is not liable for the loss or damage to any money, jewelry, documents or other articles
not placed in the safe. Hospital liability for loss of any property given to the Hospital for safekeeping is
limited by law to five hundred dollars ($500) unless You receive a written receipt for a greater amount.
8. Financial Agreement; Assignment of BeneGts/Appeal Rights
a. Insured Patients. We will bill the patient's insurance company for all the services provided during this stay.
Co-payments, co-insurance and deductibles required by the insurance company must be paid by the Patient.
Payment may berequestedbefore or at the time of service. If the insurance company or benefit plan denies all
or part of Ihe payment, the Patient agrees to be responsible to pay any amounts due to the Hospital under the
•law. The Patient also assigns all the Patient'srightsunder the Employee Retirement Income Security Act
("ERISA") or any other applicable state or federal law to Hospital to appeal the denial or underpayment and to
seek all legal remedies on behalf of the Patient in any fonun against any entity. Some common reasons an
insurance company may deny payment are:
Tbe service is not covered
The hospital is not in tbe insurance company's network
Advance authorization from the insurance company was required and not obtained
The insurance company determines the service is not medically necessary
By signing this form, You authorize us to submit a claim for payment to the Patient's insurance company or
benefit plan for the services provided to the Patient. You authorize us to dispute any denials or underpayments
to, or legally pursue legal remedies against, the Patient's insurance company or benefit plan. You authorize
and direct the insurance company or benefit plan to make direct payments to us for such services, and to accept
and adjudicate appeals fi-om the Hospital on your behalf. You appoint Hospital as the Patient's personal
representative to pursue all benefit rights. You also agree the Patient is financially responsible as allowed by
law for any charges not paid by the insurer or benefit plan.
b. Uninsured Patients. Patients without insurance must pay for services al full charges, unless other discounts
apply. Uninsured patients may qualify for govemment programs or financial assistance. Financial assistance
may include a discount from the Hospital's full charges,freecare, interest iree payment plans or other
assistance. Patients asking for govemment or financial assistance must complete an application
(sec Paragraph 9).

# Dignity Health.

Mercy 5an Juian Medici Center-

CONDITIONS OF ADMISSION
AND TREATMENT
Page 2 of 4

A# 107085334
STOLZ, TYLER
WW
10082822
DOB: 10/22/1990

DOS:
SEX:

8/12/2014
F

 c. Additional Terms, (i) We may disclose yonr information to other agencies or firms as needed, for the
sole purpose of getting a standard credit report on the undersigned. Tbat credit report may include
bvestigations of personal credit history, employment and other financial situations, (ii) All past due
accounts will be charged interest at the legal rate. If wc send the Patient's account to a collection agency or an
attomey, the Patient agrees to pay the Hospital's reasonable attorneys' fees, costs and collection expenses, (iii)
If a person other than You (or the Patient's estate) agrees to pay for the services provided to the Patient during
this stay, that person must sign the Financial Responsibility Agreement below.
d. Title to Property Used in Services. Title (o all tangible items delivered fo or used in providing services
("medical supplies", which excludes durable medical equipment) to Medicare patients will pass to the Patient
on the first date the medical supplies are used in treating the Patient. Any warranty for that property is limited
to the manufacturer's warranty, i f any. Patient consents to the Hospital's disposal of any medical waste as
required by law.
9. Financial Assistance
We can help uninsured patients enroll in govemment health care programs, such as Medi-Cal. If the Patient is
uninsured and does not qualify for govemment programs, financial assistance may be available under Dignity
Health's Patient Financial Assistance Policy. To get assistance under this policy, You must complete an
application and give certainfinancialinformation. You will be given a brochure (hat explains our billing
process and our fmancial assistance programs. You may ask to talk to fmancial counseling staff at any time.
10. Third Party Liability
If We are treating Ihe Patient for injuries caused by the actions of others. We may have the right (o additional
payments if the Patient recovers money from the person or entity that caused the injury. I f allowed by law, We
may make a claim against any award of money to the Patient. We may recover an amount equal to the
difference between full charges and the amount the Patient or the Patient's insuxuncc company paid for the
Hospital services. You agree to provide us the name of any person that may have caused the Patient's
injuries, the name ofthe person's insurance company, the name ofthe Patient's lawyer and any other
information that may help us exercise our rights.
11. Patient Certification: By signing thisform, You certify that:
You have read this form
You have received a copy of the form
You were given the opportunity to asfc questions
You understand what it means
You are the Patient or the Patient's Legal Representative
You have received the Hospital Billing Process brochure.
You have received information informing You of your Patient Rights and Responsibilities.
You have received information advising You of the Hospital's policy for implementation ofdefined
Advance Directives.
Notice to consumers: Medical doctors are licensed and regulated by tbe Medical Board ofCalifornia
(800) 633-2322 www.mbc.ca.gov and Physician Assistants are licensed and regulated by (he Physician
Assistant Committee (916) 561-8780 www.pac.ca.gov

^

Dignity Health.
Mferey San jwan Medical Certsir

Nt

107085334

STOI^, TYLER

CONDITIONS OF ADMISSION
AND TREATMENT
Page 3 of 4

m

10082822

DOS:

8/12/2014

tXlB:

10/22/1990

SEX:

F

 Date: 8/12/2014

Signature:

j\jae: 12:31:09 PM

[Patient or Patient's Legal Representative]
Name: STOLZ. TYLER

Relationship to the E^tient:
[Print Name]

Witness Signature: CHANDRA. SANJIT - MSJ
Financial Responsibility Agreement by Person Other than tbe Patient or Patient's Legal Representative:
I agree to accept financial responsibility for services given to the Patient. In particular, I accept the terms ofthe
Financial Agreement, Assignment of Insurance Benefits, and Third Party Liability provisions as stated above.
Date: 8'12/2014

Signature:

jime: 12:31.09 PM

[Financially Responsible Party]
Relationship to the Patient:

Name: STOLZ. TYLER

[Print Namej
Witness Signature: CHANDRA SANJIT - MSJ
For Hospital Use Only: Compliance with Advance Directive Policies
Ilospital representative must check one and sign:
• The Patient is incapacitated or otherwise unable to communicate, the advance directive bfonnation has
been provided to the patient's family or surrogate in accordance with Federal and State law.
• The Patient is unable to receive information regarding advance directives at this time and is not
accompanied by a legal representative. A referral will be made to the Hospital Department responsible for
follow-up.
• The Patient has been given written information about his/her right under state laws to make advance
directives and written Hospital policies regarding the Hospital's implementation of such right.
Also select from beUnv:
• The E'atient has a written advance directive about health care decisions and:
• A copy has been given to the Hospital.
• A copy has not been given to the Hospital, but the Patient has been informed of Patient's
responsibility to give a copy to the Hospital.
OR
• The I^tient does not have a written advance directive about health care decisions and:
• Wants infonnation; a follow-upreferralwill be made.
• Does not wish further information now.
Completed by: CHANDRA. SANJIT - MSJ

# Dignity Hcaltfi,

Date: 8/12/2014

A#

Mercy San Juan Medical Center

Time: 12:31:09 PM

107085334

STOLZ, TYLER

CONDITIONS OF ADMISSION
AND TREATMENT
Page 4 of 4

WW

10082822

DOS:

8/12«)14

DOB:

10/22/1990

SEX:

F

 CM-010
FOR COURT USE ONLY

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, S(aie Bar number, and address):

"Dennis P, McPherson, Esq., SBN 128879
UBALDI & M C P H E R S O N
455 University Avenue, Suite 360
Sacramento, CA 95825
TELEPHONENO.:
ATTORNEY FOR Wame);

FILED
Superior Coisrt Of Caiiforitiia,
Sacramento
06/2G/201S
igutierrez2

FAXNO,:
(916) 265-4568
Plaintiff MERCY SAN JUAN MEDICAL CENTER

(916) 265-4555

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO
STREET ADDRESS: 720 Ninth Street
r^flAiLiNGADDRESS: Sacramento, CA 95814
CITY AND ZIP CODE:

, Deputy

BRANCH NAME:

CASE NAME;

Case Nutnbur:

Mercy V Stolz

CAS
C o m p l e x Case Designation
CIVIL C A S E C O V E R S H E E T
I
I Counter
I
I Joinder
I X I Unlimited
I
I Limited
(Amount
(Amount
JUDGE:
Filed with first appearance by defendant
demanded
demanded is
(Cal.
Rules
of
Court,
rule
3.402)
DEPT:
exceeds $25,000) $25,000 or less)
Items 1-6 below/ must be completed (see instructions on page 2).
1, Check one box below for the case type that best describes this case:
Provisionally Complex Civil Litigation
Auto Tort
Contract
(Cal. Rules of Court, rules 3.400-3.403)
Auto (22)
I
I Breach of contract/warranty (06)
I
I Antitrust/Trade regulation (03)
Uninsured motorist (46)
 
  Rule 3.740 collections (09)
I
I Construction defect (10)
Other PI/PD/WD (Personal Injury/Property
other collections (09)
Damage/Wrongful Death) Tort
i
1,
I
I Mass tort (40)
^
^
'
' iTsiirance coverage (18)
I
I Securities litigation (28)
I
I Asbestos (04)
^ Environmental/Toxic tort (30)
I
I Product liability (24)
I Insurance coverage claims arising from the
I
I Medical malpractice (45)
above listed provisionally complex case
types (41)
I
I Other PI/PD/WD (23)

Non-PI/PD/WD (Other) Tort

Enforcement of Judgment

I

I Business tort/unfair business

I

I Civil rights (08)

I Enforcement of judgment (20)
iVIiscellaneous Civil Complaint

I

I Defamation (13)

I

I Fraud (16)

i

I Intellectual property (19)

I

I Professional negligence (2)

I

I Other non-PI/PD/WD tort (

I

Other complaint (not specified above) (42)
Miscellaneous Civil Petition

Employment
I

I

I Partnership and corporate governance (21)

I

I Other petition (not specified above) (43)

I Wrongful termination (36)

I
I Other employment (15)
This case
I
I is
IX
factors requiring exception?
a. I
I Large number of separately ic^.,>._-.
b. I

I RICO (27)

jles of Court. If the case is complex, mark the

I Extensive motion practice raising difficult or novel e.

issues that will be time-consuming to resolve
c. I
I Substantial amount of documentary evidence
f. I
3. Remedies sought (check all that apply): a. I
I monetary b. I
4. Number of causes of action
5. This case

I

I is

ic of witnesses
1 with related actions pending in one or more courts
in other counties, states, or countries, or in a federal court
I Substantial postjudgment judicial supervision
I nonmonetary; declaratory or injunctive relief c, I

I punitive

(specify):

I X I is not

a class action suit.

6. if there are any l^nown related cases, file and serve a notice of related s ^ e , (You maj

Date: June 25, 2015
Dennis P. McPherson. Esq
(TYPE OR PRINT NAME)

(SIGNATURE OF PARTY OR ATTORNEY FOR PARTY)

NOTICE
Plaintiff must file this cover sheet with the first paper filed in the action or proceeding (except small claims cases or cases filed
under the Probate Code, Family Code, or Welfare and Institutions Code). (Cal, Rules of Court, rule 3.220 ) Failure to file may result
in sanctions.
File this cover sheet in addition to any cover sheet required by local court rule.
If this case is complex under rule 3.400 et seq. of the California Rules of Court, you must serve a copy of this cover sheet on all
other parties to the action or proceeding.
Unless this is a collections case under rule 3.740 or a complex case, this cover sheet will be used for statistical purposes only,
Pago 1 of 2
Form Adopted for Mandalory Use
Judicial Council of California
CM-010 [Rev, July 1, 20071

CIVIL C A S E C O V E R S H E E T

Legal

SoIuuQIlS-

f "'^s ° ' CourX. rules 2.30, 3.220, 3.400-3.403, 3.740:
Cal. Standards of Judicial Administration, sld. 3.10