EPPS COULSON, LLP BLVD .Sl1111c CA1 905111 T111 (213)929-2391] - 929-2394 Dawn M. Coulson, SBN 154085 dcoulson@eppscoulson.com Gabriel M. Courey. SBN 304489 gag- gcourey@eppscoulson.com LR EPPS COULSON, LLP 4/ 011m. 1230 Ste. 200 ?"401 es Torrance. California 9050] 5;,ng i) .2021} (213) 929?2390 Telephone T, (213) 929-2394 - Facsimile Vex?Chm: 1 Attorneys for Plaintiffs, Arlene H. Rosales. as Trustee of The Arlene H. Rosales Living Trust dated February 2, 2012; and David Ross II. LLC SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF LOS ANGELES BOSTQVIEA . ARLENE H. ROSALES, AS TRUSTEE OF Case No.: THE ARLENE H. ROSALES LIVING TRUST DATED FEBRUARY 2, 2012; and DECLARATION OF RAYMOND DAVID ROSS II, LLC, a California limited PELLICER IN SUPPORT OF company, APPLICATION FOR EX PARTE Plaintiffs ORDER APPOINTING RECEIVER AND FOR ORDER TO SHOW CAUSE RE CONFIRMATION OF APPOINTMENT AND TEMPORARY RESTRAINING LEGACY HEALTHCARE CENTER, LLC, ORDER a California limited liability company; ROSE GARDEN SUBACUTE REHABILITATION CENTER, LLC a California limited liability company; DOV E. JACOBS, an individual; MIRIAM TAUB, an individual; and DOES I through 10. inclusive, VS. Defendants. DECLARATION OF RAYMOND PELLICER IN SUPPORT OF APPLICATION FOR EX PARTE ORDER APPOINTING RECEIVER AND FOR ORDER TO SHOW CAUSE RE CONFIRMATION OF APPOINT AND TEMPORARY RESTRAINING ORDER DECLARATION OF RAYMOND PELLICER 1, Raymond Pellicer, declare as follows: 1. 1 make this declaration based on, my personal knowledge. If called upon to testify to the facts in this declaration, I could and would competently do so. 2. In 2015, was employed as the Administrator at the skilled nursing facilities commonly known as Rose Garden Convalescent Hospital (currently known as ?Rose Garden Healthcare Center?) and Legacy Care of Pasadena (currently known as ?Legacy Healthcare Center?). In 2016, these facilities were operated by Rose Garden Subacute Rehabilitation Center, LLC and Legacy Health Care Center. LLC, respectively. 3. Rhodora Intal was one of the service providers that both facilities used to provide physical therapy for the residents. As the former Administrator for both facilities, I know that Ms. Intal was paid for her services in 2015 when the facilities were operated by David Ross, Inc. (Arlene Rosales, President) and PAR Operations, Inc. (Arlene Rosales, President). 4. The current operator of each facility is responsible for paying the service providers. When Dov Jacobs, as Manager for Rose Garden Subacute Rehabilitation Center, LLC and Legacy Health Care Center, LLC, took over as operator on April 16, 2016, his LLCs became responsible for paying the invoices of Ms. lntal. 5. From 2016 through 2018, 1 was employed as an Administrator at Rose Garden Convalescent Hospital and at Legacy Care of Pasadena. 6. Shortly after Mr. Jacobs took over as operator at the two facilities, I began receiving demands for payment from Ms. lntal. I referred her to Mr. Jacobs, as the new operator, so that he could handle her unpaid invoices. 7. Ms. lntal kept calling for payment and repeatedly referred her to Mr. Jacobs. Mr. Jacobs? LLCs were the operators and were responsible for paying Ms. Intal. 8. 1 was unaware that Mr. Jacobs was not making arrangements to pay Ms. Intal until it was too late and I was already subjected to a lawsuit because of his actions. 9. On August 4, 2017, Rhodora Intal ?led a lawsuit naming Dov Jacobs, Rose Garden Convalescent Hospital (still current operated by Dov Jacobs and now known as ?Rose Garden Healthcare Center?), Legacy Care ofPasadena (also still operated by Mr. Jacobs and now known as ?Legacy Healthcare Center?), Independence Healthcare Management, Inc., and myself, after Dov Jacobs failed to pay her for the services she provided to Rose Garden?s residents. A true and correct copy of the Complaint is attached as Exhibit A. 10. On March 7, 2018, a Judgment in the amount of 125,669. 1.9 was entered against all of the Defendants in the lawsuit, including myself, Dov Jacobs, Rose Garden Convalescent Hospital, Legacy Care of Pasadena, and Independence Healthcare Management, Inc. A true and correct copy of the default judgment is attached as Exhibit B. 11. On October 5, 2019, I received a letter from Wells Fargo stating that $3,339.70 was deducted from my bank account as a result of the March 7, 2018 judgment. A true and correct copy of the October 5, 2019 letter is attached as Exhibit C. 12. As an experienced Administrator of a SNF, I know that making sure service providers are paid is critically important. The residents at SNFs, including Rose Garden, are often in frail health and require various services from numerous outside providers. Failing to pay service providers runs the risk that the residents? health and safety will be compromised as service providers that are not paid inevitably stop providing necessary services. 13. When I was working as an Administrator under Dov Jacobs, there were numerous incidents where I had to deal with vendors and other service providers that were not being paid. On one occasion, I even had to inform Mr. Jacobs that the gas company had employees on site to shut off our gas if the bill was not paid immediately. 14. One of the reasons that I resigned as Administrator of both facilities in 2018 was due to the stress of having to constantly deal with service providers and vendors that were not being paid by Mr. Jacobs. I declare under penalty of perjury under the laws of the State of California that the statements above are true and correct. - 2: Date: February 2, 2020 525%) iv . RAYMOND PELLICER Exhibit A 5. I I ?if it :6 ATTORNEY OR PARTY (Name, State Bar number, and address): FOR COURT USE ONLY EDUARDO M. LOPEZ. ESQ. SEN 129575 LAW OFFICES OF EDGARDO M. LOPEZ 3600 Wilshirc Boulevard, Suite 17l6 Los Angcics. Califomia 900i 0 3 gig} TELEPHONE no: (213)380-3939 FAX no (omens);- (213)380-1611 int?: t?lit?i'l'l' ADDRESS (Optional) ATTORNEY FORtName): PlaintitTRhodora'l?. intal Physical Am?; 0 4 SUPERIOR COURT OF CALIFORNIA, COUNTY OF loos STREET ADDRESS liast . . . I 7 ., -. 9,5. u; 1" latte-m ll. flat?? l?z?rli . g. MAIUNG ADDRESS It? {Mwiwwm CITY AND ZIP CODE- Bur tilt. CA 02 "tent: nami?f BRANCH NAME. . PLAINTIFF: Rhodorc Inlal Physical 'l?hcmpisunc. DEFENDANT: Rose Garden Convalescent l-lospital, Legacy Caro ol?Pasadcna, Independence Health Care Jacobs, Raymond Pclliccr and DOES 1 TO 20 inclusive CONTRACT 00".me AMENDED COMPLAINT (Number): AMENDED CROSS-COMPLAINT (Number): Jurisdiction (check all that apply): ACTION iS A LIMITED CIVIL CASE Amount demanded does not exceed $10,000 EC 0 6 7 7 6 exceeds $10,000 but does not exceed $25,000 2 1 ACTION as AN UNLIMITED CIVIL CASE (exceeds $25,000) . I ACTION ts RECLASSIFIED by this amended complaint or cross-complaint Efrem limited to unlimited l:]from unlimited to limited CASE 1. Plaintiff? (name or names): Rhodora T. lntal Physical Therapist, .lnc. alleges causes of action against defendant? (name or names): Rose Garden Convalescent Hospital, Legacy Care of Pasadena, Independence Health Care Management at . This pleading, including attachments and exhibits, consists of the following number of pages: 5 3. a. Each plaintiff named above is a competent adutt except plaintiff (name): Rhodora lntal Physical Therapist, Inc. (1) -a corporation quali?ed to do business in California (2) Dan unincorporated entity (describe): (3) mother (specify): b. Plaintiff (name): a. :lhas complied with the ?ctitious business name laws and is doing business under the ?ctitious name (specify): '13- l:l has complied with all licensing requirements as a licensed (specify): 0. El information about additional plaintiffs who are not competent adults is shown in Attachment 3c. 4. a. Each defendant named above is a natural person except defendant (name): Rose Garden Conva~ except defendant (name): Legacy Care of Pasadena (1) a business organization, form unknd??cent (1) a business organization, form unknown (2) a corporation HOS pi ta 1 (2) a corporation (3) an unincorporated entity (describe): (3) an unincorporated entity (describe): (4) a public entity (describe): (4) E: a public entity (describe).- (5) other (speci?x): (5) other (specify): II this form is used as a cross-complaint, plaintiti means and defendant means cross-defendant. P899 1 Of 2 COMP LAINT?Contract Code of cm: Procedure. 425 12 PLD-C-OOI [Rev January 1, 2007] RECEIPT 4 DRTE FQID: ??f?4fl? ?5 PQVMEHT: 315 CHECK: $495 hm NEE it; ?i in CQRD: 50,00 PLD-C-001 SHORT TITLE: CASE NUMBER: lntal Physical vs. Rose Garden Convalescent et a1. 4. (Continued) b. The true names of defendants sued as Does are unknown to plaintiff. (1) Doe defendants (specify Doe numbers): 1'10 were the agents or employees of the named defendants and acted within the scope of that agency or employment. (7-) Doe defendants (specify Doe numbers): 1 140 are persons whose capacities are unknown to plaintiff. c. Information about additional defendants who are not natural persons is contained in Attachment 4c. d. Defendants who are joined under Code of Civil Procedure section 382 are (names): 5. Plaintiff is required to comply with a claims statute, and a. El has complied with applicable claims statutes. or b. is excused from complying because (specify): 6. This action is subject to Civil Code section 1812.10 Civil Code section 2984.4. 7. This court is the proper court because a. a defendant entered into the contract here. b. I: a defendant lived here when the contract was entered into. c. a defendant lives here now. d. the contract was to be performed here. e. a defendant is a corporation or unincorporated association and its principal place of business is here. f. :1 real property that is the subject of this action is located here. 9. other (specify): 8. The following causes of action are attached and the statements above apply to each (each complaint must have one or more causes of action attached): Breach of Contract Common Counts Other (specify): Breach of Implied Covenant of Good Faith and Fair Dealing 9. Other allegations: This action is based in whole or in part upon an open book account which accrued after January 1, . . 1987, and Plaintiff is therefore entitled to recover attorney?s fees pursuant to Section 1717.5 of the Owl 10. Plaintiff prays forjudgment for costs of suit; for such relief as is fair, just. and equitable; and for Code . a. damages of: 99,731.95 b. interest on the damages (1) according to proof (2) at the rate of (specify): 10 percent per year from (date): August 1, 2016 c. attorney's fees of: (2) according to proof. d. I: other (specify): 11. I: The paragraphs of this pleading alleged on information and belief are as follows (specify paragraph numbers): Date: July 24, 2017. 3 EDGARDO M. LOPEZ, ESQ. (TYPE OR PRINT NAME) OR ATTORNEY) 3 (if you wish to verify this pleading, affix a veri?cation.) h: [Rev. January 1, 2007] Page 2 012 SHORT TITLE: Rhodora T. Intal Physical Therapist, Inc. V. Rose Garden, et a1. CASE NUMBER: FIRST CAUSE OF of Contract (number) ATTACHMENT TO Complaint Cl Cross - Complaint (Use a separate cause of action form for each cause of action.) BC-1. Plaintiff (name): Rhodora T. Intal Physical Therapist, Inc. alleges that on or about (date): September I, 2015 a written l:i oral other (specify): agreement was made between (name parties to agreement): A copy of the agreement is attached as Exhibit A, or The essential terms of the agreement are stated in Attachment 80-1 802. On or about (dates): February 2017 defendant breached the agreement by the acts speci?ed in Attachment BC-2 (specify): Failing to pay for services rendered. I: are as follows (specify): i:i the following acts BC-3. Plaintiff has performed all obligations to defendant except those obligations plaintiff was prevented or excused from performing. 8C4. Plaintiff suffered damages legally (proximately) caused by defendant's breach of the agreement El as stated in Attachment BC-4 I: as follows (specify): In the amount of $99,731.95 plus interests at the rate of 10% per annum. BC-5. Plaintiff is entitled to attorney fees by an agreement or a statute of according to proof. 80-63. Other: .c FWAprved?O'Omna' Use CAUSE OF of Contract . 3 Judicial Council of Califomia [Rev. January 1. 2007] Page 3 ?ags-Lou Code of Civil Procedure. 425.12 W.courfinfo. cagov SHORT TITLE: CASE NUMBER: Rhodora T. Intal Physical Therapist, Inc. v. Rose Garden Convalescent, et a1. SECOND CAUSE OF Counts (number) ATTACHMENTTO Complaint [3 Cross-Complaint (Use a separate cause of action form for each cause of action.) Plaintiff (name): Rhodora T. Intal Physical Therapist, Inc. alleges that defendant (name): Rose Garden Convalescent Hospital, et al. became indebted to plaintiff other (name): a. within the last four years (1) on an open book account for money due. (2) El because an account was stated in writing by and between plaintiff and defendant in which it was agreed that defendant was indebted to plaintiff. is. within the last two years four years (1) CI for money had and received by defendant for the use and bene?t of plaintiff. (2) for work, labor, services and materials rendered at the special instance and request of defendant and for which defendant promised to pay plaintiff. the sum of 99,731.95 the reasonable value. (3) for goods, wares. and merchandise sold and delivered to defendant and for which defendant promised to pay plaintiff the sum of the reasonable value. (4) for money lent by plaintiff to defendant at defendant's request. (5) for money paid, laid out, and expended to or for defendant at defendant's special instance and request. (6) other (specify): CC-2. 99,731.95 which is the reasonable value. is due and unpaid despite plaintiff's demand, plus prejudgment interest according to proof at the rate of 10 percent per year from (date): Plaintiff is entitled to attorney fees by an agreement or a statute C) of according to proof. C04. Other: Page 4 ?ml. . . . Form Approved for Optional Use Code of cm Procedure. 425.12 1 Judicial Council of Califomia CAUSE OF ACTION common counts (Rev. January 1. 2009] MC-025 CASE NUMBER: SHORT Rhodora T. lntal Physical Therapist, Inc. v; Rose Garden, et at. (Number): 4 (This Attachment may be used with any Judicial Council form.) THIRD CAUSE OF ACTION - Breach of Implied Covernant of Good Faith and Fair Dealing Plaintiff realleges and incorproates all of the preceding paragraphs in this complaint. California law implies a covenant of good faith and fair delaing in all contracts between parties entered into in the State of California. As a result of the action of all the defendants and each of them, set forth hereinabove, said defendants have violated the implied covenant of good faith and fair dealing in the agreement as against the Plaintiff herein, and as a result thereof, Plaintiff is entitled to damages prayed, according to proof. (if the item that this Attachment concerns is made under penalty of perjury, all statements in this Page i of 5 :21] Attachment are made under penalty of penury. (Add pages as required) Form Approved for Optional Use ATTACH ENT Judicial Council ofCalifomia . . . to inc-025 [Rem July 1.2009] to Judncnal COUDCII Form MC-025 SHORT TITLE: CASE NUMBER: Intal Physical vs. Rose Garden Convalescent et a1. ATTACHMENT (Number): 5 (This Attachment may be used with any Judicial Council form.) 4. a.Each defendant named above is a natural person except defendant (name): Independence Health Care Management,Ir:c. (1). a business organization, form unknown (2). a corporation (3). an unincorporated entity(describe): (4) a public entity(describe): (5). other (specify): (If the item that this Attachment concerns is made under penalty of perjury, all statements in this Page (I of 2 Attachment are made under penalty of perjury.) A pages as required) Form Approved for Optional Use ATTACH NT Judicial CouncilofCalilomia . . . Mcezsmev. July 1. 20091 to Councn Form I A EXHIBIT A THERAPY CONTRACT This agreement made this of September-12035 by and between a cooperation doing business as: Rose Garden Convalescent Hosnitai (Name of facility)(hereinafter referred as ?PU-and Rhodora T. Intai Physical Therapist, Inc (Name of Vendor)(hereinafter referred to as ?Vendor or of Vendor will provide Physical Therapy Services 1. fl arm; This agreement shall commence on Sentem her 01. 2015 and shall automatically renew itself at the end of each year without any further notice between parties. Either party may terminate thisagreement without cause upon thirty (30) days written notice to ?order partysuch termination. may terminate this Agreementfona .causeon 48 hours notice by phane toxV. ?For cause? means improperly performed services-or billed improperly in the sole judgement of F. No prior writ-ten notice-or warnings-needs .to have been given t'by Fin order for to terminate ?For cause?. Notice: Any notice required to be provided to any party to this agreement shall be in writing and shall be considered effective as of the date of the deposit with'the United States Postal Service by certi?ed or registered mail, postage, prepaid,. return receipt and addressed to the parties as follows: Vendor Rhodora T. Intai Physical Therapist, Inc. 2739 Fountain St. Pomona, Ca 91767. i531 N- mod (MAM Services: The parties agree that is to provide-only services under terms of this Agreement in Accordance with allappiicabie government-requirements. ?Shall render services in accordance wither-dots given the physicians if requested by F. will participate in (1) utilization review or managed care meetings; (2) Patient Care Policy committee meetings; (3) Resident care plan conference; (4) Interdisciplinary team meetings; (5) Eva- luations/ screening of all residents on admissions; and (6) Provide consultations and in-services to the staff. Primary therapist in will he a licensed or registered therapist. Facility: Rose Garden Convalescent Hospital Billing and Payment Procedure: Attached an Exhibit are the charges for all Physical, Occupational Speech therapy provided. Such charges shall not becharged without written approval by F?s home of?ce. Billing shall be for services beginning the ?rst day of the month to the last day of the month (hereinafter referred to as the Billing Period?) according to submitted to no tater than seven (7) days-after-theend of the billingperiod. will owe to on any contract between them. Payment due after-60?? '75?-day of the billing month. Denialwor Disallowanee: F-shali have the right todeny 50% of payment to on any service ?billed ?by which is denied or disallowed ?by Medicare or other payer source (tag. HMO) either on auditor disallowed at closure of cost report or other review denied or disallowed before or after the date of this agreement. If payment is made by on a claim and then on an audit or review such payment is denied, disallowed or put under review, then shall be credited in such amount on we then current bill otherwise owed to V. If no-longer servicee'F, shall . nevertheless be liable to: repay F. 10. Suchliability ishere by guaranteed personally by the ownership/p ri'ncipalsof V. On request from F, shall contest and appeal any denial at its own expense. If for any reason believes services are excessive, may withhold or deny payment on bill from for its services. will cooperate in any appeal process. If on its own elects to appeal, agrees to provide with any additional information needed for said appeal. agrees to reimburse within thirty (30) days of his receipt-ofzsaid recovered amounts, minus the costofattorney?s fees and cost incurred in :such recovery. ?V'shall not beowed payments for HMO patients unless treatment authorised authorized in writing by F?sadm'inistrator and iv followed F?s managedrcarc protocols-and completed all F?s required HMO forms. Vsunderstands that in effect including without limitation getting written authorization fromadmini?strator for all treatments and following module/prices guidelines set by F. gecords: shall maintain at all'time service and therapy logs. Such logs shall be submitted to together with. each request for payment and approved by before will become liable: for V?s service. Amy adverse conscq uences from not maintaining these logs properly shall be the burden of. V. Pursuant to section. 1381000). of Title-42. of the United States Code. shall make available a copy of this contract and suchrecords necessary to certify the cost of service provided by for four (4) years after termination of this agreement. Independent Contractor: This agreement does not constitute ahiring of by F. It is theparties Intention that shall be anuindependent contractor and not F?s employees. Vishall retainsole and absolutediscretion and judgments in the mannerand meansof providing services to provided Vcomvplicswith all policies and regulations of Fedc raliState Agencies and F. This .agreem ent shall net be constructed as a partnership F"shall not be liable for any loan rned by V. V?s services shall be rendered in an ef?cient and satisfactory manner in?strict accordance with the currently approved methods and practices in V?s professional Specialty. Vendor?sgzuali?catigns: will submit a copy of current license-and for registration with. renewals from applicable regulatory authorities. Will submit a. copy of hisfher resume demonstrating professional memberships, training- and diplomas that demonstrate that is quali?ed by educationandlor experience to render services. Working Area and Equipment: Any specialized equipment necessary for V?s accomplishments of theservices under-misragreement not already provided byF-s?hadl be the responsibleof V. Insurance Indemnity: V'shallsubmit to Fa policy oracerti'?cate ofinsurance issued byan insurance company to F. Indicating that has (1) worker?s Compensation and (2) complete liability insurance coverage, including coverage for any acts of professional malpractice. Such insurance shall be in amounts reasonably satisfactory to but not less than $1,000,000.00 per person or incident and ($300,000) each occurrence of property damage. Said policies shall cover errors and omissions-and provide that the insurance company will not cancel said policy of insurance without giving 10 days-advance written notice. This agreement shall terminate if cannot maintain insurance coverage-duringterm of this-agreement. agrees to save indemnity, defend and hold harmless from any injury or damage that may result to. any person or property by or from any actor emission to act by or V?s agent, employees. or invitees or from any damage incurred by V?s agent, employees from any cause whatsoever arising from or related to V?s performance under this Agreement. shall render defense at V?s sole cost on behalf of for any proceeding or Suit in connection with such allegation of damage. -.. s. 10. Suchliability ishere by guaranteed personally by the ownershiplpri'ncipalsofv. On request from F, shall contest and appeal any denial at its (mm expense. If for any reason believes services are excessive, F'may withhold or deny. payment on bill from far its Services. will cooperate in any appeal process. If F?on its owo elects to appeal, agrees to provide With any additional information needed for said appeal agrees to tel-m bumeV within thirty (30) days 401' his receipt-ofzsald P?mm?lmt? minus thei?ostnfa?tomegds fees and cost incurred in snehmmy?l?shallnot beowed payments for HMO patients unlessuea?cmen?taufhoo?lmed authorized in writing by F5 adminismtorzand followed managed care pmtoccband F?s required EMQ forms. inclfoct including without limitation getting- written-authorization from administpator for all theatmems and following module/prices guidelines set by F. shall maintain stall timeseruiceand therapy logs. Such logs-shall hesnhm-itted to together ndth. each request for payment and approved by. before F-will become liable. for We service. Any adverse co uences from not maintaining shall he the bursts: of. V. Pin-scant to; sec?oml?aiml): of 'l?ille42 of the United Stateande; shall make axailahle a copy ofthiscontnactend suchlrecord's neceSsai-ytn certify thccostof service provided by for four (4) years after termination of this agreement. . trae . Thisagreemcni doeinotco 'uteahirin-gofv by F.1tlsmepar?es Intention clhat shall- be anzindependent-contcactormnd notIl?fsemp'lOyeosa retainsOIe and ahso?lute-discretlhn and judgments in the to presided VcOinpliesewith all policies and-regulations of FederahlStane Agencies and F. This agreement shall not as a Ffshall not-be liable fur-anylinturrcd by V. V?s services Shall be rendered in an efficient and 'sa?sfactery manner inst?ct accordance with the currently approved methods and practices-in ?V?s professional Specialty. Vgn' dam [gli?ca?Q? will submits copy afoul-rm" for regim-a.? tion with renewals front-applicable negnlator?y authorities. Will submit alcopy of hither resume memberships, trainingand diplomas that demonstrahe' that is quali?ed by edm?onzandlor experience to. render 58m. ,?g?dng? Area and Egulpment Any specialized equipmentneceSSary for V?szacc?omplishments not the sardines under thisaagt?eement not already providedhy .llshall hethe fesponsiblceof V. um ea 1? . ?Yrshallsubmitto Fa policy 'ai?in'snmm issued hyan insurance company to Indicating that has (1) worker?s Compensation and (2) complete liabilityinsuran'ce coverage, including coverage for any acts of professiOn-al malpractice. Such insurance shall be in amounts reasonably satisfactory to hut'ho?t less than $1,000,000.00 per person-0r incident each occurrence of property damage. Said policies shall cover yernm'sland omisSions-and provide that the'insurance company will not cancel said policy withwt giving 10 days advance written notice. Thisagreem ent shall terminate if V?cannot maintain insurance coveragednringterm of thisagxeemisnt. V- agrm to save imlemnity;i defend and hold F- har-mless from any injui-yor damage that maymsult to any person or property by or from any act or- emission to act by Or Y?s agent, employees or invitees or from any damage incurred by V?s agent, employees from any cause whatsoever arising frIOm or related to V?s performance under this Agreement. shall render defense at V?s-sole cost on behalf of?F for any proceeding or Suit in connection with such allegation of damage. . .. . 4' 11. Arbitration: In a dispute. where acetammpensation from under any Went, thepam'es: Shall submit tobinding arbitration toacoordanee withthe rulesoi? the American Arbitration ASsociation with each party to be responsible for its own attorney fees and costs incurred in such dispute. No attorney fees or cost shall be due to the prevailing party. Prior to Such Submission, each party shall make ?a good faith effort to mediate the dispute through an arbitrator?'esigued by the as a mediator. Thereafter, after at least such mediation - meetings, if the parties ran?not the mediator-on aisettlement, the parties pursuant to thezrules'of Fishall befree to pursue in scivil court ifr?V?ssei-vices is defective many mayor ifF'?aoed bysa thind party becaweof'V?s conduct. 12. Facing Corporate Of?ce: acknowledges and agrees that until signed by the chief ?nancial Of?cer, this Agreement or any modi?cation thereto will not be binding upon the parties hereto. 13. _Q~?vil Rights: agrees to comply with Title VI if the: Cinil Rights Act of 1964 and all - req uinementsef the Department ewamEducat-ioniand welfare and related regulations. '14. gem adios: In addition to those remedies provided herein. F-shall available all remedies provided bylaw. 1'5. Thisagreement may notbesingd by either partywithout express written consent of-the other party. Each: party tothis agreementacimowledgoa that no representation, promises uragreementonanyor o?ierwise inure been made in their behalf?ietae?ether; 16. shall notify of any ADR as soon as receives an audit letter and give 12-2 weeksto review.- all rehab documentation. shall?p?rovide all-reviewed documentation to prior to submission of an appeal letter to CMS. Agreement, Statement" or promise not contained in the. Agreement shall be valid or binding. Any modi?cation of ?ns Agreement will be effective only ifit is signed by all parties. to this Agreement. Alumni/clan) Bll?f (349.1(- ?Da?e Date- - 3. i 1? a? 3.. 5.35.} Rhodora T. Intal Physical Therapy Services, Inc. 2739 Fountain St, Pomona Ca 9176.? Tel. No. (213)448-7127 fax Email: - PROPOSED RATES FOR THERAPY SERVICES FOR ROSE GARDEN CONVALESCENT HOSPITAL: PART A: permin. PART B: 1. 75% Vendorand 25% Facility HMO Skilled 1. Level 2: 80 per day Level 90 per day 2. Speech Therapy: $1.25 pea: minute MEDICAL 1. WK 11. 12. 13. 14. ggrbi'tration: In a dispute. where. seeks compensation from under any agreement, theparties shall submit tobinding arbitration to accordance withthe rules of the American. Arbitration Association with each party to be responsible for its own attorney fees and costs incurred in Such dispute. No attorney fees or cost shall be due to the prevailing party. Prior to such submission, each party shall make a good faith effort to mediate the dispute through an arbitrator designed by the AA as a mediator. Thereafter, after at least two such mediation - meetings, if the parties cannoi volu'ntary?agree with the m?ediatoron asettlemenh the parties shall commence arbitration parsnant to the rulesiof Ari-A. F-ishai] be free to pursue in civil court is defective in:any wayior ij? Fis sued by-a third party becausewof W5 conduct Facilitv Corporate Of?ce: acknowledges and agrees that until signed by the chief ?nancial Of?cer, this Agreement or any modi?cation thereto will not be binding upon the parties hereto. Civil Rights: agrees to comply with Title VI if the Civil Rights Act of 1964 and all req uirements- of the Department of Health, Ed ucation-and welfare and related regulations. Remedies: In addition to those remedies provided herein. shall available all remedies provided by law. 15. Miscellaneous: This agreement may not besigned by either partywit?hout express written 16. consent of the other party. Each party to this agreement acknowledges that no representation, promises or'agreement, orally or otherwise have been made byanypartyorianym-oreacting in their behalf theme ether. shall notify of any ADR as soon as receives an audit letter and give 1-2 weeks to review: all rehab documentation. shall provide all reviewed documentation to prior to submission of an appeal letter to CMS. Agreement, statement or promise not contained in the. Agreement shall be valid? or binding. Any modi?cation of this Agreement will be effective only if it is and signed by all parties to- this Agreement. airl? all; tquu blrille (Ma/if ?Daile Date: .. -.. .. . . THERAPY CONTRACT agree nt made th?M lib by and between a cooperation doing business as: RM lot ol? Roi (Name of facilitthereinaftel reierred as ea") and hoEo T. Intel Physical Therapist, Inc (Name of Vendor)(hereinatter referred to as ?Vendor or? ?o Vendor will provide Physical Therapy Services I. Ie_rm_; This agreement shall commence on ?5 and shall autom tically renew itself at the end of each year withdut'any further notice between parties. Either arty may terminate this agreement without cause upon thirty (30) days written notice to order arty such termination. may terminate this Agreementfor a cause on 48 hours notice by pho to V. ?For cause" means imprOperly performed services or billed improperly in the sole Ju gement of F. No prior written notice or warnings needs to have been given by in order to terminate ?For cause?. 2. ?otice; Any notice required to be provided to any party to this agreement shall be in writing and shall be considered effective as of the date of the deposit with the United States Postal Service by certi?ed or registered mail, postage, prepaid, return receipt and addressed to the parties as follows: Vendor: Rhodora T. Intal Physical Therapist, Inc. . 2739 Fountain St. Pomona, Ca 91767 acme. Lena/4 Did a (incite [670 Mi one an; in. di ?liloia 3. 8311355; The parties agree that is to provide only services under terms of this Agreement in Accord anee with all applicable government requirements. shall render services in accordance with orders given the physicians if requested by F. will participate in: (1) utilization review or managed care UIR meetings; (2) Patient Care Policy committee meetings; (3) Resident care plan conference; (4) Interdisciplinary team meetings; (5) Eva? iuatio screening of all residents an admissions; and Provide consultations and in-services to the tail?. Primary therapist in will be a licensed or registered therapist. cc - Attached an Exhibit are the charges for all Physical, Occup tionai 82 Speech therapy provided. Such charges shall not be charged without written appro by F?s home of?ce. Billing shall be for services beginning the first day of the month to the lint day of the month (hereinafter referred to as the Billing Period?) according to submitted to no later than seven (7) days after the end of the billing period. will owe to on any contract between them. Payment due after 60?? 'day of the billing month. 5. MW shall have the right to deny 50% of payment to on any service billed ly which is denied or disallowed by Medicare or other payer source (eg. HMO) either on auditor disallowed at closure of cost report or other review denied or disallowed before or after it date oi?thls agreement. if payment is made by on a claim and then on an audit or review such payment is denied, disallowed or put under review, than shall be credited in such agnount on it?s then currentbill otherwise owed to V. If no longer services F, shall nevert teless be liable to repay F. 6. 9 0 Such liability is here by guaranteed personally by the ofV. On request from F, shall contest and appeal any denial at its own expense. If for any reason believes services are excessive, may withhold or deny payment on bill from for its services. will cooperate in any appeal process. If on its own elects to appeal, agrees to provide Fwith any additional information needed for said appeal. agrees to reimburse within thirty (30) days of his receipt of said recovered annuals, minus the cost of attorney?s fees and cost incurred in such recovery. shall not he owed payments for HMO patients unless treatment authorized authorized in writing by F's administrator and followed F?s managed care protocols and campleted all F?s required HMO forms. understands that in effect including without limitation getting written authorization from administrator for all treatments and following madt guidelines set by F. Ramos; shall maintain at all time service and therapy logs. Such logs shall be Submitted to tog: titer with each request for payment and approved by before will become liable for V?s service. Any adverse consequences from not maintaining these logs property shall be the burden of V. Pursuant to section 13951900) of Title 42 of the United States Code. shall ILnake available a copy of this contract and such records necessary to certify the cost of service provided by for four (4) years after termination of this agreement. Rhyming; This agreement does not constitute a hiring of by F. It is the parties Intention that shall be an independent contractor and not F?s employees. shall retain sole and absolute discretion and judgments in the manner and means of providing services to provided complies with all policies and regulations of FederaiIState Agencies and F. This agreement shall not be constructed as a partnership Fshall not be liable for any incurred by V. V?s st rvices shall be rendered in an efficient and satisfactory manner in strict accordance with the currently approved methods and practices in V?s professional specialty. - will submit a copy of current license and for registration with renewals from applicable regulatory authorities. will submit a copy of blather resume stra?ng professional memberships, training and diplomas that demonstrate that is qualified by education and/or experience to render services. 9. Boris Any specialized equipment necessary for V?s accomplishments of the services under this agreement not already provided by shall be the responsible of V. 10. MW shall submit to Fa policy or certificate of insurance issued by an insurance company to F. Indicating that has (I) worker?s Compensation and (2.) complete liability insurance coverage. including coverage for any acts of professional malpractice. Such insurance shall be In amounts reasonably satisfactory to but not less than $1,000,000.00 per person or incident and ($300,000) each occurrence of property damage. Said policies shall cover errors and omissions and provide that the insurance company will not cancel said policy of in turancc without giving F10 days advance written notice. This agreement shall terminate if ca nnot maintain insurance coverage during term agreement agrees to save inde city, defend and hold harmless no": any injury or damage that may result to any per: 11 or property by or from any act or omission to act by or V?s agent, employees or invtt ea or from any damage incurred by W: agent, employees from any cause whatsoever arlsi from or related to performance under this Agreement. shall render defense at X?s to cost on behalf of for any proceeding or suit in connection with such allegation of am ge. - a 11. ill? - In a dispute where seeks compensation from under any agreement1 the parties shall bm it to binding arbitration to accordance with the rules of the American Arbitration Association with each party to be responsible for its own attorney fees and costs lncurrtd in such dispute. No attorney fees or cost shall be due to the prevailing party. Prior to such alibmission, each party shall make a good faith effort to mediate the diapute through an designed by the as a mediator. Thereafter, after at least two such mediation meetings, it the parties cannot voluntary agree with the mediator on a settlement the parties shall mmenco arbitration pursuant to the rules of shall be free to pm?ue in civii cougt i 'tV?s services is defective in any way or if is sued by a third party because acknowledges and agrees that until signed by the chief ?nancial Officer, this Agreement or any modi?cation thereto will not be binding upon the parties hereto. i3. agrees to comply with Title Vi ii? the Civil Rights Act oi? 1964 and all . requirements of the Department of Health, Education and welfare and related regulations. i4. Wig; In addition to those remedies provided herein. shall available all remedies provided bylaw. This agreement may not be signed by either party without express written consen of the other party. Each party to this agreement acknowledges that no representation, promis or agreement, orally or otherwise have been made by any party or anymore acting in their half that no other. 16. Fshail otiiy of any ADR as soon as receives an audit letter and give 141 weeks to review all rel: documentation. shall provide all reviewed documentation to prior to submission of an dppeai letter to CMS. AgreemennLatatement or promise not contained in the Agreement shall be valid or binding. Any modiiloatlm of this Agreement will be effective only tilt is in writing and signed by all parties to this Agreement impel Oils . Mmj?dn?m? WWEWW title [agile Dale Date chi. - mumsAl?nquXu-v u? . . . Rhodora T. Intal Physical Therapy Services, Inc. 2739 Fountain Pomona Ca 91767 Tel. No (213)448-7l27 fax Email: PROPOSED RATES FOR THERAPY SERVICES FOR LEGACY CARE NURSING HOME: PART A: @?lelm PART B: 1. 75% Vendor and 25% Facility fQ/el??sl? HMO Skilled 1. Level 2: 80 per day Level 3: 90 per day 2. Speech Therapy: $1.25 per minute wkug MEDICAL 1. Exhibit NEW mews oi: amounts? are new wrmodr? meme sun: am sumo ?otsam! for cram Stamp- tows BLANK IF some ls BY CLERK OF WE count} Supexior Court of Los Angeles County. North ,Central Glendale District 600 E. Broadway NCGD -- Glendale, CA 91206 8' (foamy mm ATTORNEY FOR (Nome): SUPERIGR COURT OF CALIFORNIA, COUNTY OF L95 ANGELES MAR if .3 COURTHOUSE ADDRESS: I 12th Glendale Courthouse 600 E. Broadway Ave. 1 Glendale, CA 91206 4 PmmifF: Mil-Cam; whom? Rhodora T. Intel Physical Therapist, Inc. oeremoaar? . mm Rose Garden Convalescent Hospital et a1. NOTICE OF ENTRY OF: [El JUDGMENT Li] 7 EC067076 OTHER ORDER To the above named parties and to their attorneys of record, you are hereby given notice of entry of: Judgment in the above-entitled matter. entered on (date): MARCH 07. 2018 Order of Dismissal in the above-entitled matter, ?led on (date): El Order . ?led on (date): DECLARATION or MAILING I, (typed or printed name) LARRY HIRONAKA 7 do hereby (check one): declare under penalty of perjury under the laws of the State of California that I am an active member of the State Bar of Califomla; declare under penalty of perjury under the laws of the State of California that I am . (check one) employed in a resident of Los ANGELES County, (where mailing downed) over the age of 18 years. and not a party to the cause within; that my (check one) businesle] residence address is as shown above; and that on the date shown below I served the notice of entry of the above-named document ?led and entered herein, by depositing true copies thereof in sealed envelope(s). with postage fully prepaid. in the United States Mail Service located at GLENDALE CALIFORNIA (city) (state) addressed to the parties named below: EDGARDO M. LOPEZ, ESQ. 1 1 Law Offices of Edgardo M. Lopez 3600 Wilshire Blvd., Suite 1716 Los Angeles, CA 90010 Additional names and addresses on attached sheet. Dated: - MR 1 21m Signed: a . ordealamnt) L. NAKA Typed or printed name of decialanti - HIRONAKA 123 (Rev. 0110?) NOTICE OF ENTRY OF Code cw. Pros. 664.5. 10133 LAsc Approved 01.05 DIS MISSAUOTHER ORDER Cal. Rules crooun. rules 8.104 a 8.751 none ATTORNEY oi; mart wrrnour ATTORNEY tum, an, be: marrow, and address}: FOR COURTUSE {my .. eoonttoo M. LOPEZ. ESQ. SBN 129575 Law Of?ces of Edgardo M. Lopez 3600 Wiishit'e Boulevard, Suite i716, LoeAttgoies, California 90010 newenona no: PM No. ten-me. (213)330-1611 3 . em menses edlopezlew?ca .meilcom mower Foe i?teintiff Rho ore. T. Intel Physical Therapistlne. I sweeten-count or: CALIFORMA. count? OF Lee Angeies MR 0 1? ?018 smear newness; 6 Broadwny MAKING Cinnamon. Glendale, CA 91203 BRANCH MAME: North Central District Rhodora total Physical Therapist, inc. oemsnonm: Rose Garden Convateeoent Hosnimlet at. CASE NUMBER JUDGMENT By Clerk By Default After Court rrtat EC067076 By Court i:l On Stipulation Defendant Did Not AppearatTrlai JUDGMENT 1. av DEFAULT Defendant was properly served with a copy of the summons and oompteint. b. Defendant failed to answer the complaint or appear and defend the action within the time allowed by law. 0. Defendant's default was entered by the Clerk upon plaintiff?s application. d. Clerk's Judgment (Code Civ, Proc. 5 585(3)). Defendant wee sued only on a co this state for the recovery of money. . Court Judgment (Code cw. Proc.,? 585th?. The court considered (1) I: plaintiffs testimony and other evidence. . .- . (2) E3 written decimation (Code cw. ProcSTIPULATIOM 3. Plaintiff and defendant agreed (stipulated) that a judgment be entere judgment and b. the signed written stipulation wee ?ied in the use. c. the stipulation wee stated in open noon the stipulation was stated on the record. 3. AFTER COURT The jury was waived. The court considered the evidence. a. The case was tried on (date and time): before (name of judicial of?cer): b. Appearances by: Plainti? (name each): Plaintiffs attorney {name each}: (1) (1) (2) (2) Continued on Attachment 3b. Defendant (name each): I: Defendant ?s attorney {name each): (1) (1) (2) (2) Continued on Attachment 3b- c. Defendant did not appear at trial. Defendant was properly served with notice of trial. d. Astetement of decision (Code Civ. Proc. ?632) was not was requested. ntract or Judgment of a court of In this case. Tire court approved the stipulated Pmton Form Approved tor opium our JUDGMENT Code of Civil Procedwo. 55 535, 054 6 Commit oi Catiiomin (New January 1, 2002] PLAINTIFF: Rhodora T. Inc. . EC067076 w} DEFENDANT: Rose Garden Convalescent Hospital et a1. JUDGMENT Is ENTERED As FOLLOWS BY: THE COURT THE CLERK 4. E3 Sttpuiated Judgment Judgment is entered according to the etiputation of the parties. 5, Parties. Judgment is a. for plaintiff (name each): c. for (name each): - Rhodora Intel Physical Therapist Inc. and against defendant (names): and against orese?c?aefendant (name each): Rose Garden Convalescent Hospital Continued on Attachment 5a. Continued on Attachment 5c. b. for defendant (name each): d. for moss-{tetendant (name each): 6. Amount. a. Oran-demure named In item so above mun! pay 8- Detendant named In Item an above must cross-oomptainant on the cross-oompteint: pay plaintiff on the complaint: (1) Damages 99,731?95 (1) Damages (2) Prejudgment 19,946.39 (2) Prejudgment 3 interest at the interest at the annuai rate of 10 annuat rate of (3) Attomey fees 5,000.00 (3) Attorney fees (4) Costs . 990.85 (4) Costs (5) Other (spam): 5 (5) (6) TOTAL 125,669.19 (6) row. b. Plaintiff to receive nothing from defendant 7 d; [j Cross-complainant to receive nothing from named in item 5b. cross-defendant named in item so. Defendant named in item 5b to recover Ctosedefendant named in Item 56 to recover costs costs and attorney fees and attorney fees 5 7. Other (spasm: new; . autumn [13/ Date: [3 Clerk. by I . Deputy team.) CERTIFICATE (Optional) 1 certify that this is a true copy of the original judgment on ?ts in the court. Date: Clerk. by 7 Deputy Pageant: [New January 1, JUDGMENT we must-tn; SHORT TITLE: . - Rhodora T. Intal vs. Rose Garden Convalescent Hospital at 130067076 ATTACHMENT (Number): 58 Page 3 of 3 (This Attachment may be used with any Judicial Council form.) (Add pages as required) 4 5. Parties. Judgment is 5 a. for Plaintiff Rhodora T. Intal Physical Therapist, Inc. and against defendant(s): 7 2. Legacy Care of Pasadena 3. Independence Health Care Management, Inc. 8 4. Raymond Pellioer 5. Dov Jacobs (If the Item that this Attachment concerns Is made under penalty of perjury, all statements In this Attachment are made under penalty ofpedury.) Farm m6 for 0950415! Una ATTACHMENT gov Jud Cum-? a! Ca?iiomln mm Logamal, Inc 20?71 to Judiclai Council Form has in? COPY nrrormav no wrmour ATTORNEY mama meadow): FOR COURT USE ONLY EDGARDOM LOPEZ, ESQ 3814129575 Law Offioos of Ed ardoM Lope 36011 Wiiohiro Boo ovoid Suite 1715 Los Angeles, California 90010 001 :1 CRMED COPY . ORIGINAL Fl ED memes no (213)330?3939 rent to. roam (213)380461 1 Los memes sups??m coum emu. mmropwx edicpozlaw?gmait com . Amaronnmo}: Intel Physical ?l?heraprsLInc. MAR 02 201B SUPERIOR coum or CALIFORNIA. comm or: Los Angeles 8mm mam: 600 East Broadway Sherri B. Carter, Executive Gillan/Clerk Lillao Es 0, De Glendale, CA 91206 5' amasemre North Central District-Glendale Courthouse Rhodora T. Intal Physical TherapisLInc. wenonrmnesmnoam: Rose Garden Convalescent Hospital et a1. REQUEST FOR Entry or Default Clerk's Judgment (Application) Court Judgment 1. TO THE CLERK: 0n the complaint or crammpleinl ?led a. on (date): August 4, 2017 b, by (name): Plaintiff Rhodora T. c. Enter default ofdefendanl (names): BY FAX (IN-100 CASE nume?? EC 067076 d. I request: court judgment under Code of Pmoodure sections 685(1)). 585(0). 989. agalnot defendant (names): (Toolinrony required. Apply to the clerk for a hearing date, unless the court will enters judgment On an af?davit under Code Cr?v Ploo. 585(6) e. Enter clerk's judgment (1) for restitution of the premises only and Issue a writ of execution on the judgment. Code of Civil Procedure section 1174(0) does not apply. (Code Civ. Proc.. 5 1169.) include in the Judgment all tenants. subtenanls. named claimants. and outer occupants of the premises. The Projudgmant Claim of Right to Possession was served in compliance with Code of Civil Procedure section 415.46. under Code of Civil Procedure section 585(3). (Complete the declaration under Code Orv. Proc., 5 585.5 on the '88le 51-) (3) - for default previously entered on {deto}: December 1: 2017 2. Judgment to be entered. Amount Credits 3 9?1 3. Demand of complaint 99.73 L95 b. Statement of damalos (1) Special (2) General :5 5 c. Interest . 1934539 d. Costs (see reverse) 990-35 3 e. Attorney fees . . . . . . . . . 51009-09 5 r. 701'an 125,669.19 3 9. Daily damages were demanded in complaint at the rate of: per day beginning (dale): Personal injury or wrongful death actions; Code Proo, 425.11.) 3. (Check if ?led in an unlawful detainer case) Legal document assistant or unlawful detainer assistant information is on the reverse {complete item 4). Date; March 1 2018 . EDGARDO M. tom. ESQ, (TYPE on mm new (grammar. or nun-?x? on 1111;953:157 FOR (1) Default entered as requested on (date): (2) Default NOT entered as requested (state reason): FOR COURT use ONLY Clerk, by 7 7 . Deputy I P3931012 mm?mmwg 0* REQUEST FOR ENTRY or DEFAULT 55 5854811169 CIV-1wf?ov We 1. 2007} (Application to Enter Default) (?tilt-?109 Rhodore T. into] Physical - CABS NUMBER: DEFENDANTIRESPONDENT: Rose Garden Convalescent Hospital et ai. EC 067076 4. Legal document assistant or unlawful dmtner mutant (Bin. Prof. Code. 5 6?00 ct seen). A legal document assistant or unlawful detainer assistant Ci did did not for compensation give advice or assistance with this term. (if declarant has received any help or advice for pay item a legal document assistant or unlawful deteriter slate): at. Assistant's name: c. Telephone no.: la. Street address, city. and zip code: d. County 6. Registration no.: i. Expires on (date): a. Doctor-?an under Code crown Procedure section 503.5 (required ror entry orooraurr under Code on. Prue, 5 some?. This action contract or installment sale for goods or services subject to Clv. Code. 1801 et seq. (Unruh Actconditional sales contract subject to Civ. Code, 2981 et seq. (Rees?Levering Motor Vehicle Sales and Finenee Actobligation for goods. loans. or extensions of credit subject to Code Civ. Prom, 396(b). 6. Declaration of melting (Code Ctv. Prom. 587).. A copy of this Request for Entry of Defeuit was a. not mailed to the following detendante? whose addresses are unknown to plaintiff or plaintiffs attorney (names): b. mailed ?rst-dose. postage prepaid, in a sealed envelope addressed to each defendants attomey of record or. if none. to each defendants last known address as follows: Mailed on (date): (2) To (specify names and addresses show on the envelopes): declare under penalty of perjury under the laws of the State of California that the foregoing items correct. Date: March i, 20l8. EDGARDO M. LOPEZ, ESQ. mm: ORPRINT we} randomizing? 0W 7. Memorandum of costs (required if money judgment requested). Costs and disbursements are as Code Civ. Free. 10335): a. Clerk?s ?ling fees 435-09 b. Process server?s fees 555-35 Cr (SNOWTOTAL 990 35 f. Costs and disbursements are waived. 9- i am the attorney. agent, or party who claims these costs. To the best of my knowledge and belief this memorandum Of 0035 ?3 correct and these costs were necessarily incurred in this case. I declare under penalty of perjury under the laws of the State of Celifomla that the foregoing is true and correct. Date: March I, 2018. New? EDUARDO M. LOPEZ, ESQ. 9 more on PRINT mas) (elements or new 8. Declaration of nonmilitary steals (required for a judgment). No defendant named in itemctga of the application is in the military service so as to be entitled to the bene?ts of the Servicemembers Civil Relief Act (50 U.S.C. App. 501 et seq.). declare under penalty of perjury under the laws of the State of California that the foregoing kW Date: Mamh l, 2018. My? EDGARDO M. LOPEZ, ESQ. 9 (TYPE on PRINT NAME) (Staying: or we may. Jammy rm; REQUEST FOR ENTRY or DEFAULT (Application to Enter Default) or?? ?w GOPY wow on mm wrnlour monuev: sure out no. 129575 FOR my one EDGARDO M. LOPEZ. Eso. - FIRM NAME: LAW OFFICES OF EDGARDO M. LOPEZ smear nomass: 3600 Boulevard, Suite 1716 only: Los Angeles. Callfomla snm: CA up cone 90010 TCI-TMED COPY TELEPHONE Ho: (213)380-3939 FAX no: (21 (3)380-1611 ORIGINAL moness; edicpezlaw?gmaitoom LOS ANGELES SUPERIOR COURT ATTORNEY FOR (Nam: Plaintiff Rhodora T. Intal Physical TherapisLlno. . summon COURT or: museum, COUNTY oz: Los Angeles MAR 0 2 2913 mm 600 Broadway Sherri B. Carter. Executive Of?cer/Clerk 0008 Glendale, CA 91206 By Lilian Espejo, Deputy BRANCH ma- Pl?intitflPe?tioner: Rhodora T. Intal Physical Therapistlno Defandanthospondent Rose Garden Convalescent Hospltal we ?mom REQUEST FOR DISMISSAL EC 067078 A conformed copy will be returned by the clerk unless a ma?tod of rotum is provided the document. form may not be used for dlamtsoo! of a derivative action or a class action or of any party or (loose of action in a class action. (Cal. Rules of Court. rules 3.760 and 3.170.) 1. To THE CLERK: Please lltlo action as follows: a. (1) With prejudloe (2) Without prejudice b. (1) Complaint (2) [j Potltion ?led by (name): on (date): By FAX (4) by (name): 00(11819}: (5) Entire actlon of all partles and all causes of action (6) Other (specify):' as to DOES 1-20 lnoluslve 2. (Complete in all cases oxospt family law cases.) The court did not waive court fees and costs for a party in thIs case. (71113 Infomadon may be obtained from the clerk If court fees and costs mm waived the declaration on the back of this form must be oomplol . DatezMaroh 1. 2018. - EDGARDO M. LOPEZ. ESQ. .. w- (TYPE 0R 0F [jg amour? mm moans?) El 'll aims: requested lsol'apod?od parties only or speci?ed causes oraollon only. Attorney or party WWI may for: or (17$de cross-complaints only. so state and beauty the parties. causes of [3:1 If I Dafendanthespondent aotlon. or morplalnts to be Cross Complainant 3. TO THE CLERK: Consent to the above dismissal is hereby given." Date: mp5 OR NAME OF ATTORNEY :3 mm WITHOUT arrows?) (SIGNATUREI It a cross-comm! - or Roaoonoo (Foamy Law) soaklng af?rmative Atlomey or party anomey for: relief - Is on ?le. the attorney tormoomplalmm (respondent) must algn Plainmeu?onef DefendanURespondenl consent limited by Code of Pmoodura section 581 Cross Complainant To be completed by clerk) 4. Dismissal entered as requestod on (date): 5 on (date): HARD 2 2018 3181007?? (name): AS STATED Am 6. not entered as requested for the-following roaoons (specify): 7. a. [awomey orpalty wlthout attorney noti?ed on (date): 2 2018 SHERRI Ru CARTER b. [j Attomay or party without attorney not noti?ed. Filing party failed to provide a copy to be conformed means to return conformed copy Date: 22018 Clerk. by Ln, ssmo ,mm mm fmomm REQUEST FOR CMI 10[Rov, Jan 1,2013] unwound. annoy .an 2:53?? I "3 Chi-110 Rhodora T. mm! Physicat Themptamnc.? . $2353 Defandanthespondem: Rose Garden Hosp-Ital RECOVERY OF WANED COURT FEES AND COSTS if a party whose court fees and costs were Initially waived has mmvered or wilt recover 310.000 or more In vaiuo by way of sot?emam, compromise. arbitration award. mediation Settle-mom. or other moons. the court has a statutory lien on that recovery. The court may rafuae to dismiss the 0888 um" "10 Iran '3 satis?ed. (Gov, Code. 6853?.) Declaration Concemtng Waived Court Fees 1. The court waived court fees and costs in this action for (name): 2. The person named In item 1 is (check one below): a. not recovering anything of value by this action. b. recovering toss than $10,000 in value by this action 6. mcovortng 319.080 or mom in vatua by this action. (Ifltem 201.9 checked Item 3 must be completed.) 3. All court fees and court costs that were waived In this action have been paid to the court (check one): Yes No I doctors under penatty of parjury under the laws of the State of Ca?fomla that the tnfonnatton above to true and correct ?we on we or ammev PW muons mommy (SEGMTURE) Date: cw-noxaw.ery1.2ma: REQUEST FOR DISMISSAL Exhibit I mess?ng pl) 150}: l?hucnix.? 29779 AZ 85038 OCICBEI 5. 2019: RAYMOND PELLECER 71301. DANA PL . 9528314108 .. Subject: Required withdrawal from, your accoz.111temiing in 3997 ,ignggi; 7 :7 .3, 3? f1 order n: Wa-want to let you know that on October 4, 2019;.- Wells Fai-g?ngaS Mt}? @2533; . as; the amount of which requires us by 13w to deduci money from 30111 n: resultwe withdrew $3,339.70 from year account on October 4, 2019 and charge a no i?efur??iable processing fee . - Act?tint Number Debit Amount Bank Fee $3,339.70 - .. 312.5430 1f 'y'?ii fcoz?d lik?nloreix1fofma?on 356th the legal order, 1515358 contabf: :?Los ANGE-LES mum SHERIFF Case N0EEC067076 If yQ?-ihave questions abouf your account, please call Weils- Fargo Customer Servicie at (809)-344? g3170;324 hour's a'day, 7d33>sa week -- 3; . . . Thank you. Sinc?f?iy, . prf?iM Operations Manager Legal' O??der Processing 144.;0mwculf.