1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 EASTERN DISTRICT OF CALIFORNIA 10 11 VIRGINIA GUEVARA, Case No. 1:22-cv-0490 JLT CDB

12 Plaintiff, ORDER DECLINING THE FINDINGS AND RECOMMENDATIONS, GRANTING 13 v. PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, AND REMANDING THE 14 FRANK BISIGNANO, MATTER PURSUANT TO SENTENCE FOUR Commissioner of Social Security1 OF

(g) 15 Defendant. ORDER DIRECTING ENTRY OF 16 JUDGMENT IN FAVOR OF PLAINTIFF AND AGAINST DEFENDANT 17 (Docs. 18, 20, & 23)

18 19 Virginia Guevara seeks judicial review of the administrative decision to deny her 20 application for supplemental security income under Title XVI of the Social Security Act. (Docs. 21 1, 23.) Plaintiff contends the administrative law judge committed harmful error at step two of the 22 sequential evaluation in finding her mental impairments were not severe, and substantial evidence 23 does not support the residual functional capacity because the ALJ had a duty to develop the 24 record. (See Doc. 18 at 7, 20-36.) Plaintiff requests the Court remand the matter for further 25 proceedings. (Id. at 37.) The Commissioner asserts the Court should affirm the administrative 26 decision. (Doc. 24.) 27

1 Frank Bisignano became the Commissioner of Social Security on May 6, 2025. Pursuant to Rule 25(d) 1 The magistrate judge found that “[s]ubstantial evidence supports the ALJ’s determination 2 that Plaintiff’s mental impairments were not severe.” (Doc. 23 at 9; see also

.) The 3 magistrate judge observed that “[t]he ALJ considered Plaintiff’s medical records, including 4 multiple reports of ‘no aberrant behavior noted,’ good insight and judgment with normal mood, 5 and denials of depression.” (Id. at 9, quoting AR 16 [Doc. 13-1 at 21].) The magistrate judge 6 found the medical records cited by the ALJ support the conclusion that “Plaintiff had no more 7 than a mild limitation in any of the functional areas” under Paragraph B. (Id. at 9-10.) The 8 magistrate judge also reviewed the records identified by Plaintiff and found she did not present 9 “any evidence from medical sources that [her] impairments impacted her basic work abilities as 10 required to establish they were severe.” (Id.) The magistrate judge determined that “even if the 11 ALJ erred in finding Plaintiff’s mental impairments were non-severe, any error was harmless 12 because the ALJ proceeded through the sequential analysis and considered all of Plaintiff’s 13 impairments in formulating the RFC.” (Id. at 11.) Moreover, the magistrate judge observed: 14 “Plaintiff fails to point to any alleged limitations caused by her mental impairments that the ALJ 15 failed to consider or include in the RFC.” (Id.) 16 The magistrate judge rejected Plaintiff’s assertion that “the ALJ had a duty to further 17 develop the record because she underwent two surgeries after the state agency consultants’ 18 review of the record.” (Doc. 23 at 10; see also

.) The magistrate judge found there 19 was “nothing in the ALJ’s decision indicating that she interpreted raw medical data or relied on 20 her own medical judgment in constructing the RFC.” (Id. at 12.) In addition, the magistrate 21 judge determined, there was nothing “suggesting to the Court that the record was ambiguous or 22 inadequate as would be necessary to trigger the ALJ’s duty to further develop the record.” (Id. at 23 13.) The magistrate judge stated: “[T]he ALJ relied on the state agency medical opinions, 24 acknowledged Plaintiff had undergone surgeries since the experts reviewed the record and 25 reported post-surgical leg and tailbone pain, and imposed limitations greater than those opined 26 by the experts based on Plaintiff’s complaints.” (Id., emphasis in original.) The magistrate 27 judge concluded that because the limitations identified by the ALJ “resulted in a narrower RFC 1 Finally, the magistrate judge found the ALJ properly evaluated Plaintiff’s subjective 2 complaints “concerning her ability to sit, stand, and walk.” (Doc. 23 at 13-16.) The magistrate 3 judge observed that “the ALJ credited Plaintiff’s testimony and included [a] sit/stand limitation.” 4 (Id. at 16.) The magistrate judge determined the ALJ “provided specific, clear, and convincing 5 reasons for rejecting Plaintiff’s testimony that she was more limited in her ability to sit and 6 stand,” including inconsistencies with Plaintiff’s own statements regarding improvement after 7 surgery and “the lack of objective medical evidence to support Plaintiff’s complaints.” (Id.; see 8 also

.) 9 The magistrate judge recommended the Court deny Plaintiff’s motion for summary 10 judgment, affirm the ALJ’s decision, and enter judgment in favor of the Commissioner. (Doc. 23 11 at 17.) Plaintiff filed timely objections, arguing the Court should decline the Findings and 12 Recommendations. (Doc. 25.) The Commissioner filed a response, asserting the magistrate 13 judge properly addressed the issues raised and maintaining the Court should affirm the 14 administrative decision. (Doc. 26.) 15 According to

(b)(1), the Court performed a de novo review of this case. 16 Having carefully reviewed the entire matter—including Plaintiff’s objections and the 17 Commissioner’s response—the Court concludes the findings related to the ALJ’s step two 18 findings and Plaintiff’s subjective complaints are supported by the record and proper analysis. 19 However, the Court finds substantial evidence does not support the physical RFC determination 20 and the ALJ had a duty to develop the record. 21 After Plaintiff filed her application for SSI benefits, two agency physicians reviewed 22 available medical records and found Plaintiff was limited to performing light work with 23 additional postural limitations. (Doc. 13-1 at 26; see also

.) The ALJ found 24 the opinions were “unpersuasive,” explaining:

25 These opinions are supported by rationale based on a review of the evidence available at the time of determination but are not entirely 26 consistent with the evidence showing the claimant had to have additional limitations that are not work-preclusive given reports and 27 numbness and weakness prior to lumbar surgery and post-surgical leg and tailbone pain supportive of reduced stand/ walk and a sit-stand option, but generally normal strength and gait throughout the record 1 despite pre-surgical positive straight leg raise testing and reduced cervical, shoulder, and lumbar range of motions.” 2 3 (Id., citations omitted.) Importantly, the medical opinions of the agency physicians were the only 4 medical opinions in the record. Because the ALJ found both were “unpersuasive,” the magistrate 5 judge erred in finding the ALJ “relied on” the opinions. 6 As the ALJ acknowledged, after the agency physicians reviewed the available medical 7 records, Plaintiff had two surgical procedures involving the placement of screws and plates in 8 her spine. (See Doc. 13-3 at 5.) The “multilevel spinal surgery” included “fusion at L5-SQ and 9 decompressive laminectomy and fusion at L3-4 and L4-5.” (Doc. 13-1 at 24, citations omitted.) 10 It is undisputed that no physician reviewed Plaintiff’s medical records following the procedures 11 and offered a medical opinion regarding Plaintiff’s physical limitations and abilities. 12 The Court is unable to find the substantial evidence supports the ALJ’s decision regarding 13 Plaintiff’s physical RFC given the lack of medical opinions following Plaintiff’s surgical 14 procedures. Rather, the ALJ’s duty to further develop the record was triggered given the absence 15 of such an opinion. See, e.g., Patricia C. v. Saul,

, at *22 (S.D. Cal. Aug. 10, 16 2020) (finding substantial evidence did not support the RFC and the ALJ had a duty to develop 17 the record where “there [was] no opinion evidence from any treating or examining physician 18 regarding Plaintiff’s post-surgery functional limitations”), adopted by

(S.D. 19 Cal. Sept. 10, 2010); Sepulveda v. Astrue,

, at *1 (C.D. Cal. July 28, 2010) 20 (finding the duty to develop the record was triggered and “the ALJ erred by not ordering [the] 21 plaintiff to undergo a consultative examination, when the … medical records did not include an 22 assessment of plaintiff’s post-surgery functional limitations”); see also Mendenhall v. Astrue, 23

, at *12 (D. Az. Mar. 16, 2012) (“[T]he record is devoid of any assessment from 24 a medical source of Plaintiff’s physical residual functional capacity post-surgery. The instant 25 record does not contain adequate medical information from which the ALJ could possibly assess 26 Plaintiff's post-surgical physical residual functional capacity.”). 27 Remand for further administrative proceedings is appropriate for the ALJ to develop the record and make new findings related to Plaintiff’s physical RFC. See Kail v. Heckler,

1496, 1497 (9th Cir. 1984); see also Patricia C.,

, at *23 (remanding for 2 | further proceedings where the record was not “fully developed with respect to Plaintiff's physical 3 | functional limitations after her... surgery”). Accordingly, the Court ORDERS: 4 1. The Court declines to adopt the Findings and Recommendations (Doc. 23). 5 2. Plaintiff's motion for summary judgment (Docs. 18) is GRANTED. 6 3. The Commissioner’s request to affirm (Doc. 20) is DENIED. 7 4. The matter is REMANDED pursuant to sentence four of

(g) for 8 further proceedings. 9 5. The Clerk of Court is directed to terminate pending motions; enter judgment in 10 favor of Plaintiff Virginia Guevara and against Defendant Frank Bisignano, 11 Commissioner of Social Security; and to close this case. 12 3 IT IS SO ORDERED. | Dated: _ September 29, 2025 Cerin | Tower TED STATES DISTRICT JUDGE 15 16 17 18 19 20 21 22 23 24 25 26 27 28