Residents at Atria Park in San Mateo and Atria Walnut Creek died last summer after they ingested caustic cleaning solutions.
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Three people at the San Mateo facility on Aug. 27, 2022, drank dishwasher liquid, which was in a beverage pitcher left on a kitchen counter, according to an investigative report by DSS dated April 14. Two of them died and one was injured.
DSS in March filed a legal action to revoke the facility's license and the case is pending.
Jason Montiel, a spokesperson for DSS, said that the pending revocation may be appealed and may result in a revocation, probation, or it may be dismissed by a judge. The facility may remain open during this process, which remains ongoing, he said.
A spokesperson for Atria Senior Living said Thursday that they disagree with the DSS decision about the San Mateo facility and have filed a notice of contest to appeal it.
"During this process, Atria Park of San Mateo will remain open, and our employees continue to be focused on providing a safe and welcoming environment for all our residents," the spokesperson said.
DSS said that the dishwasher soap had normally come to the San Mateo facility in 1-gallon containers, but that "weeks prior" to the poisonings, management had been ordering 5-gallon containers. Employees would pour the liquid into a beverage pitcher to then pour into the dishwashing machine, which holds 1 gallon.
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The state found that an employee left the full beverage pitcher on the kitchen counter next to the sink, noting that no staff member had labeled it as cleaner. A staff member subsequently picked up the pitcher and poured its contents into three glasses, thinking it was juice. The glasses were served to three residents, referred to as "R1, R2, and R3" in the official report.
"Upon being served, R1's lips began to swell and was black and red in color," reads the report. "R2 yelled after drinking out of the juice cup and then sat down."
Once staff determined it was soap and not juice, they called 911.
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Resident "1" died due to severe chemical burns after ingesting highly alkaline fluid. R2 was admitted to the hospital with "acute respiratory distress requiring intubation" and later died. R3 survived, but had burns to their lips, mouth and tongue.
"This incident has been a tragedy," said Atria Senior Living. "It is in no way indicative of the quality care our staff provide each and every day. We remain deeply saddened by the deaths of our residents, and our hearts are with their families and loved ones."
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The San Mateo County District Attorney's Office charged Atria Park employee Alisia Rivera Mendoza, 35, in April with two counts of involuntary manslaughter and three counts of elder abuse. She is due to be arraigned on May 12.
Meanwhile, at Atria Walnut Creek, a resident drank cleaning solution on Aug. 23, 2022, and later died.
Constantine Albert Canoun, 94, lived in the memory care unit of the facility and was rushed to the hospital after ingesting an all-purpose cleaning solution. He died on Aug. 31 after suffering injuries to his stomach, esophagus and part of his throat, authorities said.
Canoun had dementia, and DSS noted that, as such, a staff member should have been in his presence at all times.
Somehow, Canoun had died of injuries consistent with drinking a caustic liquid cleaning agent, the report said. Cleaning supplies were stored in the facility's kitchen on the shelf underneath the kitchen counter, the state said.
A DSS investigation into his death dated April 18 on the department's website found that Canoun had wandered into the facility's dining room before midnight and was found sitting in a chair with a staff member's lunch in front of him, steak strips and Flamin' Hot Cheetos. The kitchen door had been left unlocked.
According to the report, "R1," or Canoun, vomited and coughed up food, telling the staff member that he had been poisoned.
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"Based on observation, interviews, and records review by the Department, it was determined that R1 was not adequately supervised, resulting in R1 being injured and expiring due to ingestion of a caustic cleaning agent," reads the report.
The Contra Costa County District Attorney's Office filed charges in January against an employee at the Walnut Creek facility.
Lateshia Sherise Starling, 54, of San Pablo, is facing one count of felony elder abuse resulting in the death of Canoun.
However, DSS has not yet made a move to pull the license from the Walnut Creek facility, as the department has done in San Mateo.
The family of a woman who died in the San Mateo facility, 93-year-old Trudy Maxwell, filed suit last September outlining allegations of "stunning and inexcusable neglect and abuse" over a period of time that culminated in her death on Aug. 29.
Lawyers for Maxwell's family said in their claim that Canoun's hospitalization for drinking cleaning solution should have raised a "red flag" at Atria's other facilities before it happened again in San Mateo.
Atria said last September that the "incidents at our San Mateo and Walnut Creek communities are isolated and unrelated."
On Thursday, Atria said, "As always, we are focused on the safety, health, and well-being of all our residents."