Defendants Atria claim that an employee mistook a glass of Ultra Klene industrial cleaner for juice and gave it to a resident to drink. (COTCHETT, PITRE & McCARTHY LLC)
Two Bay Area care homes in which three elderly residents died last summer from poisoning recently had investigations carried out by the state’s Department of Social Services (DSS), but so far only one facility is in danger of losing its license as a result.
Residents at Atria Park in San Mateo and Atria Walnut Creek died last summer after they ingested caustic cleaning solutions.
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.
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.
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.”
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.
“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.”
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Yup. Looks like fruit punch.
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But let’s apply liberal logic principles…
Given CA’s looney “it’s not my fault” laws, Atria should play the victim and sue the cleaning fluid’s manufacturer because the jug looks like a retail fruit juice container and can “obviously” be mistaken by a reasonable person.
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If you had read the article you would have learned that the Atria staff was emptying 5-gallon containers of cleaning fluid into drinking beverage pitchers. Apparently the dish washing machine has a 1-gallon capacity for cleaning fluid and so the drinking beverage pitchers were used as measuring cups as part of re-filling the dish washing machine. A staff member then left or more beverage pitchers of cleaning fluid on the counter, and also did not label it/them. The manufacturer also sells the fluid in 1-gallon containers but Atria management found it was cheaper to buy the 5-gallon containers.
It is a shame how little care “caretakers” take with our loved ones. So sad that either you are a hyper wealthy individual who can either personally watch over your parents/grandparents when they need it, or hire a premium caretaker at 200k/year, or you risk it with this dimwits who serve them poison by negligence.
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Care facilities don’t exactly hire high quality, professional-level caretakers.
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More often attending staff
barely have a high school diploma or a green card.
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Wow…..what a stupid excuse. even a child knows the difference in smell between cleaning solution and juice. If the caregiver cannot smell and is oblivious feeding others unknowns than they do not need to be caregivers. Dementia patients are vulnerable and cannot be their own advocate that is why we put trust in caregivers. Something sounds fishy here and I believe there is a lot more of this story that we don’t know. Horrible.
When a caregiver wants you gone…WATCH OUT!
You’ve been fooled into splitting your family and leaving your elderly in the hands of people that hate them and wish them dead.
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Are caretakers required to be licensed vocational nurses?
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If not, why not?
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Maybe CA should raise professional standards instead of always accommodating the lowest common denominator under the guise of “equity”.
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“Out of an abundance of caution…”
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I’d say the administrators are very lax in their solemn duty.
Shut ’em down….. they deserve better care
Horrible death. Surviving with the after effects can be even worse. Poor souls.