A second care home for the elderly owned by Atria Senior Living where a resident died after ingesting a caustic liquid may have its license revoked, according to the California Department of Social Services (DSS).
DSS filed a legal action on April 27 to pull the license of Atria Walnut Creek, where one man died. According to the man's coroner's report, obtained by NBC Bay Area, the cause of death was: caustic injury to pharynx, esophagus and stomach, due to; ingestion of liquid cleaning agent.
The family of the victim, 94-year-old Constantine Albert Canoun, said Atria management initially blamed their father saying he ate Flaming Hot Cheetos and his hospitalization was food-related. Atria stood by that narrative for months, until the victim's coroner's report confirmed he died from ingested cleaning chemical.
DSS in March filed a legal action to pull the license of Atria Park of San Mateo after two people died and one person was injured after drinking industrial grade dishwasher liquid.
Both cases with the DSS are pending and Atria said it is appealing both.
"We disagree with the Department of Social Services' decision and have filed a notice of contest to appeal that decision," a spokesperson for Atria said Thursday about the Walnut Creek case. "We are committed to working with them to reach a resolution of that appeal. Atria Walnut Creek will remain open during this process. Our employees remain focused on providing a safe and welcoming environment for all our residents."
Jason Montiel, a spokesperson for DSS, said that pending revocations may be appealed and may result in a revocation, probation, or it may be dismissed by a judge. The facilities may remain open during this process, which remains ongoing, he said.
Canoun lived in the memory care unit of the Walnut Creek facility and ingesting the all-purpose cleaning solution the night of Aug. 23. Around midnight Aug. 24, he was rushed to the hospital and died on Aug. 31.
Canoun had dementia, and DSS noted that, as such, a staff member should have been in his presence at all times and should have kept cleaning agents out of reach.
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Somehow, Canoun had gotten his hands on a 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. 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.
"Our hearts continue to be with the family and loved ones of the resident affected by this tragedy," said Atria. "As always, we are committed to the safety, health, and well-being of all our residents."
On Aug. 27, 2022, three people at the San Mateo facility 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 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 a hospital with "acute respiratory distress requiring intubation" and later died. R3 survived, but had burns to their lips, mouth and tongue.
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 Friday.
Atria said that the poisonings at the San Mateo care home were "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."
"Not only was the death of Mr. Canoun completely needless because there was not enough staff and the poison wasn't locked up, [Atria] did nothing. They could've saved the lives of two other people had they instead told the truth rather than go on this Flaming Hot Cheetos charade," said attorney Kathryn Stebner who represents the family in the Walnut Creek case.
