After conducting investigations into two Bay Area care homes where three elderly residents died from ingesting cleaning solution last summer, the California Department of Social Services (DSS) has moved to revoke the license of Atria Park in San Mateo.

The facility is an assisted living and memory care facility on the border of San Mateo and Foster City, owned by parent company Atria Senior Living that manages more than 340 independent living, assisted living, supportive living, and memory care facilities in 44 states.

But the troubled facility saw two preventable and high-profile deaths due to poisioning last summer. According to the report from the DSS investigation released in April, as reported by ABC7, an employee left a full beverage pitcher containing dishwasher soap on the kitchen counter next to the sink at the San Mateo facility — unmarked.

Apparently, employees usually ordered 1-gallon containers of the soap, which fit inside the dishwashing machine, but had recently received 5-gallon containers. Staff members would reportedly pour the excess soap into a pitcher in the kitchen, but one employee mistook the unlabelled liquor for juice and poured it into three glasses for residents. Three elderly residents drank it and immediately became ill.

According to ABC7, the report said that "upon being served, [one resident’s] lips began to swell and was black and red in color, and [another] yelled after drinking out of the juice cup and then sat down."

Staff realized the mistake and called 911, but of the three elderly residents drank it, two died, while one suffered injuries.

The investigation also found that the facility had 12 complaints alleging staff negligence before the dishwasher soap incident.

And in another similar incident last summer just four days later, a resident at another facility in Walnut Creek owned by the same parent company Atria also apparently drank cleaning solution and later died. A 94-year-old resident with dementia reportedly wandered unsupervised into the kitchen and drank cleaning liquid, and died eight days later after suffering injuries to his stomach, esophagus, and part of his throat. An employee at the facility is facing one count of felony elder abuse related to his death, as someone was supposed to be with the resident at all times.

The case against the San Mateo facility is still pending, as counsel has appealed the decision. The facility remains open during this process — but the victims' families have publicly called for accountability.

RELATED: Senior Care Worker Charged With Elder Abuse After 94-Year-Old Man Dies From Drinking Cleaning Fluid [SFist]

Feature image of Atria Park San Mateo via Google Street View.