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St. Cloud may opt out of state’s ‘granny pod’ law sctimes.com: http://www.sctimes.com/story/news/local/2016/07/22/st-cloud-may-opt-out-states-grannypod-law/87380212/ Jenny Berg, jberg@stcloudtimes.com 2:49 p.m. CDT July 22, 2016 A new Minnesota law will allow, beginning Sept. 1, homeowners to put temporary dwellings for those with health care needs in residential lots. Cities can choose to opt out of the law.(Photo: Photo: Thinkstock) Starting Sept. 1, caregivers in Minnesota will be allowed to house people with care needs in small trailers in their backyard — unless cities choose to opt out of the new law. St. Cloud city staff are recommending just that — to prohibit the temporary “granny pods” or “drop homes” on residential lots, at least until staff and St. Cloud City Council can further discuss the issue. “There is the wiggle room for each municipality to make an interpretation about their own community … and if they think these structures are appropriate,” said Matt Glaesman, community development director. “There is a choice to be made here that would opt out of the state law and would essentially prohibit these in our community until we can have a good policy debate about whether these are allowed or not,” he continued. “But with the impending Sept. 1 deadline, we need to take action to essentially say we’re opting entirely out of the law. We’re not going to allow these, but we’re going to have a better discussion going forward.” The City Council will host a public hearing on a proposed ordinance to opt out of the new law during its meeting at 6 p.m. Monday. City Council will then vote on whether to approve bypassing the new law. The law, signed into law by Gov. Mark Dayton in May, created a new process for landowners to place mobile and temporary residential dwellings on their property. The units are meant to provide transitional housing for those who are mentally or physically impaired and need help with two or more activities crucial to daily living, as certified by a physician. The law limits the time frame for the dwellings to six months, with the possibility for a one-time six-month renewal. The law does not restrict the age of those living in the temporary homes, but limits the number of residents to one per dwelling. The dwellings must be designed to meet accessibility and building standards, provide access to water and electrical utilities, be portable, and have sewer management. They cannot exceed 300 gross square feet or attach to a permanent foundation. The League of Minnesota Cities lobbied for an opt-out provision to the law so cities and counties still had control over zoning. “The initial legislation, the way the bill was introduced, made it a permitted use that anyone could do on their property. Period,” said Craig Johnson, lobbyist for the League of Minnesota Cities. “That was significantly changed as we worked with the authors over the legislative session.” Johnson said cities can choose to enact their own version of the law, but those cities must opt out of the state law first. If cities do not opt out, they would be required to start accepting permits for the temporary dwellings beginning Sept. 1. So why create a law that cities can simply choose to opt out of? Johnson said proponents of the legislation desired a standardized law, which would make it easier for stakeholders such as granny pod manufacturers. “This way, if (cities) don’t opt out, they will know exactly what the law will be,” he said. While the League of Minnesota Cities is not tracking which municipalities are opting out of the law, Johnson said many cities are refusing the state mandate. “I would say a majority of cities that I’ve heard from are opting out,” he said. Follow Jenny Berg at www.facebook.com/sctimesjenny and on Twitter @bergjenny. GENERATIONS Small Board-and-Care Homes in the Age of Assisted Living By Paula C. Carder, Leslie A. M.or£ian, andj. Kevin Eckert T he past decade has taken a disproportionate seen the development number of very frail and The challenge of defining, of regulation for assisted low-income older people. living across the United Information on small licensing and monitorin^f States (MoUica, 2002), board-and-care homes is forcing policy makers to at best incomplete and at these ‘mom and pop’ settings. consider whether and how worst anecdotal and prejto draw the boundaries for udicial. A review of pubthis category of housing lished literature reveals a with services. This article presents the approaches decrease in studies since the late 1990s, with a of two states to defining, licensing, and moni1996 AARP study (Folkemer et al., 1996) repretoring small board-and-care settings for older senting the last national review of regulatory people. Oregon has a designated adult fosterissues. Have researchers answered all ofthe care program and regulations, while Maryland important questions about this setting type.’ regulates small homes under the broader cateMore likely, this lack of attention is due to the gory of”assisted living.” Tlie two case-study states increasing dominance of assisted living and to represent veiy different policy responses ro small the “invisibility” (Sherman and Newman, 1988) board-and-care homes, demonstrating some of and “social marginality” (Morgan, Eckert, and the diversity that is taking place nationally. This Lyon, 1995) of small board-and-care homes. article reviews how the current age of assisted Added to these shifts are the public policy choices living aiFects small board-and-care homes. some states have made to include board-andcare under the newer assisted-living category. For decades, small board-and-care settings have served an important, albeit at times overFollowing is a brief review of board-and-care looked and at other times scandalous, role in literature and demographics of the two casecommunity-based care for older people who study states. The primary focus ofthe literature have physical and cognitive impairments. With compares the regulatory approaches, with Orethe recent increase in assisted Uving residences gon representing states with distinct adult-careand changes in regulatory requirements, now is home regulations and Maryland representing a good time to review the role of small settings. those that define small homes as assisted living. Historically, these “mom and pop” homes have Because the purpose here is to draw lessons, served a diverse group of clients, but they have neither state’s approach is held up as better; each 24 Winter 2005-2006 Supportive Housing for an Aging Society has pros and cons. We suggest that (i) the different regulatory approaches result in different responses from the operators of small boardand-care homes, and (2) despite distinct approaches to defining and monitoring small settings for older people, the essential nature of small group homes (i.e., personalized, familystyle care) persists. TYPES OF SETTINGS AND CLIENTS The variety of types and definitions of boardand-care homes ranges fi-om small single-family homes to purpose-built homes or large institutions, with the former more numerous. Many terms compete to describe the type of setting represented in this article, mdnd^^ adultfbster care,£iroup home, and domiciliary care home. In keeping with studies of two of the authors (Morgan and Eckert), we use the term boardand-care. The meaning of “small” also varies, with most states setting the number at five or six residents. Board-and-care homes vary in terms of regulatory oversight and reimbursement alternatives. Some states define, license, and monitor these settings, while others do not, and studies report varied findings regarding the effect of regulations on quality of care (Lyon, 1997; Wildfire et al., 1997-98). Over time, the range of available public subsidies that benefit lowincome people, such as the Medicaid Home and Community-Based Services I9i5(c) waiver, have increased. In 1995, eight of twenty-six states that had an adult foster-care program used Medicaid waivers to pay for direct-care services (Folkemer et al., 1996). In 2004, over forty states used Medicaid to pay for services in a residential care program, including assisted living and adult foster care (Mollica and JohnsonLaMarche, 2005). The diversity of settings makes counting the number of board-and-care homes and the number of individual residents a daunting task. Results of two studies conduaed in the 1990s produced some estimates: 34,090 licensed homes housing 613,483 persons over age 21 (Clark et al., 1994); 31,942 facilities and 504,750 beds (Hawes et al., 1993). The General Accounting Office (GAO) estimated 75,000 licensed and unlicensed homes, housing half a million per- sons; unlicensed facilities (primarily small homes) were estimated at more than one-third ofthe total, or 28,000 (GAO, 1994). Who resides in small board-and-care settings.^ A ten-state study of 512 board-and-care homes found that nearly two-thirds ofthe residents were over the age of 65, and almost one-fourth were over 85 (Phillips et al., 1995). A four-state study that collected information on 665 residents in 113 facilities with fewer than sixteen residents found that nearly half (46 percent) were over age 85, and a majority were female and unmarried (Morgan, Gruber-Baldini, and Magaziner, 2001). Comparing residents of smaller settings in that study to those in larger assistedliving facilities (i.e., more than seventeen residents), the smaller facilities house a higher proportion of minority elders, especially Afiican Americans (Howard et al., 2002); people with lower educational levels (Morgan, Grubcr-Baldini, and Magaziner, 2001); people with higher physical dependency and more people with cognitive impairment (Morgan, Gruber-Baldini, and Magaziner, 2001); and a higher proportion of clients who relied on public assistance (Steams and Morgan, 2001). Single state studies in Georgia (Ball et al., 2000; Quinn et al., 1999), Maryland (Morgan, Eckert, and Lyon, 1995), Oregon (Kane et al., 1991), and Washington (Curtis, Kiyak, and Hedrick, 2000) confirm that small board-and-care homes provide services to very ftail older people, many of whom have very limited financial resources. Two STATES’ REGULATORY APPROACHES When making comparisons among states, policy analysts often look to national models (Rose, 1993), with Oregon cited as a successful case of implementing community-based alternatives to skilled nursing facilities (GAO, 1994; Justice and Heestand, 2003; O’Keeffe, 2000). Oregon represents a smaller number of states that have a designated adult foster-care program and assisted living defined as an apartment-style residence; Maryland represents a larger number of states that use the term assisted living broadly to include settings of various sizes (Johnson and La-Marche, 2005). Notably, fortyone states and the Distria of Columbia use the term assisted living as a licensure category, and Winter 2005-2006 25 GENERATIONS thirty of these states set a minimum number of residents permitted, from one, two, three, or more persons. The logic of these numbers is not always clear, but the use of such numbers tells us that policy makers believe that size of setting matters. Oregon and Maryland would seem to have more differences than commonalities in population characteristics and long-term-care systems. Oregon is a largely rural. West Coast state while Maryland is an East Coast state and more densely populated. The states are comparable in percentage of older people, poverty status of older people, and percentage with self-care or mobilit)’ limitations, but Maryland’s percentage of minority elders in the state’s older population (24 percent) far exceeds that in Oregon (5.7 percent), and the household income of older people is 16 percent higher in Maryland than in Oregon (Gibson ct al., 2004). There is a noticeable difference in long-term-care systems, with Oregon reporting 2 percent of people over age 65 in nursing homes compared to Maryland’s 4 percent, and forty-six residential care beds per 1,000 persons in Oregon compared to twentythree in Maryland (Gibson et al., 2004). Like other states, these two states want to promote small, family-Uke care homes while at the same time assuring public safety (Kane et al., 1991; Multnomah County, 1994; Office of Health Care Quality, 2005). In the following, we compare selected features of Oregon and Maryland regulations for small care settings that have an effect on the people who live and work in them. Table i lists these features. The overall policy strategy is key to understanding the differences between the two states. Oregon officials began developing their adult foster-care program in the early 1980s in order to increase community-based alternatives to nursing facilities. They raised the public reimbursement level, allowed case managers to negotiate rates for clients, and assigned agency staff as adult foster-care promoters to recruit potential operators (Kane et al., 1991). The local area agencies on aging contract to license, monitor, and conduct other activities related to licensure. Maryland officials reclassified small boardand-care homes under the 1996 assisted-living 26 Winter 2005-2006 program regulations; before that time, homes with two to four residents had the option of being “registered,” and larger homes operated under county and state health department oversight but were not licensed (Morgan, Eckert, and Lyon, 1995). Until implementing the assisted-living program regulations in 1999, Mar}’land had twelve to fifteen public agencies administered by three executive departments, all with differing standards for monitoring safety and quality, a circumstance described in an AARP study entitled The Board and Care System: A Regulatory Jungle (Dobkin, 1989). Though Maryland’s assisted living regulations established the Office of Health Care Quality (OHCQ) as the primary oversight agency, in reality, multiple agencies retain varying degrees of responsibility, including local health departments and area agencies on aging ( O H C Q , 2005). The result of multiple oversight agencies is multiple interpretations of what small assisted-living homes are, can be, or should be and whom they can serve. Despite taking very different approaches to classifying small board-and-care homes, there are some similarities in how the two states’ regulatory programs work. They both require three daily meals, assistance with personal care, resident assessment, and care planning. They also permit nurse delegation of certain tasks and offer medication assistance. On the fiscal front, despite some differences, both states have the Medicaid I9i5(c) Home and Community-Based Services waiver. Maryland uses the same reimbursement rate for all providers regardless of size, while Oregon uses a different calculation for adult foster-care and assisted living providers, with the reimbursement rate for the highest level of care in adult foster care less than that for assisted living. Studies ofthe reliability and validity of resident assessments (Kane, 2000), combined with our collective experience in these types of settings, suggest that the level of care actually provided may not reflca that described in the regulatory descriptions of care levels and associated reimbursement rates. Thus, it is possible, if not likely, that Oregon’s adult fostercare providers receive less financial compensation for providing services comparable to those found in assisted living settings. Supportive Housing for an Aging Society Table 1. Comparison of Small Board-and-Care Regulatory Requirements in Maryland and Oregon Regjilatory requirements Licensure category Number of residents permitted Licensed Maryland Assisted living program Oregon Adult foster care I or more 1-5 Yes Yes StaflSng requirements Staffing level Sufficient to meet resident needs Sufficient to meet resident needs Awake overnight staff No No Require owner to live on site No No Provider training or certification Direct-care staff training Yes, effective fall 2005 Yes, set by department, requires completion of test By provider only Yes, set by department, requires completion of test Required services Assessment and care planning Yes Yes All ADLs Yes Yes 3 meals Yes Yes HCBS I9i5(c) waiver Yes, since 2001 Yes, since 1981 Medicaid reimbursement rate as of July I, 2005 Tier II $1,668; Tier m $2,103 Base $917; Tier III $1,592 Waiver slots 3,135 No. Instead, an expenditure limit is established. Waiver waiting list Yes No Other public subsidies Yes Yes Number of assisted living facilities 1,576 192 Number of homes licensed for 1-5 persons 963 1,791 Number of other licensed residential care settings NA 238 Total assisted-living and/or community-based residential care settings 1,579 2,221 Total capacity 18,549 29,390 622,506 455,628 People age 65 + . Winter 2005-2006 27 GENERATIONS Both states express the goal of providing “homelike” care., made explicit in Oregon’s rules and in policy reports by Maryland’s licensing agency (OHCQ, 2004). In addition, they permit flexible staffing levels. In both cases, a manager is accountable, though that person does not need to be on site twenty-four hours per day and can delegate responsibility to an employee. Oregon requires training of both managers and staiF, including successful completion of a competency examination; Maryland recently mandated an eighty-hour training program for all assisted living managers, regardless of facility size (oHCQ, 2005). Finally, both states designate the scope ofcare permitted in specific homes, with Oregon defining three classifications of adult foster care based on the provider’s qualifications (e.g., years of experience, healthcare professional certification) and Maryland defining three levels of care corresponding to the amount of care needed by residents. In contrast, Oregon does not designate types of assisted living settings. Neither state requires that the owner live on site, though many owners do. An AARP study of twenty-six states noted a small trend toward corporate or multiple ownership of small boardand-care homes by providers who do not live in the home but hire either Uve-in or shift personnel (Folkemer et al., 1996). Officials in Oregon and Maryland have expressed concern that multiple ownership threatens both the quality of care and the family-like nattire of small homes (Mulmomah County, 1994; OHCQ, 2005). EFFECTS ON CARE PROVIDERS Different regulatory approaches have had varying effects on care providers. In Maryland, defining small board-and-care homes as assisted living has proven to be a double-edged sword (OHCQ, 2005). Providers report confusion regarding how to meet the requirements, differences among regulators within and across agencies, and costly regulatory burdens from the new paperwork, staffing, and physical plant standards. For example, posting of menus and activity calendars in a home licensed for three persons seems illogical. The state surveyors found themselves helping many providers, including some with lirnited reading abilities, to comply with administrative requirements 28 Winter 2005-2006 rather than quality of care or process-oriented outcomes. Surveyors report that they spend an inordinate amount of time on administrative tasks for homes licensed to care for only two to three individuals (OHCQ, 2004). On the positive side, defining small homes as assisted living may have given a new level of visibility and legitimacy to the work of operators of these settings, including equal pay for equal services. For example, a state work group on assisted living regulations included a committee on small homes. Oregon’s decision to create and finance a designated program to license and monitor providers that care for five or fewer adults has resulted in benefits associated with organizational differentiation, such as specialized knowledge (Scott, r992). For example, the oversight agencies develop training programs attuned to the specific needs of small home providers. In addition, it is easy for consumers to recognize the difference between adult foster-care and assisted living residences. However, these disd n a categories of care might be responsible for an “us versus them” attitude wherein assisted living operators consider the adult foster-care homes as marginal. The relatively large number of adult foster-care homes run by immigrants might sustain such an attitude. Assisted-living trade organizations rarely attract adult foster-care operators, who thus might miss out on valuable training and advocacy programs. Finally, the state’s efforts led to an initial rapid growth of adult foster-care settings, but this number leveled off and has been declining since the mid 1990s (Hernandez, 2005). T H E IMPACT OF REGULATION ON THE LIVES OF RESIDENTS Regulation of course has an impact on the lives of residents. What does the evidence show about residents’ quality of life? In Oregon, the majority of people assessed as requiring nursing-home level of care reside in communitybased settings, including adult foster care, assisted living, and residential carefecilitiesQusdce and Heestand, 2003). Surveys of residents and family members in one county indicated a high level of satisfaction (Scannell, 2004,2005). A survey of 127 residents in forty-six different Oregon adult foster-care homes describes Supportive Housing for an Aging Society aspects of resident satisfaction, including relationships with other residents, staff, and family members; having a say in the move into the home; interest in activities; and quality of care (Scannell, 2004). A survey of thirty-six family members representing nineteen homes indicated that families appreciate the regiuladon and monitoring of their relatives’ homes, believing that the local oversight keeps the homes “accountable.” Because of a perception that “there are bad homes out there,” residents’ family members appreciated that homes were monitored and providers trained. The second possible regulatory impact is on a resident’s feeling of “conneaedness” within the home. A four-state (including Maryland) study of 193 residential settings, including 113 small homes, compared organizational policies, resident characteristics, and environmental features (Zimmerman, Eckert, and Wildfire, 2001). While the quantitative analyses often favored the characteristics of larger facilities, the study’s research interviewers consistendy reported that the smaller facilities possessed qualities that the structured surveys missed. They described the primary strengths of small board-and-care homes as the interacdon between residents and the home’s stafif, family engagement, and resident-facility fit; the term connectedness describes this set of qualides (Eckert, Zimmerman, and Morgan, 2001). The survey of Oregon adult foster-care residents described above found that interpersonal aspects of care were associated with overall sadsfacdon (Scannell, 2004). Similarly, the survey ofthe residents’ family members indicated that the interpersonal reladonship between the resident and the provider is central to sadsfacdon, with this item ranking as the third highest out often quality indicators (Scannell, 2005). This quality, sometimes referred to as family-like, home-style, or personalized, has been associated with adult foster homes in other states (Ball et al., 2005; Folkemer et al., 1996; Morgan, Eckert, and Lyon, 1995). DISCUSSION For over 100 years, small board-and-care homes have provided shelter, assistance with personal needs, and end-of-life care to a diverse group of individuals. A significant number of homes accept people with very low incomes. With recent changes in state and federal longterm-care policies andfinancing,die time is dght to review the role of these settings. We compared two states’ approaches to reguladng small homes and considered the effea on providers and consumers. Though the states differ in several key ways, it seems that on the ground, the settings, services, providers, and residents have much in common, especially an appreciadon for the connectedness, or interpersonal reladonships, afforded by smaller homes. Evaluating the quality of small board-andcare homes remains a challenge. Existing measures may not be attuned to the interpersonal dimension of care provided in small homes, and, to the extent that researchers and policy makers use such measures, negadve findings could lead to regulatory and funding disadvantages that result in the loss of small settings (Morgan et al., 2004). The adult foster-care program operated by Multnomah County in Oregon is unique in surveying residents and their family members, providing an important source of informadon for directing policy decisions such as the type and amount of provider training (Scannell, 2004). Nadonally, public financing of such surveys is very rare. States face a variety of issues in deciding whedier and how to regulate board-and-carc settings, including resources, affordability, local culture, quality standards, and consumer demand. For example, Maryland’s Office of Health Care Quality recendy proposed revising the assisted living rules to designate two new categodes, one called “adult family home” certified (rather than licensed) for one to four residents, and another called “residendal care” licensed for five to nine persons (OHCQ, 2005). These changes indicate policy makers’ realizadon that “one size does notfitall,” as well as the organizadonal burden of licensing large numbers of very small homes. We speculate that reguladons may have more of an effect on providers ofthe smallest board-and-care homes than on residents, at least in terms of residents’ perceptions of quality, which may differ from those of policy makers. However, reguladons, especially those that fail to recognize the charactedsdcs ofsmaller homes, might have an unintended negadve effect on resWinter 2005-2006 29 GENERATIONS idents via providers who either close or cannot keep up with regulatory demands. CONCLUSION Policies that support the nature of small homes (e.g., connectedness or the “mom and pop” approach) and quality care are cridcal to the long-term success of these settings (Morgan, Eckert, and Lyon 1995; Steams and Morgan, 2001). Here we suggest the pros and cons of two different approaches to regulating small homes. Pros of using assisted living as an umbrella term: • Affords legitimacy to settings tradidonally seen as marginal. • Makes the practices and needs of smallhome operators more visible. • Offers operators of small homes public reimbiarsement commensurate with those paid to operators of larger homes. • Provides increased opportunity for informadon exchange among different types of assisted living providers. Cons of using assisted living as an umbrella term: • One size does not fit all. • Small homes cannot meet proposed nadonal models of assisted living. • Surveyors accustomed to larger care settings may unfairly penalize small ones. Pros of a designated adult foster-care program: • Specializadon breeds experdse (e.g., training, rules that fit the realides ofthe setting). • Recognidon is a disdna but important part ofthe home and community-based services landscape. • Designadon makes comparing opdons easier for consumers. Cons of a designated adult foster-care program: • Small homes might remain marginalized and “invisible.” • Operators may have limited access to new best-pracdce concepts. In conclusion, small board-and-care homes have seen many changes over their long history as a residendal setting for firail older people. The U.S. populadon has aged and the range of public subsidies for low-income residents has 30 Winter 2005-2006 increased (though they still do not meet demand). Senior housing has taken many forms, fi’om leisure communides to demenda-carc settings to public housing with services to (amazingly!) even a cruise-ship model (American Geriatrics Society, 2005). The advent of assisted living represents the latest change in the housing-with-sendces arena, though in some places assisted living is a distinct category, and in others it has subsumed the pre-exisdng small board-and-care home. Despite many changes and regulatory approaches, these settings continue to provide healthcare and personal care to individuals with complex care needs. The settings offer an attracdve opdon based on a combinadon of affordability, homelike environment, and personalized care to many older people who might otherwise require insdtudonalizadon. The coming of age of assisted living, and the resulting changes in regulatory approaches, present both benefits and burdens to small board-and-care homes, c/3 Paula C. Carder, PhD., is visiting assistantpvfessor, Leslie A. Morgan, Ph.D., is professor and associate dean, andj. Kevin Eckert, PkD., is professor and dean, all at Erickson School of Aging Studies, University ofMaryland, Baltimore County, Baltimore. Acknowledgements: The authors would iike to thankJohn Muliin, director ofCladmmas County Social Services, and Shelly Immel, training specialistforthe Multnomah County Adult Care Home Program in Oregon, for their technical assistance. REFERENCES American Geriatrics Society (AGS). 2005. Majority of Seniors Would Prefer Living Aboard Cruise Ship to Assisted-Living, According to study released at American Geriatrics Society’s Annual Meeting. [Newswire]. Available at http://wtim>Mmericat^matria.m^/nem/assisted_ livin0.shtml. Accessed January 9, 2006. Ball, M., et al. 2005. Communities of Cure: Assisted Living for African Amerimn Elders. Baltimore: Johns Hopkins University Press. Ball, M., et al. 2000. “Quality of Life in Assisted Living Facilities: Viewpoints ofKesidentsrJournal ofAppUed Gerontology 19: 304-25. Clark, R. R, et al. 1994. Licensed Board-and-Carc Homes: Preliminary Findingsfromthe 1991 National Health Provider Inventory. 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Understanding Medicaid Home and Community-Based Services: A Primer. Washington, D.G.: U.S. Department of Health and Human Services, Assistant Secretary for Planning and Evaluation (ASPE). Phillips, G., et al. 1995. Report on the Effects of Regulation on Quality of Care: Analysis ofthe Effect of Regulation on the Quality of Care in Board and Care Homes. Washington, D.G.: ASPE. Available at http://aspe.hhs.gov/ daltcp/reports/b&crptes.htm. Accessed August 17, 2005. Quinn, M. E., et al. 1999. “Health Gharacteristics of Elderly Personal Gare Home Residents.”/o«n!a/ of Advanced Nursing 30(2): 410-17. Hemandez, M. 2005. Residential Long-Term Care in Oregon: Policy and Supply Trends A cross Provider Types and Rose, R. 1993. Lesson-Drawing in Public Policy. Regions, 19S4-2004. Paper presented at the annual meeting Ghatham, N.J.: Ghatham House. ofthe Gerontological Societ)’ ofAmerica, Orlando, Fla. Scannell, A. 2005. Pilot Study of Family Satisfaction Howard, D. 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Eckert, cds..,Assisted Living: Needs, Practices, and Policies in Residential Carefbr the Eldedy. Baltimore: Johns Hopkins University Press. Wildfire, J. B., et al. 1997-98. “The Effea of Regulation on the Quality of Gare in Board-and-Gare Homes.” Generations 21(4): 25-9. Zimmerman, S., Eckert, J. K., and Wildfire, J. B. 2001. “The Process of Gare.” In S. I. Zimmerman, P. D. Sloane, and J. K. Eckert, eds.. Assisted Living: Needs, Practices, and Policies in Residential Carefbr the Elderly. Baltimore: Johns Hopkins University Press. Winter 2005-2006 3’

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  • Fill in your paper’s requirements in the “PAPER DETAILS” section.
  • Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
  • Click “CREATE ACCOUNT & SIGN IN” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
  • From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.

About AcademicWritersBay.com

AcademicWritersBay.com is an easy-to-use and reliable service that is ready to assist you with your papers 24/7/ 365days a year. 99% of our customers are happy with their papers. Our team is efficient and will always tackle your essay needs comprehensively assuring you of excellent results. Feel free to ask them anything concerning your essay demands or Order.

AcademicWritersBay.com is a private company that offers academic support and assistance to students at all levels. Our mission is to provide proficient and high quality academic services to our highly esteemed clients. AcademicWritersBay.com is equipped with competent and proficient writers to tackle all types of your academic needs, and provide you with excellent results. Most of our writers are holders of master’s degrees or PhDs, which is an surety of excellent results to our clients. We provide assistance to students all over the world.
We provide high quality term papers, research papers, essays, proposals, theses and many others. At AcademicWritersBay.com, you can be sure of excellent grades in your assignments and final exams.

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