Residential Assisted Living: The Small House Model on Long Island

Families from other parts of the country call me asking for a residential assisted living home, the kind of converted house with six or eight residents that is common in Arizona, Texas and California. They are surprised by what they find here. Long Island has very few of them, and the ones that exist are licensed and inspected under rules that are stricter than most families expect.

The direct answer: residential assisted living is care delivered in a small, home sized setting rather than a large community, with a handful of residents, a live in or around the clock staff, and the same personal care an assisted living building provides. On Long Island the closest matches are the smaller licensed adult homes and the family type homes certified through the counties. This post explains how the model works here, who fits it and what to check before you choose one.

What residential assisted living is

Residential assisted living is the small house model: an ordinary house, or a small purpose built home, where a few older adults live together with caregivers who help with bathing, dressing, meals and medication. The resident has a bedroom, sometimes shared, and the living room, kitchen and yard are shared the way they would be in any home. Nobody wears a badge and nobody rings for an aide on another floor.

In New York the model exists under two licenses. The State Department of Health licenses adult homes of all sizes, and some of those on Long Island are small, in the range of a few dozen residents in a converted house or an older building. Family type homes for adults are smaller still, serving up to a handful of residents in a private home, and they are certified and inspected through the county social services district rather than the state. Confirm the current licensing of any home you are considering, because the two are inspected differently and allow different levels of care. I lay out all the settings on my senior housing on Long Island page; this post is about the smallest end of that range.

Residential vs traditional assisted living: how they compare

The two settings deliver the same category of care, personal help and supervision short of daily nursing, and they feel nothing alike. Here is the comparison I draw for families who are deciding between a small home and a community.

Question	Residential small home	Traditional assisted living community
Size	A handful of residents up to a few dozen	Dozens to well over a hundred apartments
Staffing	A small, consistent team; owner often on site; aide to resident ratio can be very low	Aides on every floor around the clock, a nurse overseeing care plans, a full department structure
Living space	A bedroom, often shared, and a shared house	A private apartment with a bathroom and often a kitchenette
Meals	Home cooking at one table	Restaurant style dining with menu choices
Activities	Whatever the house does together: television, cards, the garden, outings in a van	A full daily calendar, outings, clubs, fitness
Licenses	Adult home or family type home; enhanced and special needs certifications are rare	Assisted living residence, often with enhanced and special needs certifications
Pricing	Usually one monthly rate with few add ons	Base rate plus a care level, or all inclusive

On Long Island, most families end up in a traditional community, not because the small homes are worse but because there are so few of them and because the licenses in the larger buildings let a resident stay longer as needs rise. I explain the larger model on my assisted living on Long Island page.

The benefits of the small house model

The benefits are real, and for the right person they outweigh everything a big building offers. The direct answer: a small home gives consistency, attention and quiet that a large community cannot match.

• The same two or three caregivers every day, who know how your father likes his eggs and notice when he is off by lunchtime.
• A very low ratio of residents to staff, often lower than any large building can afford.
• A house, with a kitchen smell and a backyard, for a person who finds a lobby and a long hallway disorienting.
• Quiet. No activity calendar to be herded through, no dining room with a hundred voices.
• Fewer transitions. A resident who would get lost in a big building is never far from the living room.
• Meals cooked in the kitchen, with a resident welcome to sit and watch.

When my own mother needed care, what she wanted most was to be known. That is what a small home sells, and when the staff is stable it delivers.

The trade offs families should weigh

A small home trades scale for intimacy, and the trade cuts both ways. Here is what families give up, in rough order of how often it causes a second move.

1. License limits. Most small homes on Long Island do not hold the enhanced or special needs certifications that let a large community keep a resident who becomes chairfast, needs two person transfers or develops dementia with wandering. Needs rise, and the home may have to say goodbye.
2. Less nursing oversight. A large community has a nurse writing care plans and managing medications on site; a small home relies on the owner, an outside nurse and your parent’s own doctor.
3. Fewer activities and less social range. A resident who loves a lecture, a trip to the theater and a different table every night will be bored by a house of six.
4. Dependence on the owner. If the owner or the one great caregiver leaves, the home changes overnight.
5. Fewer private rooms and fewer amenities, which matters to some residents and not at all to others.

This is why I plan 18 to 24 months ahead with every family. A small home that fits today may not fit at month 18, and a second move is the most expensive and most disruptive event in senior living. Ask the home exactly what would cause it to ask a resident to leave, and get the answer in writing.

Services and amenities you can expect

The services are the same category as a large community, delivered on a smaller scale. A licensed small home on Long Island provides a furnished or unfurnished bedroom, three meals and snacks, housekeeping and laundry, supervision around the clock, help with bathing, dressing, toileting and walking, and assistance with medications within what the license allows. Transportation to appointments is usually arranged rather than scheduled on a fixed van route.

What is not provided is daily skilled nursing. A small home coordinates with your parent’s doctor and may host visiting providers, and hospice can come in from an outside agency, but wound care, IV treatment and rehab happen in a skilled nursing facility. Ask specifically how medications are handled, who is awake overnight, and what happens when a resident falls at 2 in the morning. The honest homes have an answer for each, and the answer involves a person who is in the house, not on call.

Who is a good candidate

The small house model fits a specific person, and getting that right is most of the decision. The direct answer: someone who needs steady personal care, prefers quiet and familiarity over programs and variety, and whose needs are likely to stay within what a small license allows for the next couple of years.

A good fit

• A person with mild to moderate dementia who is calm, does not wander and is soothed by a household routine. Talk to the doctor about the stage before deciding.
• Someone who has always been private, who dreads a dining room and a crowd.
• A person whose physical needs are moderate and stable: one person help with bathing and dressing, a walker, no lift.
• A family that visits often and wants to know every caregiver by name.

Not a good fit

• Anyone with wandering, exit seeking or agitation that needs a secured memory care neighborhood with trained staff; see my memory care page.
• Someone whose needs are rising quickly or who already needs two person transfers.
• A socially hungry person who wants a calendar, clubs and new faces.
• A couple with different needs, who are usually better served in a larger building with assisted living and memory care under one roof.

Special care needs: memory care, hospice and mobility

Small homes are often marketed for dementia, and sometimes that is right. A calm resident in the early or middle stages can do beautifully in a house where the same caregiver sits with her at every meal. What a small home usually cannot provide is a secured, purpose built memory care neighborhood with the special needs certification, the dementia trained staff ratio and the circular hallway that a wandering resident needs. On Long Island and in Queens there are about 47 memory care programs, 42 inside larger assisted living communities and 5 free standing, and none of them is a six bed house. If wandering is part of the picture, that is where I take families.

Hospice is a different story, and here the small home shines. Hospice agencies come into licensed homes of every size, and a dying resident surrounded by two familiar caregivers in a quiet bedroom is often exactly what a family hoped for. Ask the home whether it has worked with hospice before and whether it will keep a resident through the end. Mobility is the third question: ask whether the house has a first floor bedroom, a walk in shower, a ramp and a plan for a resident who can no longer manage stairs, because a converted house was built for a family, not for a walker.

Regulation and state oversight in New York

New York does not allow an unlicensed house to take in paying residents and provide personal care, and that protects families more than most states do. The direct answer: every legitimate small home on Long Island holds a license or certification, is inspected, and has a public record you can read before you visit.

Who oversees what

• Adult homes, of any size, are licensed and inspected by the State Department of Health, and inspection results are published on the department’s website.
• Family type homes for adults are certified and inspected through the county social services district, Nassau or Suffolk, with a cap on the number of residents.
• Both are covered by the state Long Term Care Ombudsman Program, a free advocate for residents of licensed homes.
• Enhanced and special needs certifications, which let a home keep residents with higher physical needs or dementia, are separate approvals from the State Department of Health and most small homes do not hold them.

Confirm the current rules before you rely on them, because the categories and the inspection schedules change. Then do three things on every visit: ask to see the license and the most recent inspection, ask who is awake overnight, and ask what would cause the home to discharge a resident. An unlicensed house with a kind owner is not a safe answer, however warm the kitchen feels, because nobody is checking.

Cost structure, how to choose and how I help

Small homes on Long Island usually charge one monthly rate that covers the room, meals and personal care, with fewer add ons than a large community. The rate is set by the room, shared or private, and by the level of help, and it generally sits below the newer large communities and near the older ones. I do not publish dollar figures because they change every year and vary home by home; ask me for current numbers for the homes you are considering. Medicare does not pay for assisted living rent in any setting. Families pay from savings, long term care insurance, VA Aid and Attendance for eligible veterans and life insurance, and Medicaid helps only through the Assisted Living Program, which is rarely available in the smallest homes; confirm the current rules.

How to choose

1. Match the license to the need: calm dementia and stable physical needs fit a small home; wandering or rising needs point to a larger community.
2. Visit at mealtime and again in the evening, and count the caregivers.
3. Read the license and the latest inspection before you fall in love with the house.
4. Ask what causes a discharge and what the notice period is.
5. Compare against two traditional communities, because the right answer is sometimes a small, quiet neighborhood inside a larger building. My post on 4 things to look for in a Long Island assisted living community applies to both.

My help is free to families; communities compensate the advisor when a family moves in. One call to understand care needs, personality, location and finances, tours together, help comparing offers and paperwork, and follow up after the move. I am a certified senior living advisor with a dementia care certification, and I have toured more than 90 communities across Nassau County, Suffolk County and Queens. Assisted Living Locators of Long Island is at 42 Prospect Ave, Glen Cove, NY 11542. Start with my senior housing on Long Island guide, then contact me and we will find the size of home that fits your parent.

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