Seniors for Sale

Nadra McSherry devoted her life to helping disabled schoolchildren. But after her husband died, she suffered a heart attack and a stroke. Now it was time for someone to help her.

Her three daughters searched for the right place. They agreed that an adult family home offered their 74-year-old mother an ideal blend of independence and care.

They inspected more than a dozen homes and grilled their owners. They were comforted that adult homes were licensed by the state Department of Social and Health Services.

In fall 2001, they settled on Narrows View Manor in Tacoma, owned by Arlie and Charlene Leno.

The ranch home is perched on a bluff in West Tacoma with spectacular views of the Tacoma Narrows. Lush gardens surrounded a rear patio. The home looked immaculate, with fresh flowers everywhere. Meals were nutritious and varied. A harpist played music weekly.

McSherry paid $3,500 a month for a bedroom, prepared meals and daily care delivered by a staff of aides.

"It seemed like the perfect place," youngest daughter Elaine Matsuda said.

McSherry's daughters had no clue that only weeks earlier, inspectors for DSHS had swept into the home and uncovered 14 safety and health violations. And they had no idea that Arlie Leno harbored a troubling past, one enabled by state regulators.

By the time they pieced it together, it was far too late to save their mother.

First: real trouble with boarding home

In 1990, Arlie Leno, 63, left his job as a nursing-home administrator and became his own boss, getting a state license to run a Tacoma boarding home with 16 adult residents. He called it Tule Lake Manor.

Boarding homes are larger versions of adult family homes, with meals, housekeeping and laundry provided by staff, and generally cost less for residents.

Leno's residents ranged from the bed bound to those with late-stage Alzheimer's disease or Down syndrome.

Despite his work experience, Leno got into trouble within a few months of opening Tule Lake Manor.

Inspectors for DSHS cited him for 18 violations, many of them serious, including failing to properly train staff, notify family when a resident fell and broke a hip, and obtain medical care for a resident who fell and was injured.

Inspectors found that one staffer had lost her nurse's-aide license for "alcohol and drug issues"; another was on probation for a felony assault conviction and, by law, was not allowed to be alone with a vulnerable adult. Only a handful of owners have employed staff convicted of "disqualifying" crimes, records show.

The state rarely invokes the ultimate penalty, revoking a home owner's license. But in 2000, DSHS revoked Leno's boarding-home license, citing a decade of abuse and neglect and evidence that residents had "suffered actual harm." Between 1990 and 2000, state inspectors had cited Leno with 135 violations, many of them serious.

Leno, who had the right to appeal, asked for a meeting. DSHS outlined his options: He could fight the revocation, which would cost them both time and money. Or he could give up his license, sell the business, and the state would rescind its revocation from his record. Leno grabbed the latter.

He sold Tule Lake Manor for $422,000 to new owners, who have no connection with Leno.

All along, details of Leno's decadelong span of violations were keyed into a DSHS computer.

Next: violations at Narrows View Manor

Five years into running his boarding home, Leno expanded into the adult-family-home business. It was 1995, shortly after the state began its campaign to boost the numbers of adult homes, when Leno and his wife, Charlene, started Narrows View Manor in Tacoma.

Charlene Leno ran the day-to-day operations. In its first five years, the home was cited for only minor infractions, records show.

After Arlie Leno gave up his boarding home in 2000, he began taking a more active role at Narrows View. After that, inspectors cited the home more often for violations, some of them serious, including failing to train staff and to screen them for infectious diseases.

While the Lenos tussled with state inspectors, they also struggled financially, according to court records. In 2002, they declared bankruptcy. They said they netted about $30,000 a year from their business but had $316,000 in mortgage and other debts, including $40,000 in delinquent federal taxes.

They sold their residence in Gig Harbor for about $225,000 and lost a Las Vegas time share to foreclosure.

More violations piled up at Narrows View Manor: They failed to create a "care plan" for each resident. The care plan is a critical blueprint that tells staff exactly what care each resident requires: what medications to take and when, how often a resident has to be turned to avoid bedsores, what diet to follow, and so on.

Arlie Leno also hired a woman convicted of felony assault to care for the residents. By law, her conviction barred her from working there.

Each time, the Lenos promised to fix the problems. DSHS sometimes imposed conditions, such as getting more training or adding staff. Most of the time, the Lenos were given fines of $100 to $300.

In July 2003, the couple separated and Charlene Leno, then 60, moved out.

Their breakup created problems for Arlie Leno as well as for his residents. His wife was listed on the state license as the "provider," meaning she was the owner responsible for overseeing care.

DSHS considered her the glue that held the home together. She had training in CPR and in caring for seniors. She was responsible for making sure staffers were screened for tuberculosis and didn't have "disqualifying" felonies such as assault.

Arlie Leno's solution was to lie repeatedly to inspectors about his wife's whereabouts. For nearly a year, state records show, he told DSHS investigators that his wife was away on vacation or visiting family.

DSHS officials eventually unraveled his deception. Leno had lied four times, the state concluded. DSHS' penalty for lying to its staff is a $100 fine. So the agency fined him $400.

A DSHS inspector wrote an e-mail to a colleague about Charlene Leno's absence and predicted: "Without her oversight the home will not stay in compliance."

As problems mount, sore goes untreated

That same year, 2004, Arlie Leno committed perhaps his most brazen violation. He sneaked an extra resident into Narrows View. By law, he was limited to six residents, but he added a seventh, apparently to squeeze out more profits.

During a DSHS inspection in July 2004, Leno told a staffer that he had only six residents, five female and one male. The inspector became suspicious when he spotted a second male resident walk out of the staff bedroom, and asked his identity.

Leno admitted that he housed seven, not six, residents, records show.

Where did the caregiver sleep, then? the inspector wanted to know.

Leno pointed to a rolled-up sleeping bag propped against a living-room wall.

In another case, a resident fell on the bathroom floor and broke her leg but the caregiver refused to call an ambulance. "We don't do that here," DSHS records recount the caregiver as saying. "We call the family to take them."

The injured woman's family wasn't called until nearly three hours after she fell, records show.

DSHS threatened harsh action. In talking to Leno's former wife, an inspector learned that she had left the home one year earlier and that she'd had "an ongoing battle" with Leno, she said, over adding residents beyond the legal limit.

But because Arlie Leno promised to remedy problems and appeared cooperative, DSHS settled for modest fines.

All through this time, McSherry's daughters and other family members visited her nearly every day at Narrows View; daughter Janice McDonald, who worked at a hospital nearby, would stop in after work.

On the surface, the home appeared to be fine.

"One might wonder why we didn't see what was going on," Elaine Matsuda would later explain. "There are some things that are so subtle. And what Arlie Leno didn't want us to see is not going to happen while we're there."

The McSherry family knew nothing of Leno's serious violations. Leno did not have to post them nor inform residents, as nursing homes are required to do.

In June 2006, McSherry developed a small bedsore on her tailbone. The daughters arranged for a registered nurse to visit the Leno home and treat her wound.

Once the wound had sufficiently healed, the nurse showed aides at Narrows View how to treat pressure sores. She told the staff to alert her or McSherry's doctor if the sore flared again.

Within two months, McSherry's pressure sore re-emerged, medical records show. But no one at the home recognized its danger and no one in McSherry's family was told about it, nor were her doctor or nurse.

The wound remained untreated for more than a month. Aides did rub an ointment on it each day. But the ointment was not suitable for pressure sores. In fact, records show, the ointment made it worse.

Owner fined $3,200 for a painful death

Years of poor health had inured McSherry to pain. But after sitting for a month with a festering bedsore, she finally blurted out, "My bottom hurts," McDonald recalled.

She undressed her mother, then gasped. "There was a quarter-size hole in the skin. It went to the bone," she said.

A nurse visiting Leno's home at the time examined McSherry's tailbone and was alarmed. It was the worst pressure sore she had seen in 20 years of practice, she later told DSHS investigators. It was a Stage IV ulcer, meaning it had eaten through her skin, muscles and connective tissue, down to the bone.

McSherry was rushed to the emergency room, then admitted to Allenmore Hospital. For nearly a month, doctors unleashed a medical arsenal against the raging infection and the pain. Nothing worked.

McDonald was with her mother on the night of Oct. 19, 2006, and "had a sense this wasn't going to get any better." Before leaving for home, she bent down and whispered the Lord's Prayer in her mother's ear.

The next morning, according to hospital records, McSherry bolted awake and yelled, "Janice!" A few moments later she died.

Dr. Richard Waltman, who signed her death certificate, said McSherry died of a heart attack brought on by infection from the bedsore. "It was too much for her body to handle," he said.

Matsuda filed a complaint with DSHS.

"My mother died a horrifically painful death. She weighed 80 pounds when she died. They were giving her morphine that would have knocked out a 400-pound football player," Matsuda said. "She still would scream and yell and cry out in pain and delirium from the medication."

Adult-home inspectors, looking into the complaint, queried their network computer for Leno's infractions. Other than the violations at Narrows View Manor, he had a clean slate.

DSHS kept its boarding-home violations in a database that was not linked to the database for adult-family-home violations. (The databases have since been linked.)

DSHS determined that Leno's mistreatment of McSherry did not warrant revoking his license. It required him, for the first time, to post his violations publicly. And it did fine him $3,200: $100 for each of the 32 days that he failed to provide proper care to McSherry — the price of one preventable death.

This infuriated Matsuda and her sisters.

Agency bosses overrule inspectors

Since McSherry's death, DSHS found more serious violations at Leno's home.

In May 2007, a female resident was found crawling in the middle of a four-lane street in a busy intersection. The woman, who had Alzheimer's disease, ended up in a nearby emergency room with a head wound.

A DSHS document, written days after the incident, delivered a stern warning:

"His repeated failed practices and violations of licensing requirements demonstrate his inability and lack of understanding to carry out the responsibility to provide for the health, safety and well-being of the vulnerable adults residing in his adult family home, placing them at risk of harm."

In May 2007, Janice Schurman, a DSHS supervisor, wrote to her superiors that field investigators felt Leno should lose his license.

"This is one with a loonnng history of noncompliance. Field is recommending revocation, I support it," she wrote.

Supervisors overruled her. DSHS supervisors ultimately ruled in favor of Leno, who will be 83 years old this year. He holds a dubious record: No adult-home owner has amassed as many serious violations as Leno has and still remained open for business.

Agency officials initially defended their actions involving Leno. As they sometimes do with problem homes, they inspected Narrows View more frequently and imposed conditions, such as enhanced training for staff, that made it safer, said Joyce Stockwell, who oversees adult family homes for DSHS.

It's not uncommon for field investigators to be overruled, Stockwell said.

"Enforcement is never done in the field because there are emotions that come in," she said.

However, in a subsequent interview, Stockwell last week said, "In hindsight, we would have made a different decision."

A claim of 'deliberate indifference'

McSherry's daughters were haunted by their mother's neglect. Matsuda contacted Seattle attorney Anthony Shapiro, who determined that Arlie Leno had no major assets and did not carry liability insurance.

At the time of McSherry's death, DSHS had waived insurance requirements for adult-home owners because it was deemed too expensive.

Shapiro embraced a novel strategy: He filed a civil suit against DSHS under the legal doctrine of "deliberate indifference." He had to prove that DSHS knew that a substantial risk to residents existed at Leno's adult family home and chose to ignore it.

"This was not the only incident in Narrows View's history where pressure ulcers and pressure sores cropped up among patients," Shapiro said. "They had a long history of people having pressure sores and DSHS knew about it and other than noting it, and coming in periodically, the practice at this home really never changed.

"Each time somebody brought it up to DSHS superiors — we must shut this man down — they were rebuked and no material action was taken."

DSHS settled with McSherry's family late last year for $565,000. Leno, also named in the suit, reached a confidential settlement with the family.

Phone call to DSHS ends in a surprise

Matsuda and her sisters hope the story of their mother's death will empower other families to look beneath the surface if they have a loved one in an adult family home.

"I'm angry. And that's putting it mildly. I'm frustrated and feeling guilty a little," she said. "We didn't know. And I didn't complain early enough to save her. I should have had my eyes opened wider.

"I will be honest with you, and I'll kick myself to the day I die, I didn't know I should call DSHS" before deciding to put her mother in Leno's home. Even if she had called, knowing all she knows about the agency now, Matsuda said, "I don't know if I would have gotten what I needed."

She may be right.

A Times reporter telephoned a DSHS regional office and, as any member of the public can do, asked about the enforcement history at Arlie Leno's home. The reporter was not asked for identity or affiliation.

A DSHS staffer, reading from a computer file, characterized the bulk of Leno's history of violations as minor infractions and "paperwork problems."

When she came to the 2006 violations regarding McSherry, the staffer noted that a resident had developed a "little pressure ulcer."

When asked if the woman died from neglect, the DSHS staffer consulted the enforcement computer once again.

Oh, no, she said. "It doesn't show anything about a death."




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The location of the home was secret. Only potential buyers with a $500,000 line of credit could learn its Seattle address. The seller insisted on discretion because the price included three frail seniors who lived inside.

A Bothell real-estate listing last year touted five seniors for $120,000, "sold separately" from the home. Bids for five vulnerable adults in Arlington opened at $90,000 — "cash only."

These deals aren't illegal. Washington officials not only know about it, they allow it.

Twenty years ago, the state Department of Social and Health Services began licensing homeowners to provide spare bedrooms and care for the old or frail who might otherwise have to live in nursing homes.

These private residences — called adult family homes — were marketed as opportunities for seniors to live in cozy settings and familiar neighborhoods, close to family and friends, with more freedom and superior care.

The owners were given freedom, as well. To encourage this new industry, the state imposed few regulations — no requirements for a minimum level of employees or even, for many years, liability insurance.

Today, Washington is lauded nationally as a leader in community care options for seniors.

But inside the state's 2,843 adult homes, thousands of vulnerable adults have been exploited by profiteers or harmed by amateur caregivers, an investigation by The Seattle Times has found.

The Times uncovered accounts of elderly victims who were imprisoned in their rooms, roped into their beds at night, strapped to chairs during the day so they wouldn't wander off, drugged into submission or left without proper medical treatment for weeks.

In a Shoreline home, a worker whose previous experience was at McDonald's broke a resident's neck when attempting to move her from her bed. At a Seattle home, a worker handed a lit cigarette to a resident who was connected to an oxygen tank, setting off a fiery explosion.

In scores of cases, owners raked in monthly payments while they pinched pennies and eliminated meals, turned off the heat, or left residents in urine-soiled clothing for days.

"DSHS has pushed so hard and developed these adult family homes so quickly that they have little ability to oversee them. It should scare people," said Gary Weeks, director of the Washington Health Care Association, which represents nursing homes.

About 11,200 people reside in adult family homes across the state. About three out of five residents are private pay. There are about 1,100 homes in King County alone, more than three times the number of Starbucks stores.

The pace of licensing is so furious that, on average, the state issues a new one every day.

Officials at DSHS, which inspects the homes at least every 18 months, say the majority are run by caring, competent providers with good records. Officials say the agency's standards are among the highest of those states that allow similar homes.

However, The Times examined 15 years of inspection reports and found that, time and again, DSHS excused reports of abuse and neglect, even when it knew that violators lied to its investigators, provided falsified medical records, or contributed to preventable deaths.

Overlapping trends exacerbate the problem: Washington's aged population is growing. State budgets are underfunded, resulting in a cost-cutting strategy to move state-subsidized patients from nursing homes into less-expensive neighborhood residences. And in today's battered economy, more people than ever hope to make money from their homes by taking in the elderly.

Even a state-approved instructor, one of nine people allowed to teach new owners how to run an adult family home (AFH), makes a get-rich pitch:

"I see other businesses struggling in these tough economic times — but AFH cash flow keeps coming in!" Jo Lyn Cornelsen, who owns a Brush Prairie, Clark County, adult family home, wrote on her business Web site. "The AFH industry elevates minimum-wage workers to six-figure-income business owners in under a year."

But a Times analysis revealed a bleak reality behind the hype: For every four new homes licensed, three older ones go out of business.

"There's always been this perception that it's easy money, that it's a way to make your mortgage payments," said Carolyn Edmonds of the state Long-Term Care Ombudsman's Office.

"Unfortunately, we see the often-tragic human cost when owners are lured by profits and not a desire to help people."

Massive bruises, both old and new

In 2008, Ann Detlefs faced a tough decision. For several years she had prayed that her husband, Darwin — at 84, eight years her senior — could stay with her in their Everett home.

But the warning signs of memory loss, erratic moods and difficulty expressing himself were diagnosed as Alzheimer's disease, and she couldn't care for him by herself.

A retired manager for IBM, he had loved woodworking, crafting toys and furniture for family members from his garage workshop. Now he couldn't take a shower by himself. He was incontinent and often so confused he would try to wander away.

Her first choice, a Seattle nursing home, had a waiting list. In May 2008, she settled on an adult family home, Hidden Gardens, where her older sister had received good care before moving elsewhere.

Owner Susan Martin charged $3,200 a month to care for Darwin Detlefs, who joined five other seniors at the three-bedroom, 2,430-square-foot ranch home in Enumclaw. Martin and her teenage daughter slept in the garage, which was converted into a bedroom.

Within weeks, Martin complained that Darwin Detlefs was combative — he escaped from the house one evening and it took 20 minutes to get him back inside.

As a result, Martin enacted new financial penalties. Nighttime assistance would cost an extra $600 monthly. Repeated demands to go to the bathroom — she dubbed it "inappropriate toileting behavior" — would bump it up to an additional $1,000 monthly.

Martin would waive penalties if families agreed to use medications to "correct the behavior" — in other words, sedate the residents, according to a copy of the rules provided to The Times.

Before long, Detlefs said, she observed signs that Martin was overwhelmed: The house looked unkempt; cat feces littered a bathtub; soiled laundry sat piled high; meals were skimpy and hastily prepared.

Martin "got terribly stressed out when her only caregiver went on vacation for two and half weeks," Detlefs would later explain.

"It became impossible for her to safely take care of six patients by herself."

In July, Detlefs spotted bruises on her husband's arms and an untreated gash on his left hand. She said Martin explained that Darwin Detlefs had tripped over an empty wheelchair.

Ann Detlefs said she was suspicious and asked her husband if he was safe. In a rare moment of coherence, he said, "At least you don't get yelled at."

Alarmed, Detlefs transferred him to an Everett nursing home on July 31. During an admission exam, a nurse discovered massive bruises, old and fresh, across his shoulders. Nurses took photographs for evidence.

"I was told that the injuries were consistent with abuse," Detlefs said.

She filed a complaint with DSHS. However, its investigation was "unable to verify alleged abuse," records show. There was no acknowledgment of the photos.

After Darwin Detlefs moved out of the Martin home, the agency received complaints about mistreatment of three other residents in the home, DSHS records show. This time, investigators wrote, the evidence of physical and emotional abuse was overwhelming. The agency revoked Martin's license.

Martin declined to be interviewed. The house was sold last month for $220,000.

Ann Detlefs still wrestles with guilt: Should she have routinely undressed her husband? Did she react too slowly? Did he suffer, unable to cry for help?

She said she kept the photos of the yellow and purple bruises on Darwin Detlefs' reed-thin body, but "I can't look at them."

Her husband died from complications of Alzheimer's last April. But in his nursing home he had regained weight and was happy despite the limitations of his disease.

That's the image of him Ann Detlefs said she chooses to remember.

More homes but fewer investigators

Washington's tiny adult-family-home industry got a boost in 1993 when the state, desperate to cut Medicaid expenses, began to relocate or steer patients from nursing homes into private residences, which cost less than half as much.

State officials maintained that nursing homes were glutted with lower-income patients, covered by Medicaid, who didn't require 24-hour care. Essentially, these residents were not infirm enough to justify the costs.

In the first year, DSHS reduced the number of its 17,448 nursing-home patients by 750. The next year, lawmakers approved relocations of 1,400 more.

State officials said the strategy, in 2008, saved $105 million in state Medicaid funds that would otherwise have gone to nursing homes.

By 2012, DSHS plans to relocate another 1,100 nursing-home patients into adult homes or other community-based facilities.

The state may not be able to adequately oversee the growing ranks of government-paid and private-paid residents in adult family homes. DSHS is not able to answer such questions as: Which homes and how many didn't provide enough food? What homes had assaults on residents?

The Times coded and analyzed the past four years of enforcement actions, more than 2,000 records, and built its own database to provide answers unavailable from DSHS.

In 2008, for example, The Times found 576 violations involving caregivers performing unauthorized medical duties; 46 cases of residents unnecessarily restrained; and 1,201 instances in which medication records were missing or incorrect.

In a Bothell home, for example, a caregiver passed out Vicodin, a narcotic pain medication, to control a resident who "talks a lot." The resident, who had no pain, was given the powerful drug at least 10 times in one month, records show.

Few cases are more tragic, or better underscore lax licensing standards, than a five-day lapse inside a Lynden, Whatcom County, adult family home.

In December 2006, owner Tony Nam, 69, was left alone with three residents when his two caregivers went on a short vacation. When the employees returned five days later, they discovered a critically ill female resident who was severely dehydrated and covered in fresh vomit. The caregivers demanded that Nam call for help.

The problem, according to a DSHS investigation, was that Nam "could not speak English well enough to explain the resident's health condition to the physician."

One of the caregivers had to grab the phone and explain the emergency.

The woman, 58, arrived at the hospital in a coma, with pneumonia in both lungs. She died five days later.

Nam's English was so bad that he later struggled to answer questions from DSHS investigators. He did not recognize the woman's symptoms as life-threatening, he told investigators.

The ability to communicate in English is one of the requirements to become an adult-family-home owner. DSHS officials could not explain how Nam passed the English requirement. They later revoked his license.

Nam couldn't be reached for comment.

Kathy Leitch, a deputy director who oversees the DSHS Aging and Disability Services Administration, said a hiring freeze — the result of state budget cuts — has left fewer investigators to monitor more homes.

Many licensing and training standards may be outdated, she said.

"There's this idea that it's a cottage industry, and that the state shouldn't be overly regulatory. Personally, I think that's a bit naive."

Unlicensed home, unnecessary death

In the early 1990s, the state limited owners of adult family homes to one residence. But lawmakers lifted the restriction when owners argued that the benefits of bulk purchasing and hiring a universal staff, to rotate among homes, enhanced quality of care.

Today, 322 people own two or more adult family homes, according to a Times analysis.

Many of the better owners have successfully juggled multiple homes. But one with a particularly rocky history is Bernardita Sarausad, 62, a registered nurse who owns six homes in Seattle, Shoreline and Edmonds. Since 1999, DSHS has halted new admissions to her homes three times after investigations uncovered substandard conditions.

State files reveal dozens of citations involving resident care, including preventable pressure ulcers (bedsores); delay of care; and undertrained staff.

Marcella Sides, of Kent, said she uncovered the same problems in 2007 with the care of her parents.

Her mother, Alice Clayton, 88, had become bedridden after a fall left her partially paralyzed. Her father, George, 87, a retired Navy veteran, could walk and care for himself. More than anything, he wanted be with his wife. Few adult family homes were willing to accommodate them both.

Sarausad told Sides she had a two-bedroom condo near Northgate that would be just right for her parents. It would cost $6,500 a month for 24-hour care for her mother and $1,500 for meals and rent for her father.

The condo, however, was not licensed as an adult family home, according to state records. Its sole caregiver was a woman accused of fraudulently posing as a registered nurse at a Tacoma nursing facility, The Times has learned. Sides knew none of this.

Sides did learn, however, that the caregiver often worked seven days a week without a break and slept on the living-room couch. "It was like slave labor," Sides said.

Unknown to Sides at first, the woman considered the condo's living room to be her space in the evening, and made Alice Clayton stay in her bedroom from 6 p.m. to 10 a.m. "I'm a prisoner in my room," she told her daughter.

Then Sides discovered an inflamed sore on her mother's left shoulder in early 2008. The caregiver and a visiting nurse said there was nothing to worry about, Sides said.

However, the wound worsened, and her mother died in March 2008 at a Seattle hospital; her husband was by her side. The death certificate cited the pressure sore and its subsequent infection as contributing causes of death.

Sides' father now lives in an assisted-living facility near Federal Way.

Sarausad would not respond to interview requests. On her Web site this month, Sarausad wrote that she plans to open three more homes this year, two in Shoreline and one in Edmonds.

Placement agencies: conflicts of interest?

Navigating the labyrinth of adult family homes can be confusing. There is no government clearinghouse to compare the quality of care and services from one home to another.

As a result, this gap has spawned a new kind of profiteer: senior-placement agencies.

These companies offer to match a senior's medical needs to the most appropriate care facility — free of charge. They will generate a list of suggested homes based on the person's medical needs and wishes, such as a private room or recreational activities.

These companies earn hefty commissions paid by owners of adult homes — a potential conflict of interest that is seldom disclosed, The Times has found.

A typical commission is equivalent to a resident's first month of rent, generally from $2,000 to $7,000.

Most of the placement companies are run out of home offices — anyone with a computer and a Web site can set up shop. No licensing, education or training is required. There are dozens in King County.

Are placement agencies steering people to homes that are the best fit — or instead to the ones that pay the highest referral fees? There is no way to know for certain.

But some in the industry are calling for more transparency and state licensing.

"I think patients in many cases are treated like a commodity and I don't like it," said Dotti Snow, 63, of Woodinville, a registered nurse who has operated Aging Safely, a placement service, for 11 years.

She said she has infuriated competitors by charging owners only half a month's rent, and by disclosing to customers that her fees are paid by the adult homes.

To try to get her to refer new residents to them, adult-family-home owners increasingly send gifts and cash to Snow. Currently, adult-home vacancies are at high levels as more financially strapped families delay paying for long-term care.

Snow said she sends back every gift card and gratuity, including, once, a check made out to her for $1,500.

Long hours yield only modest income

So far, two potential buyers have toured the Seattle adult family home on sale for $500,000 with the three residents inside. It is a 2,100-square-foot home on Northeast 133rd Street in Lake City owned by Mihai and Viorica Badet.

They've run the home since 1996 with no major citations, state files show. Mihai Badet, 62, also works full time as an engineer. His wife assists a full-time caregiver in the home. The Badets want out of the business.

Competition is stiff. Dozens of other adult family homes are on the market in Seattle and statewide. Sales pitches sound the easy-money theme: start making money now; guaranteed cash flow; opportunity of a lifetime.

The Badets know better. They care for an elderly man and two women, one of whom is bedridden. Their home grossed $168,000 last year, with monthly rent for each resident averaging $4,700. After expenses but before taxes, they netted $57,000, according to information provided to prospective buyers.

They do not have residents to fill three empty beds, so their long hours bring only a modest income. Comparable homes in their neighborhood have sold for about $400,000.

The Badets believe their home, with three residents under contract, is worth $100,000 more, if a new owner can also qualify for a DSHS license.

"You need to really like this kind of business," Mihai Badet said. "... You're tied to the house 24/7. You can't go anywhere."

He offers this advice: "You can't do this for the money."