Hawaii assisted living facility license: the OHCA apartment-model rules

What Hawaii means by “assisted living facility”

The statute defines an assisted living facility by its philosophy, not its size: “a combination of housing, health care services, and personalized supportive services designed to respond to individual needs, to promote choice, responsibility, independence, privacy, dignity, and individuality.”⁠¹ The licensing rule, HAR chapter 11-90, turns that into a physical model. An ALF “shall consist of a building complex offering dwelling units to individuals.” Meals are provided, staff are available on a 24-hour basis, and services follow each resident’s needs.⁠² The rule names three principles the facility must run on: aging in place, a negotiated plan of care, and managed risk.⁠²

The rule sets no minimum or maximum number of residents. In practice the apartment standard in the next section decides the format. A house with shared bedrooms cannot qualify, because every resident needs a private unit with a kitchenette and a full bathroom.⁠²

ALF or adult residential care home?

If you plan to care for a handful of adults in a house, the license you want is almost certainly an adult residential care home (ARCH), not an ALF. Hawaii defines an ARCH as a facility giving 24-hour living accommodations, for a fee, to unrelated adults who need at least minimal help with daily living, personal care, protection and health care, but not the professional services of a nursing facility.⁠¹ An expanded ARCH may also take residents who need intermediate or skilled nursing level care.⁠¹ OHCA licenses all of these, but under a different rule chapter (11-100.1) with its own room standards. See the Hawaii adult residential care home license guide.

Other neighbours to keep apart:

• Adult day care. Daytime-only programs need a certificate of approval, not an ALF license. See the Hawaii adult day care center guide.
• Services delivered into independent apartments. Personal care brought into residents’ own homes by an outside agency falls under the Hawaii home care agency license. Skilled nursing at home needs a home health agency license.

A small field: 17 licensed ALFs

OHCA publishes a list of every licensed ALF. The April 2026 update shows 17 facilities: 14 on Oahu, and one each in Kailua-Kona on Hawaii Island, Lihue on Kauai, and Kahului on Maui.⁠⁵ License numbers on the list run as high as 25-ALF.⁠⁵ The same list shows each license’s expiration date, so you can see how renewals are staggered.

The low count tells you what OHCA has in front of it. A new ALF application is unusual, and the published materials are thin. OHCA posts no ALF application form or checklist online. You get the form by calling the State Licensing Section at (808) 692-7400, or by writing to 601 Kamokila Boulevard, Room 361, Kapolei, HI 96707.⁠⁴ The rule only says the application is made “on a form provided by the department.”⁠²

No certificate of need, no federal certification

Two approvals that slow down other Hawaii health facilities do not apply here:

• Certificate of need. HRS 323D-54 lists the facilities exempt from Hawaii’s certificate of need law. Item 15 is “extended care adult residential care homes and assisted living facilities.”⁠⁷ You do not need a filing with the State Health Planning and Development Agency before applying to OHCA.
• Medicare/Medicaid certification. OHCA’s table of facility types shows no federal regulation (42 CFR) for assisted living facilities.⁠⁸ The only operating license is the state license under chapter 11-90.

The apartment standard

Section 11-90-4 is short, but it decides your building plan. Each resident must have:⁠²

Source: ⁠²

The rule allows units to be disconnected from cooking, not built without it. If you are converting an existing building, budget for kitchenettes in every unit.

Under section 11-90-3(n), separate buildings on contiguous sites that run as one unit under the same management can share one license. Each building still needs its own staffing plan, approved by the department in advance.⁠²

County approvals and what the application must contain

OHCA will not license a building until you can show it is legal for this occupancy at the county level. Section 11-90-3(o) lists ten items the application must include:⁠²

1. Ownership

   The identity and financial interest of anyone, including stockholders, owning 10% or more.

2. Governance

   Each corporate officer and director, each general partner, or the governing body of a government facility.

3. Contracts

   A summary of all lease, management and sales agreements tied to the facility’s operation and ownership. Copies must be produced if the department asks.

4. Administrator

   The administrator’s name and three references.

5. Addresses

   Facility location and mailing address.

6. Capacity

   The maximum number of residents at any one time.

7. Staff

   Documents showing staff qualifications and training.

8. Fire

   Verification of the facility’s evacuation capacity designation for fire and life safety.

9. Budget

   A proposed annual budget showing sources of revenue.

10. Codes

    Evidence that the premises meet state and county building, housing and fire codes for this occupancy. That includes the county building code occupancy rules, county zoning, a county use permit where required, and state sanitation and environmental health rules.

Item 9 matters more than it looks. Under section 11-90-3(k), DOH can deny a license for “financial inability to operate and conduct the facility” to the rule’s standards.⁠² The same subsection allows denial for failing to meet the chapter, for a criminal conviction, or for a substantiated civil finding of abuse, neglect or misappropriation of resident funds.⁠²

Chapter 11-90 asks for “verification of evacuation capacity designation for fire and life safety protection” but does not say which agency issues it or what document counts as verification.⁠² No OHCA page found on 2026-10-12 answers that either. Ask the State Licensing Section what proof it accepts, and ask the county fire department that covers your site what it will certify.

Background checks for owners, staff and volunteers

HRS 321-15.2 names assisted living facilities among the “healthcare facilities” covered by DOH’s background check law.⁠⁶ Applicants and operators must consent to checks. If the applicant is an entity, that includes its principals, directors, partners, managers, agents and representatives who will have access to residents or their finances or records.⁠⁶ Every prospective direct patient access employee and adult volunteer is checked as well, and so are new hires after licensure.⁠⁶

A check covers:⁠⁶

• the adult protective services central registry
• state child abuse and neglect records
• criminal history
• sex offender registry records
• the certified nurse aide registry
• the same records from any other state where the person lived

An annual name inquiry into state criminal history files follows.⁠⁶ DOH can deny or revoke a license if someone refuses a check or fingerprints, or has disqualifying information. The FBI and Hawaii criminal justice data center fees may be passed on to the applicant, operator, employee or volunteer.⁠⁶

The administrator and staff training

Section 11-90-6 sets three requirements for the administrator or director:⁠²

• at least two years’ experience in a management role in the housing, health care services or personal care industries, or any mix of them
• evidence of completing an assisted living facility administrator’s course, or an equivalent course acceptable to the department
• responsibility for training all staff in providing services and in the principles of assisted living

The rule does not name approved courses, and no list appears on OHCA’s State Licensing Section page.⁠²⁠⁴ Ask the State Licensing Section, before your administrator enrolls, whether the course is acceptable to the department.

Every staff member needs DOH tuberculosis clearance and training in CPR and first aid.⁠² Section 11-90-7 requires an orientation for all new employees on the philosophy, organization, practice and goals of assisted living. Ongoing in-service training must total at least six hours a year.⁠² You also need written policies built around individuality, independence, dignity and a home-like environment.⁠²

Chapter 11-90 sets no numerical staff-to-resident ratio. Instead it requires 24-hour on-site direct staff to meet residents’ needs, and licensed nursing staff available seven days a week for care management and monitoring.⁠² The rule defines “licensed nurse” as a registered nurse licensed in Hawaii.⁠² Your staffing plan is reviewed against those standards, and against your residents’ service plans.

Services you must offer from the first resident

Section 11-90-8(b) lists what the facility itself must provide:⁠²

• 24-hour on-site direct staff
• three meals a day, seven days a week, including modified diets and snacks, with menus evaluated and approved by a dietitian twice a year
• laundry, to the extent a resident cannot do it
• chances for individual and group socializing, with recreational or social activities offered daily
• help with all activities of daily living: bathing, eating, dressing, hygiene, grooming, toileting and walking
• nursing assessment, health monitoring and routine nursing tasks, including tasks a registered nurse delegates to unlicensed assistive personnel under Board of Nursing rules
• household services such as floor cleaning, dusting and bed making

The facility must also be able to provide or arrange transportation to medical and social appointments, ancillary medical services (physician, pharmacist, therapy, podiatry), barber and beauty care, and support for residents with behavior problems. It must also arrange social work services and keep a personal fund account for residents that shows deposits and withdrawals.⁠²

Medications

Residents may self-medicate with prescription drugs only with a written order from a physician or a prescribing advanced practice registered nurse. Over-the-counter drugs may be kept in the unit without an order unless a prescriber says otherwise.⁠² When two people share a unit, each one’s ability to keep medications safely must be assessed. If safety is a concern, medications go in a locked container.⁠² A registered pharmacist, registered nurse or physician must review self-medicating residents’ drugs at least every 90 days. An RN or physician must review every medication the facility administers on the same 90-day cycle.⁠²

Admission contracts, service plans and discharge

Hawaii’s rule leans heavily on written agreements. At admission you must give or complete:⁠²

1. A service listing

   It shows the services offered, the base rate, what the base rate includes, the fee for each additional service, and services you do not provide but will help arrange.

2. A handbook or house rules

   It states the assisted living philosophy and the conditions for occupying a unit.

3. A service plan

   It is developed with the resident and significant others.

4. A signed service contract

   It covers services, rates and when extra fees can be charged.

5. Notice of resident rights

   This includes complaint and appeal steps.

6. A named alternate decision-maker

   or legal representative.

The initial service plan must be in place before the resident moves in and revised within 30 days if needed.⁠² Section 11-90-8 calls for review at least annually, but the rule’s definition of “service plan” says at least semi-annually, or when the resident’s condition changes.⁠² Reviewing every six months satisfies both.

For discharge, residents get 14 days’ written notice when their behavior is an imminent danger, when you cannot meet their needs, or when they have a documented pattern of breaking the agreements assisted living depends on.⁠² Written notice is also required for non-payment or if the license is revoked, not renewed or surrendered.⁠² A resident can ask in writing for an informal conference within 10 days of receiving the notice.⁠²

Emergency and disaster planning on an island

Section 11-90-5 requires written emergency procedures. They must cover quick access to a primary care provider, transport to a hospital, a first aid kit, and evacuation drills every quarter for staff and residents.⁠² The disaster plan must cover evacuating residents with impaired mobility or cognition, and moving all residents to a predetermined facility that can take them.⁠² That arrangement must be backed by a written transfer agreement, renewed every two years.⁠²

Islands outside Oahu each have only one licensed ALF,⁠⁵ and the facility or facilities named in your transfer agreement must together be able to take all of your residents. Line it up before you apply, because the plan must exist and be kept in the facility.

From application to license

The rule and the fee chapter together set this order:

1. Confirm the site with the county

   Get the occupancy classification, zoning clearance and any use permit, plus the fire evacuation capacity designation. All of them are application exhibits.⁠²

2. Request the form from OHCA

   and file the application with the ten items above, including the proposed budget and administrator references.⁠²⁠⁴

3. Complete background checks

   on the applicant, its principals and every hire.⁠⁶

4. Initial survey

   DOH surveys the facility before issuing any initial license. Afterward it notifies you in writing that you are in full compliance, or that you must submit a plan of correction.⁠³ Under chapter 11-90, a plan of correction is due within 10 days of receiving the deficiency list.⁠²

5. Pay the initial fee

   within 10 days of receiving OHCA’s full-compliance notice.⁠³ No license issues until all fees are paid.⁠³

6. Post the license

   where the public can see it, then begin admissions. Operating or admitting residents before licensure violates the rule. Running an unlicensed ALF can lead to fines under HRS 321-20.⁠²

Neither the statute nor the rules state a processing time for an ALF application.

Fees as published on 2026-10-12

Source: ⁠³

Fees are non-refundable. Pay by corporate check, bank or financial institution check, or money order to “State of Hawaii OHCA SF”, or electronically where available. Personal checks and cash are refused, and a bounced check makes the application incomplete.⁠³ For comparison, the same schedule charges $350 for an initial ARCH license and $1,500 for a home care agency.⁠³

Renewal, inspections and changes

A license runs for at least two years unless it says otherwise.⁠² DOH inspects each ALF at least every two years for relicensing. It may also enter without notice at any reasonable time.⁠² Keep summary reports of licensing inspections on file at the facility, available on request.⁠² Pay the renewal fee at least 30 days before the renewal date. Not paying forfeits the license on the renewal date.⁠³ If the renewal paperwork is still being processed, DOH may extend the license once the fee is paid.⁠³

If deficiencies are found, a plan of correction is due in 10 days. If a follow-up survey finds no substantial progress, the license will not be renewed. The director may issue a provisional license instead.⁠² Notify DOH 15 days before any change of name, location, ownership or licensed occupancy. DOH may inspect, and issues a new license if the facility complies.⁠² The director may grant a waiver of a specific rule for up to one year.⁠²

How Hawaii ALFs are paid through Medicaid

Hawaii’s Medicaid program, QUEST Integration, runs as a section 1115 demonstration. CMS extended it on January 8, 2025, through December 31, 2029.⁠¹⁰ Members who meet an institutional level of care were already eligible for assisted living facility services. The 2025 extension added the benefit for an “at risk” group: people who do not yet meet an institutional level of care but are at risk of deteriorating to it, shown by a functional assessment score above a set threshold or a need for hands-on help with at least one daily living or instrumental daily living task due to a health condition. They must also lack caregiver support for that help.⁠¹⁰

The Medicaid service covers personal care and supportive services such as homemaker, chore, attendant services and meal preparation, delivered in a DOH-licensed ALF. “Payment for room and board is prohibited.”⁠¹⁰ Rent and meals for a Medicaid-funded resident therefore need another source. The CMS letter does not describe how QUEST Integration health plans contract with ALFs or what they pay, so ask the plans and the Department of Human Services’ Med-QUEST division about provider enrollment and rates before you count on Medicaid revenue.

A rule change is pending

Chapter 11-90 has been in force since August 23, 1999.⁠² DOH’s rulemaking page lists chapter 11-90 as “Pending amendment” under OHCA, with contact number (808) 692-7227.⁠⁹ As of 2026-10-12, no draft text or public hearing notice for it is posted.⁠⁹ A new project could end up licensed under revised standards. Ask the State Licensing Section about the status before you lock in a building design. The page does not say what the amendment will change or when it will take effect, so ask OHCA at (808) 692-7227.

Sources

1. 1
   Hawaii State Legislature, Hawaii Revised Statutes, section 321-15.1 (Definitions) Checked 12 Oct 2026 · Back to text ↑
2. 2
   Hawaii Department of Health, Hawaii Administrative Rules, chapter 11-90 (Assisted Living Facility) Checked 12 Oct 2026 · Back to text ↑
3. 3
   Hawaii Department of Health, Hawaii Administrative Rules, chapter 11-103.1 (Licensure and Certification Fees for Health Care Facilities and Agencies) Checked 12 Oct 2026 · Back to text ↑
4. 4
   Hawaii Department of Health, Office of Health Care Assurance, State Licensing Section Checked 12 Oct 2026 · Back to text ↑
5. 5
   Hawaii Department of Health, Office of Health Care Assurance, Assisted Living Facility list (updated 4/2026) Checked 12 Oct 2026 · Back to text ↑
6. 6
   Hawaii State Legislature, Hawaii Revised Statutes, section 321-15.2 (Background checks) Checked 12 Oct 2026 · Back to text ↑
7. 7
   Hawaii State Legislature, Hawaii Revised Statutes, section 323D-54 (Exemptions from certificate of need requirements) Checked 12 Oct 2026 · Back to text ↑
8. 8
   Hawaii Department of Health, Office of Health Care Assurance, Type of Hawaii State Licensed and/or Federal Certified Facilities or Agencies Checked 12 Oct 2026 · Back to text ↑
9. 9
   Hawaii Department of Health, Proposed Changes to Department of Health Administrative Rules Title 11 Checked 12 Oct 2026 · Back to text ↑
10. 10
    Centers for Medicare & Medicaid Services, CMS approval letter, Hawaii QUEST Integration section 1115 demonstration extension (January 8, 2025) Checked 12 Oct 2026 · Back to text ↑

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