North Carolina adult care home license: certificate of need, DHSR steps and fees

Which North Carolina license fits your assisted living project

North Carolina law treats “assisted living residence” as a broad label, not a license. It covers any group housing and services program for two or more unrelated adults that offers at least one meal a day and housekeeping, and provides personal care either directly or through a licensed home care or hospice agency. The statute names three types: adult care homes, adult care homes that serve only elderly persons, and multiunit assisted housing with services.⁠¹

The licensed type is the adult care home. The housing operator provides 24-hour scheduled and unscheduled personal care, and designated trained staff may give medications.⁠¹ Which rules apply depends on size:

Scroll the table sideways to see every column.

If you plan six beds or fewer, read the North Carolina family care home license guide instead. That route avoids the certificate of need entirely.

Multiunit assisted housing with services is a different business model. A licensed home care or hospice agency delivers the hands-on care under a written care plan. Residents may choose any provider, the housing operator may not bundle housing and personal care charges, and no resident may need 24-hour supervision.⁠¹ You register a disclosure statement rather than get licensed, but running one without registering is a Class H felony carrying a fine of $1,000 a day.⁠³ As of 2026-10-12, DHSR warns that disclosure reviews are taking longer than the standard 30 days because of a surge in applications, and you may not admit residents before you are registered.⁠¹¹ The care itself would come from an agency licensed under the North Carolina home care agency license.

The certificate of need gate comes first

Unlike most states, North Carolina has kept adult care home beds under certificate of need (CON) control. A 1997 law put a statewide moratorium on new beds, and since 2001 they have been regulated through CON.⁠¹⁶ DHSR states it plainly: “No one may develop new adult care home beds without a certificate of need.”⁠¹⁰ The CON statute defines an adult care home as a facility with seven or more beds, which is why the 2-6 bed family care home falls outside it.⁠⁵

Each of North Carolina’s 100 counties is its own service area. Every year the State Medical Facilities Plan (SMFP) projects bed demand five years out and compares it with existing and approved beds.⁠¹⁶ A county gets a need determination only if its deficit is at least 10% of projected need with licensed-bed occupancy of 80% or more, or if the deficit is 50% or more.⁠¹⁶

Scroll the table sideways to see every column.

The 2026 plan states that “there is no need anywhere else in the state and no other reviews are scheduled.”⁠¹⁶ The proposed 2027 plan uses the same wording for its two counties and makes no substantive change to the adult care home methodology.⁠¹⁷ Anyone may apply to meet a need determination, not just the existing operators whose numbers created it. Deadlines are absolute, with filing due by 5:00 p.m. on the deadline date.⁠¹⁶

Both 2026 deadlines have passed as of 2026-10-12. The proposed 2027 plan lists the Alleghany and Chowan deadlines as “To be determined,” and the sources reviewed on that date do not give them. Ask the CON Section (919-855-3873) for the schedule once the final 2027 plan is approved.

There are two other ways to get beds. Under Policy LTC-2, existing licensed beds can be relocated from one county to another through a CON application.⁠¹⁶ You can also buy an existing licensed home. A facility licensed as an adult care home within the preceding 12 months still counts as an existing health service facility for CON purposes.⁠²

How the CON review runs, as DHSR describes it:⁠¹⁰

1. File on schedule

   Applications are accepted only for counties where a review is scheduled. If you will lease the building, the owner/lessor and the lessee must file a joint application.

2. Comments

   Anyone may file written comments within 30 days of the start of the review period.

3. Public hearing

   The CON Section holds it 30 to 50 days into the review, and you can respond to comments there.

4. Decision

   Approval or denial comes within 150 days of the start of the review period.

5. Issuance

   The CON is issued 35 days after approval unless someone files a petition for a contested case hearing.

The CON application fee is $5,000 plus 0.3% of any proposed capital expenditure above $1 million, capped at $50,000. It is not refundable, even if the CON is denied.⁠⁶ Your licensed bed count and services must then match the CON.⁠⁹

Site, building and fire safety

After the CON is issued, you work with two DHSR sections in parallel: the Construction Section and the Adult Care Licensure Section.⁠¹⁰

The site must be approved by local zoning boards and by DHSR before construction. It also needs road and emergency-vehicle access and local health department approval for water, sewage and garbage.⁠⁹ Any building being licensed as an adult care home for the first time, including a conversion from another use, must meet the North Carolina State Building Codes for new construction. Which code section applies depends on size:⁠⁹

• 13 or more residents: I-2 Institutional Occupancy, plus the sanitation rules in 15A NCAC 18A .1300.
• 7 to 12 residents: the Large Residential Care Facilities section of the Building Code, plus the residential care sanitation rules in 15A NCAC 18A .1600.

Plan review. You send two sets of floor plans and specifications to the Construction Section. One set is enough if the project is under 10,000 square feet or the local building department has authority for Institutional plan review. The Construction Section invoices a review fee and does not start until it is paid. Review usually runs in three stages: schematic, design development and final working drawings.⁠¹⁰ Drawing approval expires one year after approval unless a building permit has been issued by then.⁠⁹

Review fees under G.S. 131E-267(f) are $175 plus $0.10 per square foot for projects up to 2,000 square feet, and $350 plus $0.20 per square foot for larger projects.⁠⁷ DHSR’s special care unit page still quotes $87 plus $0.05 per square foot.⁠¹⁵ The Construction Section sets the actual amount on its invoice. Rule 10A NCAC 13F .0204(b)(2) ties the fee to G.S. 131E-267, but no official source states which of the two figures the Construction Section applies to a given invoice. Ask the Construction Section (919-855-3893) for the amount before you submit plans.

Minimum spaces under 10A NCAC 13F .0305:⁠⁹

Live-in staff are allowed only in homes licensed for 7 to 12 residents, and they may not occupy a licensed bed.⁠⁹ The fire alarm must transmit automatically to the local fire department dispatch center, and you need at least one 5-pound A-B-C extinguisher for every 2,500 square feet.⁠⁹

Final inspection. At least two weeks before construction is finished, send the Construction Section a letter requesting the final inspection, and copy the Adult Care Licensure Section to avoid licensing delays. Every system must be working on the inspection date. The section does not do punch-list inspections. When the building passes, it sends you a construction approval letter and recommends licensure to the Adult Care Licensure Section.⁠¹⁰

The administrator certificate

Every adult care home licensed on or after January 1, 2000 must have an administrator certified under G.S. 90, Article 20A.⁠⁹ The administrator is responsible to DHSR and to the county department of social services for compliance with the rules.⁠⁹ The DHSR requirements for an Assisted Living Administrator Certificate, as published on 2026-10-12:⁠¹⁴

• At least 21 years old.
• A high school diploma plus the equivalent of two years of college coursework, or 60 months of supervisory experience in a licensed adult care home or nursing home within the seven years before applying, or a combination approved by the Department. Supervisory experience means full-time management, including hiring and firing, over at least two full-time direct-care employees.
• A 120-hour administrator-in-training (AIT) program: at least 20 hours of coursework and 100 hours of on-the-job training under a preceptor approved by the AIT provider.
• A passing score on the administrator exam given by the DHSR testing unit.
• A criminal history check by Live Scan: $14 for the state SBI report, or $38 for SBI plus FBI. The FBI report is required if you have lived in North Carolina less than five years. Applicants can request a predetermination of how their record affects eligibility for a $45 fee.

Certificates are first renewed by December 31 of the year after issue. After that, administrators need 30 hours of continuing education every two years and pay a $30 renewal fee through the DHSR Enterprise system. A late renewal means the certificate expires and the person may not act as administrator.⁠¹⁴ The certificate also qualifies the holder to run a family care home. The narrower family care home administrator approval does not qualify them for a 7+ bed home.⁠¹⁴

You also need a manager to run the home when the administrator is away. The manager must be 21 or older, have a high school diploma or GED, and have six months of training or experience in management or supervision in long-term care or health care (or be a licensed health professional).⁠⁹

Staffing by census

North Carolina sets staffing by resident census, with a separate rule for each size band. At no time may residents be left without a staff member in the building, and daily staffing must be posted where residents and visitors can see it.⁠⁹

Homes with 31 or more residents must also have a personal care aide supervisor on duty on first and second shifts. Homes with 91 or more need one on third shift as well. That means one supervisor for each block of fewer than 64 aide hours per shift.⁠⁹ In homes with fewer than 21 residents, the aide assigned to personal care on a shift may not do food service on that shift. Separate staff must cover daily housekeeping and food service.⁠⁹

Training. Anyone who gives personal care, or directly supervises those who do, must complete the Department’s 80-hour personal care training and competency evaluation program within six months of hire. This applies to staff hired after September 30, 2022.⁠⁹ Staff who give medications must pass a standardized written exam with a score of at least 90%, plus a clinical skills validation.⁠⁹ At least one person on the premises at all times must have completed CPR and choking-management training within the last 24 months.⁠⁹

Special care units for dementia

If you advertise, market or otherwise promote a special care unit for residents with Alzheimer’s disease or related disorders, you must be licensed as an adult care home with a special care unit. The license itself will show the designation.⁠⁹ Disclosure information under G.S. 131D-8 must be approved before a license showing special care unit status is issued and residents are admitted to the unit.⁠¹⁵ Adding beds for the unit requires CON approval first. Converting existing beds does not, but the plans still go to the Construction Section.⁠¹⁵ Staffing inside the unit is fixed by rule:⁠⁹

• First and second shifts: at least one trained staff person for up to 8 residents, plus 1 hour of staff time for each additional resident.
• Third shift: one staff person for up to 10 residents, plus 0.8 hours for each additional resident.
• Care coordinator: on duty 8 hours a day, 5 days a week. In units of 16 or more residents, or in freestanding units, the coordinator is in addition to the minimum staff.

Policies DHSR reviews before licensing

The Adult Care Licensure Section desk-reviews your operating policies before it will recommend a license. Its checklist (form DHSR/AC 4649) covers:⁠¹³

• medication administration, under its own guidelines document
• use of physical restraints and alternatives
• accidents and incidents, including abuse and neglect reporting to the Health Care Personnel Registry
• missing residents and supervision of wandering residents
• a fire evacuation plan and a disaster plan covering at least fire, tornado, hurricane and power outage (DHSR recommends the North Carolina Risk Management Portal template)
• infection control, with a designated on-site staff member who knows the CDC guidelines, and two-step TB testing
• grievances, refunds, visitation, smoking and alcohol
• a sample activities calendar with start and end times
• a one-month sample menu with portion sizes, plus therapeutic diet menus signed by a registered dietitian if you will serve those diets
• the resident contract you will use at admission

Application, fees and the six-month license

Rule 10A NCAC 13F .0204 requires all CON requirements to be met before you file a license application.⁠⁹ The full package:⁠⁹⁠¹²

1. Initial License Application (DHSR/AC 4603, Rev. 06/23)

   It covers the contact person, site and administrator, plus who operates the home: licensee, management company and building owner. It also covers who owns it: every owner, principal, affiliate, shareholder and member, including anyone holding 5% or more. Finally, it asks for bed capacity, including any special care unit. The licensee or its executive officer, partner or managing member signs it.

2. Plans and the construction review fee,

   through the Construction Section.

3. Local fire marshal’s approved fire and building safety inspection report,

   when construction or renovation is complete.

4. County health department sanitation approval or permit to operate

5. Certificate of occupancy

   or certificate of compliance from the local building official.

6. The nonrefundable initial license fee,

   sent with the application by check, money order or certified check payable to the N.C. Division of Health Service Regulation. Use a separate check for each application.

At those rates, a 60-bed home pays $1,540 for its initial license and $1,410 for each annual renewal.

Who decides, and on what. The license is issued once four things are in place: the Construction Section has recommended licensure, a compliance history review of the facility and its principals and affiliates is clear, your policies are approved, and a pre-licensing survey shows compliance.⁠⁹ The compliance history review has teeth. No new license may go to anyone who owned or ran a facility, including a mental health facility or child care facility, whose license was revoked or summarily suspended in the past five years. Unpaid state fines and fees also block a license.⁠² DHSR notifies you and the county department of social services of its decision in writing within 14 days of making it.⁠⁹ If you are denied, you have 30 days from the mailing of the notice to file a contested case petition.⁠²

The first license lasts six months. During that time, DHSR’s Adult Care Licensure Section surveys the home. If you are in substantial compliance, the license is extended for the rest of the calendar year.⁠² If you have no residents during the six months and DHSR cannot assess compliance, you must apply again for an initial license.⁠¹⁰ Plan your admissions and marketing to start as soon as the license is issued.

Getting paid: Special Assistance and Medicaid personal care

Two public programs pay much of the cost of care for lower-income residents.

State-County Special Assistance is a cash supplement that helps eligible residents pay adult care home room and board. The General Assembly sets the maximum rate a home may charge a Special Assistance recipient: $1,397 a month for 2026, plus a $70 personal needs allowance for the resident. Since January 1, 2023, the rate has been adjusted each year by the Social Security cost-of-living change.⁠¹⁸ For residents on Special Assistance, that maximum is the most you can charge for room and board.

Medicaid personal care services in licensed adult care homes are covered under NC Medicaid Clinical Coverage Policy 3L-1, amended January 1, 2026. Licensed adult care homes are eligible to bill.⁠¹⁹ Since November 1, 2018, any Medicaid beneficiary seeking admission must first be referred for Serious Mental Illness screening. The home cannot get a PCS assessment or prior approval without a Referral Screening ID.⁠¹⁹ Adults may be authorized up to 80 hours a month. Hours above 80 require a physician attestation of need plus the dementia-related qualifying criteria in the policy, which add up to 50 hours based on the number of exacerbating conditions, and can never exceed 130 a month.⁠¹⁹

Inspections, star ratings and renewal

DHSR inspects every adult care home every year, and inspects physical plant and life safety every two years. County departments of social services handle routine monitoring under DHSR oversight.⁠⁴ A home with the top star rating can have its annual inspection waived, but it is still inspected at least every two years.⁠⁴ DHSR issues a star-rated certificate within 45 days of mailing the survey report, and the home must display it.⁠⁹

Licenses are renewed each calendar year. The renewal application reports ownership, capacity including any special care unit, and census data, and DHSR invoices the renewal fee.⁠⁹⁠¹⁰ The renewal decision weighs the compliance history of the home and of its owners, principals and affiliates. A license is not renewed while state fines or fees are unpaid.⁠²⁠⁹ A license cannot be transferred, so a buyer files a change-of-ownership application.⁠⁹⁠¹¹ Closing a home requires at least 30 days’ written notice to DHSR, the county department of social services and the residents.⁠¹¹

Recent changes and what to watch

• Renewal fee: S.L. 2025-27 amended the adult care home renewal fee in G.S. 131D-2.5 to $360 plus $17.50 per bed for homes over six beds.⁠³
• 2027 bed need: the proposed 2027 SMFP shows need in Alleghany (10 beds) and Chowan (30 beds), with deadlines still to be set.⁠¹⁷
• Medicaid personal care: Clinical Coverage Policy 3L-1 was amended January 1, 2026.⁠¹⁹
• Assisted housing backlog: DHSR reports delays in reviewing multiunit assisted housing with services registrations.⁠¹¹

For smaller or non-residential models in North Carolina, see the family care home and adult day care program certification guides.

Sources

1. 1
   North Carolina General Assembly, N.C. Gen. Stat. § 131D-2.1 (Definitions) Checked 12 Oct 2026 · Back to text ↑
2. 2
   North Carolina General Assembly, N.C. Gen. Stat. § 131D-2.4 (Licensure of adult care homes) Checked 12 Oct 2026 · Back to text ↑
3. 3
   North Carolina General Assembly, N.C. Gen. Stat. § 131D-2.5 (License and registration fees) Checked 12 Oct 2026 · Back to text ↑
4. 4
   North Carolina General Assembly, N.C. Gen. Stat. § 131D-2.11 (Inspections, monitoring and review) Checked 12 Oct 2026 · Back to text ↑
5. 5
   North Carolina General Assembly, N.C. Gen. Stat. § 131E-176 (Certificate of need definitions) Checked 12 Oct 2026 · Back to text ↑
6. 6
   North Carolina General Assembly, N.C. Gen. Stat. § 131E-182 (Certificate of need application fee) Checked 12 Oct 2026 · Back to text ↑
7. 7
   North Carolina General Assembly, N.C. Gen. Stat. § 131E-267 (Construction project review fees) Checked 12 Oct 2026 · Back to text ↑
8. 8
   North Carolina General Assembly, N.C. Gen. Stat. § 131E-272 (Initial licensure fees for new facilities) Checked 12 Oct 2026 · Back to text ↑
9. 9
   North Carolina Office of Administrative Hearings, 10A NCAC 13F (Licensing of Adult Care Homes of Seven or More Beds) Checked 12 Oct 2026 · Back to text ↑
10. 10
    NC DHHS, Division of Health Service Regulation, License an Adult Care Home Checked 12 Oct 2026 · Back to text ↑
11. 11
    NC DHHS, Division of Health Service Regulation, Facility Licensure Information Checked 12 Oct 2026 · Back to text ↑
12. 12
    NC DHHS, Division of Health Service Regulation, Initial License Application for Adult Care Homes (DHSR/AC 4603, Rev. 06/23) Checked 12 Oct 2026 · Back to text ↑
13. 13
    NC DHHS, Division of Health Service Regulation, Adult Care Home Initial Licensure: Policy and Procedure Review (DHSR/AC 4649) Checked 12 Oct 2026 · Back to text ↑
14. 14
    NC DHHS, Division of Health Service Regulation, Assisted Living Administrator Certification Requirements and Guidelines Checked 12 Oct 2026 · Back to text ↑
15. 15
    NC DHHS, Division of Health Service Regulation, Adult Care Home Special Care Unit Approval Process Checked 12 Oct 2026 · Back to text ↑
16. 16
    NC DHHS, Division of Health Service Regulation, 2026 State Medical Facilities Plan Checked 12 Oct 2026 · Back to text ↑
17. 17
    NC DHHS, Division of Health Service Regulation, Proposed 2027 State Medical Facilities Plan Checked 12 Oct 2026 · Back to text ↑
18. 18
    NC Department of Health and Human Services, State-County Special Assistance for Adult Care Homes (2026 brochure) Checked 12 Oct 2026 · Back to text ↑
19. 19
    NC Medicaid, NC DHHS, Clinical Coverage Policy 3L-1, State Plan Personal Care Services in Congregate Settings (amended January 1, 2026) Checked 12 Oct 2026 · Back to text ↑

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