North Carolina family care home license: two to six residents, county DSS first, no CON

Two to six residents, and why the number matters

North Carolina law calls any group housing-and-services program for two or more unrelated adults an assisted living residence. An adult care home is the licensed kind: the operator provides “24-hour scheduled and unscheduled personal care services to two or more residents” ⁠³. A family care home is “an adult care home having two to six residents,” in a structure “no more than two stories high” ⁠³. The family care home rules are 10A NCAC 13G, adopted by the N.C. Medical Care Commission ⁠¹⁠².

The six-bed line decides whether you need a certificate of need. For CON purposes, an “adult care home” is a facility with seven or more beds ⁠⁹. Building a new health service facility, or changing bed capacity, is a “new institutional health service” under the CON law ⁠⁹. A family care home of two to six beds skips that process completely. Adding a seventh bed moves you to the North Carolina adult care home license and into CON review. A family care home “shall be licensed only as a family care home and not for any other level of care,” and that license ends if the home is licensed for a higher level of care ⁠².

Some neighbouring options:

• Daytime-only care for adults who go home at night is an adult day program: see North Carolina adult day care program certification.
• Personal care in clients’ own homes needs a North Carolina home care agency license.
• Mental illness or substance use treatment. Family care homes may not admit people for treatment of mental illness or alcohol or drug abuse, for maternity care, or for “professional nursing care under continuous medical supervision” ⁠². Homes built around those services are licensed under other chapters. G.S. 131D-2.4 itself refers to facilities licensable under Chapter 122C and Article 7 of Chapter 110 ⁠⁴.

The county DSS is your front door

You don’t start with the state agency in Raleigh. DHSR’s procedure says first contact “should be made with the adult services section of the local county department of social services” ⁠¹. You apply in the county where the home will be ⁠². An adult home specialist at that DSS holds an initial interview with you. At minimum, the interview covers the licensure rules and the process. The specialist also sends you to the local zoning board for approval and tells you to request an application packet from the Adult Care Licensure Section (ACLS) ⁠¹.

The specialist sends DHSR everything except your administrator application ⁠¹. Under 10A NCAC 13G .0204, the county must forward the package to DHSR within 10 business days of receiving it ⁠². The package contains:

• the Initial License Application (form DHSR/AC 4603, Rev. 06/23) ⁠¹⁠⁷;
• an approval letter from the local zoning jurisdiction ⁠²;
• a photograph of each side of an existing building and at least one of each interior space ⁠²;
• blueprints or a floor plan of each level ⁠²;
• a cover letter from the adult home specialist ⁠²;
• the nonrefundable license fee ⁠².

The floor plan needs more detail than a real-estate sketch. It must show the layout and dimensions of every room, closets included. It must also show widths of the exterior, bedroom, bathroom and kitchen doors, window sizes and sill heights, the type of construction, and how the basement and attic are used. Finally, it marks each proposed resident bedroom with its number of occupants, plus every non-resident (with ages) who will live in the home ⁠². For an existing house, DHSR asks for a 1/4-inch-per-foot scaled drawing and color prints of every exterior side, the yards and each interior room ⁠¹.

The application form asks for disclosures:

• the licensee entity type and its NC Secretary of State ID (DHSR verifies the entity with the Secretary of State);
• officers, managing members or partners, listed by individual name;
• every person holding 5% or more of the licensee, and other family care homes and adult care homes they own;
• affiliates, including management companies;
• if the building is leased, the property owner and a copy of the lease ⁠⁷.

DHSR uses these disclosures for the compliance history review that G.S. 131D-2.4 requires ⁠⁴⁠⁷.

Who is barred before they apply

Before issuing a new license, DHSR reviews the compliance history of the facility and its principals and affiliates. It may refuse a license when that history “shows a pattern of noncompliance” ⁠⁴. G.S. 131D-2.4(c) also sets fixed waiting periods. No new adult care home license, family care homes included, goes to an applicant who was an owner, principal or affiliate responsible for:

• a facility whose license was revoked: barred for five years from the revocation ⁠⁴;
• a facility whose license was summarily suspended: barred for five years after the suspension ended ⁠⁴;
• an adult care home penalized for a Type A or Type B violation: barred for one year, or until DHSR certifies substantial compliance with the correction plan, whichever comes first ⁠⁴;
• a home downgraded to a provisional license or with admissions suspended: barred for six months after restoration or termination ⁠⁴;
• a home with unpaid state fees, fines or penalties: barred until paid. Amounts under appeal don’t count ⁠⁴.

These bars also reach child care and Chapter 122C facilities, not only adult care homes ⁠⁴. If DHSR denies your license, you have 30 days from the mailing of the denial notice to file a contested case petition ⁠⁴.

Approving the administrator

Every family care home needs an administrator approved by the Department ⁠². Under 10A NCAC 13G .1501, the applicant administrator must:

1. Be 21 or older

   and a high school graduate or GED holder ⁠².

2. Pass a criminal background check

   NC residents of five years or more need a state check. Residents of less than five years need both state and national (FBI) checks ⁠².

3. Complete an approved administrator-in-training (AIT) program

   It must include at least 20 hours of instruction in N.C. assisted living law, human resources and business management, plus at least 100 hours of on-the-job training in an assisted living facility ⁠². DHSR’s page describes these as “State-approved AIT programs of 120 hours” ⁠¹.

4. Pass the Department’s written exam

   with 75% accuracy within 12 months of finishing the AIT program ⁠².

The administrator application goes directly to ACLS, not through the county. Send it with proof of age, proof of education and a completed fingerprint card with payment. The FBI results, AIT certificate and exam certificate can follow when you receive them ⁠¹. DHSR warns that state background results can take up to 2 weeks, and the FBI check up to 12 weeks for NC residents of less than five years ⁠¹. Start this early. An administrator already approved (approval dated on or after April 1, 2017) or certified sends a copy of the approval or certificate with the license application instead ⁠¹.

Approval is not permanent. Renewal requires continuing education prorated from a base of 30 hours every two years ⁠². DHSR must deny, suspend or revoke approval for certain disqualifiers:

• unreported arrests or convictions (they must be reported within 10 days);
• a finding on the Health Care Personnel Registry;
• a positive drug test or refusal to test;
• having been administrator of a home whose license was summarily suspended or noticed for revocation, weighed by tenure and nexus ⁠².

The house: what DHSR’s Construction Section checks

Which building code applies

A building licensed as a family care home for the first time must meet the North Carolina State Building Code: Residential Code. So must a home relicensed after its license was terminated for more than 60 days. Homes licensed for four to six residents must also meet the Building Code’s Licensed Residential Care Facilities Section ⁠². Converting a building from another use triggers the same requirements ⁠². Rule .0302(l) tells you to consult the local code enforcement official before starting any construction or renovation ⁠². This code split is the main design decision for a new home: three residents and six residents are not built to the same standard.

Layout and space

The building rules were readopted or amended effective April 1, 2025 ⁠². For homes licensed on or after April 1, 1984:

Sources: 10A NCAC 13G .0302, .0305, .0306, .0308, .0309 ⁠².

Bedroom rules:

• Residents may not share a bedroom with staff or other live-in non-residents.
• A room reached through a bathroom, kitchen or another bedroom can’t be a resident bedroom.
• Only rooms DHSR has authorized can be used as bedrooms ⁠².

If you live in the home, your household counts toward the bathroom ratio and needs its own bedrooms.

Bathrooms need grab bars anchored to the wall beside toilets and at tubs and showers, nonskid surfaces, privacy curtains or partitions, and exhaust vented outdoors ⁠².

Two-story houses

The statute allows two stories ⁠³. The rule adds conditions for two-story buildings ⁠²:

• each floor under 2,500 sq ft if existing construction;
• no elderly or disabled persons housed on any floor above or below grade level;
• no required resident facilities above or below grade;
• a complete NFPA 72 fire alarm system with pull stations at each exit and sounders on every floor;
• automatic transmission of alarms to the fire department, either directly or through a third-party service.

Exits

Each floor level needs two outside exits, placed so one fire is unlikely to block both. You may not exit through another resident’s bedroom. One exit door must be at least 3 ft wide and the other at least 2 ft 8 in ⁠². The principal exit must be at grade or reached by a ramp sloping no more than 1 inch per 12 inches. If any resident needs physical help to evacuate, two exits must be at grade or ramped ⁠².

Deadbolts and turn buttons on the inside of outside doors, screen and storm doors included, must be removed or disabled. All exit locks must open with one hand motion. Steps, porches and ramps need handrails on both sides ⁠². Once you admit a resident who is disoriented or wanders, every outside door needs a continuously sounding alarm audible throughout the home. This applies to existing homes too ⁠².

Fire safety and emergency planning

Rule .0316, amended effective June 1, 2025, requires ⁠²:

• one 5-lb or larger A-B-C extinguisher accessible to staff (not in the kitchen or a lockable room), and a 5-lb A-B-C or CO2 extinguisher in the kitchen;
• smoke detectors that are hard-wired, interconnected and battery-backed;
• U.L.-listed heat detectors in the attic and basement;
• a written fire evacuation plan with a floor-plan diagram posted on every floor;
• at least four unannounced fire drills a year on each shift;
• an emergency preparedness plan covering equipment failures and other hazards. A newly licensed home must submit it to the local emergency management agency within 30 days of getting the license, then review it yearly and test it with at least one drill a year.

Location and sanitation

The home must be in a location approved by local zoning boards. Its water, sewage, garbage and trash systems must be approved by the local health department ⁠². It must meet the sanitation rules for residential care facilities in 15A NCAC 18A .1600 and keep its latest sanitation and fire inspection reports on file ⁠².

How the review runs

1. Pay the plan-review invoice

   The Construction Section reviews your plans and invoices you for the review. It doesn’t start until the invoice is paid by check or money order to the Division of Health Service Regulation ⁠¹. DHSR doesn’t publish the invoice amount on its page.

2. Do the required work

   You receive a memorandum listing construction and fire-safety items to complete ⁠¹.

3. Send local approvals

   When the work is done, send the Construction Section approvals from the local building inspector, fire marshal and sanitarian ⁠¹.

4. Pass the on-site inspection

   The Construction Section inspects the home, then sends ACLS a building transmittal showing allowable bed capacity and resident evacuation capability ⁠¹.

That transmittal shapes your license. The license lists capacity separately for ambulatory residents (those who can evacuate without verbal or physical help) and non-ambulatory residents ⁠². Two rules follow from that split:

• If residents’ evacuation ability changes so the home no longer fits its licensed capacity, you must notify ACLS.
• If a resident becomes temporarily non-ambulatory, for example at end of life, you must immediately notify the Construction Section ⁠².

Zoning: residential use, with a half-mile exception

G.S. 160D-907 treats a family care home as a residential use. It is “a permissible use in all residential districts,” and a local government may not require a special use permit or variance because of the use ⁠⁸. A local government may, however, prohibit a family care home within a one-half mile radius of an existing family care home ⁠⁸. The section also requires residential (not commercial) rates for water, sewer, garbage and similar local charges ⁠⁸.

The 160D definition is narrower than the licensing one. It covers homes for up to six “resident persons with disabilities,” including physical disabilities ⁠⁸. Whether a home serving only frail elders falls within it is for your local zoning office to say. Either way, DHSR still needs that office’s approval letter ⁠¹⁠².

Staffing and training

The family care home rules don’t set a numeric staff-to-resident ratio. Instead, they set rules about presence:

• The administrator or a supervisor-in-charge must be in the home or within 500 feet of it, reachable by two-way telecommunication, at all times. No resident may ever be left alone without a staff member ⁠².
• When neither is within 500 feet, a qualified staff person must be on duty. That person may cover no more than 8 hours in 24 and no more than 24 hours a week ⁠². For a live-in operator, this is the rule that limits time away.
• At least one staff member 18 or older must be in charge of resident care at all times. Add staff as needed for housekeeping, supervision and care ⁠².
• Post daily staffing information where residents and visitors can see it ⁠².

The supervisor-in-charge must be 21 or older, have a high school diploma or GED, and earn 12 hours of continuing education a year ⁠².

Training requirements:

Sources: 10A NCAC 13G .0402-.0404, .0501, .0507-.0509 ⁠².

Every staff member, and every other person living in the home, needs a TB test on hire or move-in ⁠². Each staff member also needs:

• a signed job description;
• no findings on the Health Care Personnel Registry;
• documented annual flu immunization;
• a criminal background check under G.S. 131D-40;
• a controlled-substance screening under G.S. 131D-45;
• a valid driver’s license if they transport residents ⁠².

Policies DHSR and the county review before licensing

After the package arrives, ACLS sends the Construction Section a copy and writes to you asking for records, policies and procedures ⁠¹. The adult home specialist then meets with you on your operational plan ⁠¹. DHSR names what gets “specific emphasis”:

• staffing patterns and each staff member’s duties;
• how you will carry out the Residents’ Bill of Rights;
• admission and discharge policies;
• services and accommodations;
• life safety ⁠¹.

The specialist also reviews personnel records and walks you through civil rights compliance documents that go to the Division of Aging and Adult Services ⁠¹.

Your admission policies have to match the rules:

• Who you may admit. Residents are adults 18 or older who need a substitute home because of a physical condition or mental disability ⁠².
• Medical exam. Each resident needs an exam by a physician, PA or nurse practitioner on the Medicaid FL-2 form. It must be done no more than 90 days before admission, or within 72 hours after an emergency admission ⁠².
• Assessment and care plan. You must complete a functional assessment within 30 days of admission and every year after, and build a resident-centered care plan from it ⁠². The assessment rule was amended as recently as December 1, 2025 ⁠².

Licensing order, start to finish

1. Meet the county adult home specialist

   Get the rules overview and the zoning referral ⁠¹.

2. Get zoning approval

   in writing from the local zoning jurisdiction ⁠¹⁠².

3. Start the administrator application

   with ACLS, including fingerprints, because the FBI check can take 12 weeks ⁠¹.

4. Submit the license application package

   through the specialist: application, zoning letter, photos, floor plans, $350 fee and specialist letter. The county forwards it within 10 business days ⁠¹⁠².

5. Complete the Construction Section review

   Pay the plan-review invoice, finish the required work, send local building, fire and sanitation approvals, and pass the on-site inspection ⁠¹.

6. Get your policies approved

   Send ACLS the records and policies it asks for, and finish the specialist’s operational review ⁠¹.

7. Clear the compliance history review

   under G.S. 131D-2.4 ⁠²⁠⁴.

8. Pass the pre-licensing survey

   ACLS schedules an on-site visit with you and the specialist ⁠¹⁠².

9. Receive the license

   It comes with a cover letter, and the county gets a copy. DHSR must notify you and the county of its decision within 14 days of making it ⁠¹⁠².

DHSR doesn’t publish an overall processing time. The only stated clocks are the county’s 10 business days, the 14-day decision notice and the background-check estimates ⁠¹⁠².

Fees as published on 2026-10-12

The two figures aren’t a conflict. G.S. 131E-272 sets the $350 initial fee for new facilities with six or fewer beds, and G.S. 131D-2.5 sets the $315 annual fee ⁠⁵⁠⁶. Pay by check, money order or certified check made payable to the Division of Health Service Regulation, one check per application, with the facility name in the memo line ⁠⁷. Applications without the fee are treated as incomplete ⁠⁷.

The six-month first license and the survey that converts it

By statute, a facility not already licensed as an adult care home gets a license for six months. If it shows substantial compliance, DHSR licenses it for the rest of the calendar year ⁠⁴. ACLS surveys the home around four months after the initial license. At that point, “at least two residents should currently reside in the facility” who have lived there at least 30 days ⁠¹. If the home has no residents and ACLS can’t confirm compliance, you must reapply for an initial license ⁠¹.

In practice, you need two residents admitted by about the third month. Plan marketing and Special Assistance paperwork around that date.

Renewal, star ratings and changes of ownership

Renewal. Licenses are renewed annually on a calendar-year basis using the renewal application and the $315 fee ⁠¹⁠². In deciding renewal, DHSR considers the compliance history of the home and of its owners’ other North Carolina adult care homes, plus the hardship to residents if the license isn’t renewed ⁠². It won’t renew with unpaid state fees, fines or penalties outstanding ⁠⁴. If violations remain uncorrected at expiration, DHSR may extend the correction plan, issue a provisional license or deny the license ⁠².

Star ratings. DHSR issues a star-rated certificate and worksheet within 45 days after mailing a survey or inspection report ⁠². You must display the certificate where the public can see it, and the worksheet is posted on DHSR’s website ⁠². The star-rating rules were readopted effective August 1, 2025, and the rating calculation was amended effective June 1, 2026 ⁠².

Selling the home. The license can’t be transferred ⁠². The existing licensee must give DHSR, the county DSS and the residents at least 30 days’ written notice of a planned change. The buyer then files the Change Licensure Application with:

• a local fire marshal inspection report dated within the past 12 months;
• a county sanitation report dated within the past 12 months;
• the license fee ⁠².

DHSR won’t issue a change-of-ownership license while state fees, fines or penalties are unpaid ⁠⁴.

Getting paid: State-County Special Assistance

Many family care home residents pay through State-County Special Assistance (SA), a cash supplement for room and board in adult care homes, family care homes and group homes ⁠¹⁰. Residents must be 65 or older, or disabled, and live in a facility approved for SA. That facility “must agree to accept the state rate for special assistance residents” ⁠¹⁰. SA recipients are automatically eligible for Medicaid ⁠¹⁰. Residents apply at their county DSS ⁠¹⁰.

Effective January 1, 2026, after a 2.8% cost-of-living adjustment, the monthly SA rates are ⁠¹¹:

• Basic Rate: $1,397 (maintenance amount $1,467);
• Enhanced Rate: $1,792 (maintenance amount $1,862).

DHSR’s notice says SA rates are adjusted yearly using the federally approved Social Security cost-of-living change, if any ⁠¹¹. If you plan to accept SA residents, build your budget on the state rate, because it is what you agree to accept.

Recent rule changes

10A NCAC 13G has been readopted section by section since 2023 ⁠²:

• June 1, 2024: resident contract, medical exam, and personal funds rules readopted. The separate resident register rule was repealed.
• September 1, 2024: training documentation and activity director rules changed.
• April 1, 2025: almost the whole physical plant section (.0301-.0318), including capacity.
• June 1, 2025: fire safety and emergency preparedness amended.
• December 1, 2025: resident assessment amended.
• August 1, 2025: star-rating rules readopted; June 1, 2026: rating calculation amended.

If you’re working from an older checklist or a consultant’s packet, check it against the rule text dated after these changes.

Sources

1. 1
   NC DHHS, Division of Health Service Regulation, Adult Care Licensure Section, License a Family Care Home (2-6 Beds) Checked 12 Oct 2026 · Back to text ↑
2. 2
   NC Office of Administrative Hearings, North Carolina Administrative Code, 10A NCAC 13G: Licensing of Family Care Homes Checked 12 Oct 2026 · Back to text ↑
3. 3
   North Carolina General Assembly, G.S. 131D-2.1: Definitions Checked 12 Oct 2026 · Back to text ↑
4. 4
   North Carolina General Assembly, G.S. 131D-2.4: Licensure; compliance history review; prior violations; renewals Checked 12 Oct 2026 · Back to text ↑
5. 5
   North Carolina General Assembly, G.S. 131D-2.5: License and registration fees Checked 12 Oct 2026 · Back to text ↑
6. 6
   North Carolina General Assembly, G.S. 131E-272: Initial licensure fees for new facilities Checked 12 Oct 2026 · Back to text ↑
7. 7
   NC DHHS, Division of Health Service Regulation, Initial Application for Family Care Home, DHSR/AC 4603 (Rev. 06/23) Checked 12 Oct 2026 · Back to text ↑
8. 8
   North Carolina General Assembly, G.S. 160D-907: Family care homes Checked 12 Oct 2026 · Back to text ↑
9. 9
   North Carolina General Assembly, G.S. 131E-176: Certificate of need definitions Checked 12 Oct 2026 · Back to text ↑
10. 10
    NC DHHS, Division of Social Services, State and County Special Assistance for Adult Care Home Residents Checked 12 Oct 2026 · Back to text ↑
11. 11
    NC DHHS, Division of Social Services, Special Assistance (SA) and Special Assistance In-Home (SAIH) Rate changes, EFS-SA-04-2025 Checked 12 Oct 2026 · Back to text ↑

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