Starting a care business in Maryland

Residential care starts at two people. Housing plus supportive services or personal help for two or more residents requires an assisted living program license, and Maryland has no separate license for small homes, so a two-bedroom house and a large building apply under the same rules. Calling the arrangement a room rental does not change that: a lease does not, by itself, take you out of licensure. You apply for one of three levels of care. At 17 beds, the rules add a site plan approved by a State engineer, a local food service permit and approval to build under Health-General § 19-311. Since July 1, 2026, the program's manager must hold a license from the Board of Long-Term Care Administrators. Knowingly operating without a license is a felony.

In-home care divides at hands-on help. A business whose aides help clients with bathing, dressing, toileting or other personal care needs a residential service agency (RSA) license from OHCQ. It needs no certificate of need. An agency that only does light housekeeping, meal preparation, shopping and errands needs no license at all. Budget with care: COMAR still lists a $1,000 fee for a three-year RSA license, while OHCQ's June 2026 application says there is no fee to apply.

Skilled care is much harder to start. A home health agency license can be issued only after the Maryland Health Care Commission (MHCC) grants a certificate of need or an exemption. A new company cannot seek one: only Medicare-certified home health agencies, or a licensed and accredited hospital, nursing home or skilled-nursing RSA, qualify. An RSA that wants to apply later needs three years of skilled nursing work and three years of accreditation first. MHCC also requires new agencies to become Medicare-certified, and CMS has not enrolled new home health agencies in Medicare since May 13, 2026.

On the child care side, Maryland's word for a home daycare is "registration," but it is mandatory before you care for unrelated children for pay or advertise. A family child care home may have up to 8 children, and 9 to 12 makes it a large family child care home, with its own orientation, staff qualifications and ratios. Care outside a home, for children of different parents at least two days a week, needs a child care center license. Some tax-exempt religious programs may hold a Letter of Compliance instead. Both the first registration and the first center license last two years; after that comes a continuing version that does not expire.

Maryland licenses only medical-model adult day care. Group care for 4 or more elderly or medically disabled adults, or care for 2 or 3 in a family home, needs an adult medical day care center license, and OHCQ must approve a letter of interest before you can apply. Social programs that offer only meals and activities fall outside OHCQ's license; OHCQ sends them to the Maryland Department of Aging's Senior Center Plus program, whose approval process was not found in a regulation. OHCQ's current applications for assisted living, adult medical day care and home health list no application fee.