Starting a care business in North Carolina

For housing and care for adults, the bed count decides almost everything. State law treats any group housing-and-services program for two or more unrelated adults as an "assisted living residence". A home with two to six residents is licensed as a family care home, with no certificate of need. You apply through your county department of social services, and the fees are $350 to start and $315 a year to renew. At seven beds it becomes an adult care home, and new beds need a certificate of need. The 2026 State Medical Facilities Plan found need in only two counties, Halifax (40 beds) and Perquimans (100), and the proposed 2027 plan lists Alleghany (10) and Chowan (30). Multiunit assisted housing with services, where an outside licensed agency provides the hands-on care, is registered rather than licensed.

In-home care falls under one statute but has two licenses. If aides bathe, dress, toilet, transfer or feed clients, you need a home care agency license, at $510 a year. Since November 9, 2023, a business that offers only companion, sitter, respite or homemaker services without touching clients needs a home assistance services provider license instead, and it may not bill insurers or Medicaid. As of October 12, 2026, DHSR had not published a separate application for that license, so ask the section which form to use before you file.

Medicare certification is where home care gets hard. A certified home health agency needs a certificate of need for every office, and the 2026 plan says there is "no need anywhere in the state". The proposed 2027 plan uses the same words. An agency that sends nurses or therapists without Medicare certification is licensed as an ordinary home care agency and needs no certificate of need.

Child care licensing starts at the third unrelated child. In your own home, a family child care home may care for 8, 9 or 10 children depending on their ages. Outside a home, 3 or more preschoolers or 9 or more school-age children at one time make the program a child care center. Both start with a DCDEE pre-licensing workshop ($75 for homes, $135 for centers) and open on a six-month temporary license before receiving a star-rated license. Two recent changes matter. The "Pathways to the Stars" rating system took effect July 1, 2025, and Session Law 2025-36 raised the infant and toddler group-size limits, although DCDEE's rules had not been updated to match as of October 2026.

Adult day care certification is required by law despite its name. Every group day program for adults needs it unless the program serves three or fewer people or only the operator's relatives. A county social worker studies your program and DAAS makes the decision. Overnight respite needs a separate DHSR license, and since July 1, 2026 the bed cap is 12 instead of 6.