Last updated 2026-07-25
TL;DR
In the UK, assisted living residential care homes are inspected by the Care Quality Commission (CQC), which rates each home Outstanding, Good, Requires Improvement, or Inadequate. There's no single national CQC rating system in the US; instead, each state licenses and inspects assisted living and group homes separately, with reports filed through the state agency, not CQC.
What is assisted living?
Assisted living is housing for older adults or adults with disabilities who need help with daily activities like bathing, dressing, medication reminders, and meals, but who don't need the round-the-clock skilled nursing care a nursing home provides. Residents usually have their own room or apartment, plus access to shared dining and common areas, and staff are on site to help as needed rather than living independently at home. In the US, assisted living sits in the middle of the care spectrum: less medical than a nursing home, more supported than living alone. The exact services, staffing ratios, and even the name (some states say "residential care facility," others "personal care home") vary a lot by state, because assisted living is regulated at the state level, not federally. If you're researching what assisted living covers in a specific state, you have to check that state's licensing agency, because there's no single federal definition or rulebook. In the UK, the closest equivalent is often called "extra care housing" or "assisted living," and it's regulated differently again, through the Care Quality Commission (CQC) in England, or the equivalent bodies in Scotland, Wales, and Northern Ireland (Care Inspectorate, Care Inspectorate Wales, RQIA). This matters if you're comparing US and UK models: the CQC rating system (Outstanding, Good, Requires Improvement, Inadequate) doesn't exist in US assisted living regulation. US states use their own inspection and citation systems instead.
What is a group home?
A group home is a small residential setting, usually a single house, where a handful of unrelated residents live together and receive support from paid staff. Group homes serve several different populations: adults with intellectual or developmental disabilities (IDD), people in mental health recovery, people in substance use recovery, and in some states, seniors who need a lower level of care than nursing homes provide. Group homes are typically smaller than assisted living facilities, often housing somewhere between 2 and 10 residents, compared to assisted living communities that might house dozens to over 100. States license them under different names: "adult foster care," "community residential setting," "personal care home," or "residential care facility." The Centers for Medicare & Medicaid Services (CMS) recognizes group homes as a setting for delivering Medicaid Home and Community-Based Services (HCBS) under 42 CFR Part 441, Subpart G, which sets requirements for what counts as a qualifying home and community-based setting [1]. Because group homes serve such different populations, licensing requirements differ sharply by state and by population type. A group home for adults with IDD in one state might require a totally different staffing ratio and physical plant standard than a mental health group home three states over. If you're trying to figure out where to start, your state's licensing agency (usually under the department of health or department of human services) is the only authoritative source, not a national standard.
What is an assisted living facility?
An assisted living facility (ALF) is the licensed building or program where assisted living services are delivered. It's the legal and physical entity: the license, the building, the staff, and the policies all attach to this one licensed operation. Some states use "assisted living facility" as the official license category; others call it "residential care facility for the elderly," "personal care home," or "assisted living residence." What is assisted living facility licensing actually checking? Generally: physical plant safety (fire code, exits, room sizes), staffing (minimum ratios, training hours, background checks), resident rights (grievance procedures, admission/discharge criteria), medication management protocols, and food service safety. States conduct both an initial licensing survey before opening and periodic renewal inspections, often annually. If you're comparing this to the UK system: a UK care home registered with CQC gets inspected against five key questions, whether it's Safe, Effective, Caring, Responsive, and Well-led, and receives a public rating for each plus an overall rating [2]. US states don't use that five-domain framework or public letter/word ratings; instead, most publish inspection reports and deficiency citations that consumers have to read directly, usually on the state licensing agency's website or a searchable facility locator tool.
What is assisted living vs nursing home?
| Regulator | State licensing agency | State agency + CMS (federal) | |
|---|---|---|---|
| Medical care level | Non-medical, ADL support | 24-hour skilled nursing | |
| Public rating system | Varies by state, often none | CMS 5-Star Care Compare [3] | |
| Medicare coverage | Not covered (room & board) | Covered short-term, post-hospital | |
| Medicaid coverage | Sometimes, via HCBS waivers | Yes, in most states | If someone needs daily skilled nursing, wound vacs, or ventilator support, assisted living generally isn't the right setting, and most state licensing rules explicitly cap the level of medical acuity an assisted living facility can legally serve. |
The core difference is medical intensity. Assisted living provides help with daily living activities (bathing, dressing, meals, medication reminders) in a residential, non-medical setting. A nursing home (also called a skilled nursing facility, or SNF) provides 24-hour skilled nursing care. That includes wound care, IV therapy, physical therapy, and management of complex medical conditions, and it's regulated under a completely different federal framework than assisted living is. Nursing homes that accept Medicare or Medicaid must meet federal requirements under 42 CFR Part 483, and CMS publishes a public 5-star rating for every certified nursing home through its Care Compare tool, based on health inspections, staffing levels, and quality measures [3]. Assisted living has no equivalent federal certification or star rating system, because Medicare doesn't cover it and CMS doesn't regulate it directly. Here's a side by side: | Feature | Assisted Living | Nursing Home (SNF) |
What does assisted living provide?
Assisted living typically provides a private or semi-private room, three meals a day, help with activities of daily living (bathing, grooming, dressing, toileting, transferring), medication management or reminders, housekeeping, laundry, social and recreational activities, and 24-hour staff availability for emergencies. Many facilities also arrange transportation to medical appointments. What it generally does not provide, at least not as a baseline service, is skilled nursing care, physical rehabilitation, or complex medical treatment. Some states allow assisted living facilities to obtain a higher-tier license (sometimes called "limited nursing," "enhanced," or "Level 2") that permits more medical services like injections or catheter care, but this is state-specific and always requires additional licensing steps. Cost and service level vary enormously by state and by facility. The Genworth Cost of Care Survey, one of the most widely cited sources on long-term care costs, reported a 2023 national median monthly cost for assisted living of $5,350 [4]. That's a national median, not a guarantee. Costs run much higher in states like New York or Massachusetts and lower in rural parts of the Midwest and South, so confirm current rates with your state's aging or long-term care ombudsman office, or with facilities directly.
What is the difference between assisted living and nursing home for licensing purposes?
For an operator, the licensing difference is significant, more than cosmetic. Assisted living licenses are issued and enforced entirely by state agencies (there is no federal license), while nursing homes must meet both state licensing requirements and federal Medicare/Medicaid certification standards if they want to bill those programs, which nearly all do. That means nursing home operators face federal survey teams following the State Operations Manual and CMS's certification process, in addition to state inspections. Assisted living operators only deal with their state licensing agency, though states vary widely in how strict, frequent, and public those inspections are. Some states publish every deficiency citation online; others only release records through public records requests. Staffing requirements diverge too. Nursing homes must meet federal minimum staffing standards; CMS finalized a rule in 2024 requiring, among other things, a registered nurse on site 24 hours a day and specific total nurse staffing hours per resident day, though implementation timelines and rural exemptions are being phased in and have faced legal challenges [5]. Assisted living staffing minimums are set entirely by each state, and they range from vague ("sufficient staff to meet resident needs") to very specific hour-based ratios.
Does Medicare cover assisted living facilities?
No. Medicare does not cover the cost of room, board, or personal care services in an assisted living facility. CMS is explicit about this: Medicare Part A and Part B do not pay for long-term custodial care, which is the category assisted living falls under [6]. Medicare will cover specific medical services a resident receives while living in assisted living, things like doctor visits, physical therapy ordered by a doctor, or durable medical equipment, the same as it would for anyone living anywhere else. But it will not pay the facility's monthly rate for housing, meals, or ADL assistance. Medicaid is different, and this trips people up constantly. Many states offer Medicaid Home and Community-Based Services (HCBS) waivers that can help cover the cost of personal care services within an assisted living or residential care setting, though Medicaid still generally won't cover the room-and-board portion of the bill in most states. Medicaid.gov confirms that HCBS waivers let states "provide long-term care services in home and community settings" as an alternative to institutional care, but eligibility, waiver slots, and covered services differ state by state [7]. If Medicaid coverage is central to your business model or your family's care plan, you need to check your specific state Medicaid agency's waiver list, not assume coverage exists everywhere.
How to start a group home
Starting a group home means working through five broad stages: research your state's specific license category, write your policy and procedure manual, secure a compliant property, hire and train staff to state ratios, and pass your initial licensing inspection. The exact steps, forms, and fees are set entirely by your state's licensing agency, so there's no universal checklist that applies everywhere. A realistic sequence looks like this: 1. Identify the population you'll serve (IDD, mental health, senior, recovery) and find the matching license category with your state health or human services department. 2. Read the actual licensing regulations for that category, more than a summary. States publish these as administrative code, and they cover staffing ratios, physical plant rules, and required policies in detail. 3. Check local zoning. Many group homes qualify for reasonable accommodation protections under the Fair Housing Act, but zoning compliance still needs to be confirmed with your local planning department before you sign a lease. See our guide on assisted living facility licensing basics for how zoning and licensing interact. 4. Write your policy and procedure manual: admissions criteria, medication management, emergency procedures, staff training, resident rights, incident reporting, and grievance processes. Most state licensing applications require this manual as a submitted document, more than an internal reference. 5. Hire staff and complete required background checks and training hours before your inspection. 6. Submit your license application with the required fee (this ranges from under $500 to several thousand dollars depending on the state, confirm with your state licensing agency). 7. Pass the pre-licensing survey, which typically checks fire safety, physical plant compliance, staff files, and your written policies against the actual building and operation. Building the policy manual from scratch is usually the single biggest time sink for first-time operators, often taking weeks of research to get state-specific language right. That's the exact gap our $299 State Group Home Licensing Kit is built to close: state-specific policy templates and application checklists so you're not starting from a blank page.
How do I start a group home if I'm doing this for the first time?
If this is your first time, don't skip straight to shopping for a house. Call your state licensing agency first, before you sign a lease or spend money on renovations, and ask for the specific regulation citation for the population you want to serve. Licensing staff can usually tell you the application packet, fee schedule, and inspection checklist over the phone or by email, and this single call can save you from buying a property that will never pass zoning or physical plant review. A few mistakes show up over and over with new operators. Signing a lease before confirming zoning allows a group home use in that district. Assuming one state's rules apply to a neighboring state (they almost never do). Underestimating staff training hour requirements, which can run 20 to 40+ hours before someone can work unsupervised in some states. And writing a policy manual that's generic rather than matched to the specific citations in your state's code, which is one of the most common reasons applications get sent back for revisions. Realistically, budget for licensing fees, a criminal background check for every staff member and often every household member if it's a residential-style home, fire marshal inspection fees, and liability insurance, all before you take a single resident. None of this is fast; initial licensing review timelines commonly run 60 to 120 days in many states once a complete application is submitted, though this varies and you should confirm current timelines with your state agency.
How does the UK CQC rating system work, for comparison?
In England, the Care Quality Commission inspects and rates every registered care home against five key questions: is it Safe, Effective, Caring, Responsive, and Well-led. Each home gets a rating for each of the five, plus one overall rating, using four categories: Outstanding, Good, Requires Improvement, or Inadequate [2]. CQC states its purpose directly: it exists to "make sure health and social care services provide people with safe, effective, compassionate, high-quality care" and to encourage services to improve. Ratings are published publicly on CQC's website and are searchable by home name or postcode, similar in spirit to how CMS publishes nursing home star ratings in the US, but structurally different, since CQC covers both care homes and home care agencies under one framework, and the ratings language (words, not stars or numbers) is unique to the UK system. There is no US equivalent that spans all assisted living facilities nationally. CMS's 5-star system applies only to Medicare/Medicaid-certified nursing homes, not assisted living. If you're researching US facilities, the honest answer is: check your specific state's licensing agency website, which usually posts inspection reports, complaint histories, and sometimes a facility search tool, but rarely a single letter-grade rating like CQC's.
What should I check on an inspection report before choosing a facility or filing a license application?
Families choosing a facility and operators preparing for their own inspection both need to check the same categories: fire and life safety compliance, staffing levels against required ratios, medication management records, resident grievance and incident logs, and background check documentation for all staff. For families, most states let you search inspection history and substantiated complaints on the state licensing agency's public website, and it's worth reading the actual citation language, more than a summary score, since a "minor paperwork" citation reads very differently from a "failure to administer medication as ordered" citation. For operators, the same categories are exactly what your pre-licensing survey will check, so building your written policies to mirror your state's actual inspection checklist (not a generic template) is the difference between a first-pass approval and a re-inspection. Our assisted living facilities overview walks through how these categories map across different state licensing frameworks.
Frequently asked questions
What is assisted living?
Assisted living is residential housing with support services for people who need help with daily activities like bathing, dressing, and medication management, but don't need 24-hour skilled nursing care. It's regulated at the state level in the US, so services, staffing, and terminology vary depending on where the facility is located.
What is a group home?
A group home is a small residential setting, usually a house, where a limited number of unrelated residents live together and receive support from paid staff. Group homes serve populations including adults with intellectual/developmental disabilities, mental health needs, substance use recovery, or seniors, and licensing rules differ by state and population type.
What is an assisted living facility?
An assisted living facility is the licensed building and program where assisted living services are delivered, including the physical plant, staff, and written policies. States use varying license names for this, such as residential care facility or personal care home, and each state sets its own physical plant, staffing, and inspection requirements.
What is the difference between assisted living and nursing home?
Assisted living provides help with daily living activities in a non-medical, residential setting, while a nursing home provides 24-hour skilled nursing care for people with more complex medical needs. Nursing homes must meet federal Medicare/Medicaid certification rules under 42 CFR Part 483; assisted living is regulated only at the state level with no federal certification.
Does Medicare cover assisted living facilities?
No. Medicare does not pay for room, board, or personal care services in assisted living, since it classifies this as custodial long-term care, which Medicare Part A and B exclude. Medicare may still cover specific medical services, like doctor visits or physical therapy, received while someone lives in assisted living.
Does Medicaid cover assisted living?
In many states, Medicaid Home and Community-Based Services (HCBS) waivers can help cover personal care costs in assisted living, but room-and-board charges are usually not covered even then. Availability, waiver waitlists, and covered services differ significantly by state, so check with your state Medicaid agency directly.
How to start a group home?
Starting a group home involves choosing your state's specific license category for your target population, reading the actual licensing regulations, confirming local zoning allows the use, writing a compliant policy and procedure manual, hiring staff to meet training and ratio requirements, and passing your state's pre-licensing inspection.
How do I start a group home in my state specifically?
Contact your state's health or human services licensing division directly and ask for the regulation citation and application packet for your target population (IDD, mental health, senior, or recovery). Requirements, fees, and inspection timelines are set entirely at the state level, so a checklist from another state won't reliably apply to yours.
What does the CQC rating system mean in the UK?
CQC (Care Quality Commission) rates UK care homes across five categories, Safe, Effective, Caring, Responsive, and Well-led, plus an overall rating, using four possible labels: Outstanding, Good, Requires Improvement, or Inadequate. Ratings are published publicly and searchable by care home name or postcode on CQC's website.
Is there a US equivalent to the UK's CQC rating for assisted living?
No single national equivalent exists. CMS publishes a 5-star Care Compare rating for Medicare/Medicaid-certified nursing homes, but assisted living facilities in the US are licensed and inspected only at the state level, and most states don't use a letter-grade or star rating system the way CQC does.
What's the difference between assisted living and residential care home?
In US usage, the terms often overlap, and some states literally use "residential care facility" as the official license name for what's commonly called assisted living. In the UK, "residential care home" is a common general term for a care home registered with CQC, distinct from "assisted living" or "extra care housing," which typically involves more independent living.
How much does assisted living cost per month?
The Genworth Cost of Care Survey reported a 2023 national median monthly cost for assisted living of $5,350, though this varies widely by state and region. Costs are typically much higher in the Northeast and lower in parts of the Midwest and South, so check current local rates directly with facilities.
What staffing ratios do assisted living facilities need to meet?
Staffing ratio requirements are set entirely by state licensing agencies and vary widely, from vague standards like "sufficient staff to meet resident needs" to specific hour-per-resident formulas. There is no federal staffing ratio requirement for assisted living, unlike the federal minimum staffing standards CMS applies to certified nursing homes.
Sources
- eCFR, Home and Community-Based Settings requirements: CMS requirements for qualifying home and community-based settings under Medicaid HCBS
- Care Quality Commission, How we monitor, inspect and regulate: CQC's five key questions (Safe, Effective, Caring, Responsive, Well-led) and rating categories
- CMS, Nursing Home Care Compare / Five-Star Quality Rating System: CMS publishes a public 5-star rating for Medicare/Medicaid-certified nursing homes
- Genworth, Cost of Care Survey 2023: 2023 national median monthly cost for assisted living of $5,350
- CMS, Minimum Staffing Standards for Long-Term Care Facilities final rule: CMS 2024 final rule requiring 24/7 RN on site and minimum nurse staffing hours per resident day in nursing homes
- Medicare.gov, Long-term care coverage: Medicare does not cover long-term custodial care such as assisted living room, board, and personal care
- Medicaid.gov, Home & Community-Based Services: Medicaid HCBS waivers allow states to provide long-term care services in home and community settings as an alternative to institutional care
- eCFR, Requirements for States and Long Term Care Facilities: Federal nursing home requirements under 42 CFR Part 483 that apply in addition to state licensing