Last updated 2026-07-25
TL;DR
In Virginia, assisted living facilities are licensed by the Virginia Department of Social Services (DSS) under 22VAC40-73, not by the health department. DSS licensing covers staffing ratios, resident assessments (the UAI), medication management, life safety inspections, and background checks. Facilities range from small adult family homes to large campuses with dozens of beds.
What does DSS have to do with assisted living facilities in Virginia?
In Virginia, the Department of Social Services is the state agency that licenses assisted living facilities (ALFs), not the Department of Health. This surprises a lot of people moving into Virginia from states where health departments run senior care licensing. Virginia's Division of Licensing Programs, inside DSS, regulates ALFs under the Standards for Licensed Assisted Living Facilities, 22VAC40-73. The statutory authority sits in the Code of Virginia, Title 63.2, Chapter 17, which defines an assisted living facility as "any congregate residential setting that provides or coordinates personal and health care services, 24-hour supervision, and assistance (scheduled and unscheduled) for the maintenance or care of four or more adults who are aged, infirm or disabled" [1]. That four-or-more threshold matters. Homes caring for three or fewer adults generally fall outside ALF licensure and may be regulated differently or not at all, depending on the arrangement. DSS handles the whole lifecycle: initial application review, background checks, plan review for the physical plant, the pre-licensure inspection, and then annual (or more frequent, if there are complaints) renewal inspections. If you are building a licensing packet for Virginia, you are building it for DSS, and you should bookmark the assisted living facility overview alongside the actual regulation text, because DSS updates forms and checklists more often than most people expect. One quick clarification worth sitting with: DSS licenses assisted living facilities. It does not license nursing homes (that's the Virginia Department of Health) and it does not license most standalone group homes for adults with intellectual or developmental disabilities (that's the Department of Behavioral Health and Developmental Services, DBHDS). If your model blends personal care with skilled nursing, or targets an IDD population specifically, you may need a different license entirely, or two.
What is assisted living, exactly?
Assisted living is a licensed residential care model for adults who need help with daily activities like bathing, dressing, medication reminders, and mobility, but who don't need the round-the-clock skilled nursing care a nursing home provides. It sits in the middle of the care spectrum: more support than independent senior living, less medical intensity than a nursing facility. There is no single federal definition of assisted living. States, not the federal government, license and define these facilities, which is why the resident population covered, the required staffing, and even the minimum bed count differ from one state to the next. That's true nationally and it's true in Virginia specifically: the 22VAC40-73 definition above is Virginia's own language, and another state's version could look quite different on paper while describing a similar building. What ties every state's version together is the basic promise: a home-like residential setting, not a hospital or nursing floor, where staff help with daily living tasks and coordinate additional health services as needed.
What is a group home, and how is it different from an assisted living facility?
A group home is a residential setting, usually a single house or small building, where a small number of people with a shared support need (developmental disability, mental illness, substance use recovery, or similar) live together with staff support. The term is used loosely across the industry. But the regulatory reality is specific: who licenses a group home, and under what rules, depends entirely on the population it serves and the state it's in. In Virginia, group homes serving adults with intellectual or developmental disabilities are typically licensed by DBHDS under its own regulatory chapters, separate from DSS's ALF rules. Group homes serving children may fall under yet another set of DSS or Department of Education rules. An assisted living facility, by contrast, is specifically the DSS-licensed model for aged, infirm, or disabled adults needing personal care and supervision, as defined in 63.2-100 above. The practical difference for an operator: if you're building a house for four adults with IDD who need day-to-day support but not medical care, you're probably looking at DBHDS licensure. If you're building a residence for seniors or adults with physical or cognitive decline who need help with ADLs and medication, you're looking at DSS's ALF license. Get this wrong at the application stage and you'll lose months. Read the assisted living facilities primer and confirm your target population with your state licensing agency before you draft floor plans or sign a lease.
What does an assisted living facility actually provide day to day?
An assisted living facility provides housing plus a defined bundle of personal care and supervision, not skilled medical treatment. Under Virginia's regulations, a licensed ALF must provide, at minimum: assistance with activities of daily living (bathing, dressing, toileting, eating, mobility), 24-hour staff supervision, three meals a day plus snacks, medication management or administration consistent with the resident's assessed needs, housekeeping and laundry, and a system for responding to emergencies [2]. Beyond that baseline, Virginia sorts residents into levels of care based on the Uniform Assessment Instrument (UAI), a standardized tool DSS requires before or at admission. The UAI score determines whether a resident needs "minimal," "intermittent," or "continuous" personal or nursing care, and that classification in turn dictates staffing ratios, whether the facility can serve that resident at all, and what care plan documentation is required [2]. Facilities can add services on top of the baseline. Some run dedicated memory care units, with additional physical plant and staffing rules under 22VAC40-73. Some coordinate hospice. Some contract with home health agencies for skilled nursing visits. What an ALF cannot do is function as an unlicensed nursing home. If a resident's needs exceed what personal care and coordinated services can safely manage, the facility is required to plan for discharge or transfer to a higher level of care.
What is the difference between assisted living and a nursing home?
| Virginia licensing agency | Department of Social Services (DSS) | Virginia Department of Health | |
|---|---|---|---|
| Care level | Personal care, ADL assistance, supervision | Skilled nursing, physician-ordered medical care | |
| Staffing | Direct care staff, some licensed nurses depending on level | Licensed nurses on duty around the clock | |
| Typical resident | Needs help with daily living, stable health | Needs ongoing medical/rehab care | |
| Medicare coverage | Generally not covered (see below) | Covered short-term for skilled care post-hospitalization | A lot of prospective operators think of these as a continuum they can slide along freely. In practice, the license, the building code occupancy classification, and the staffing model are different enough that converting an ALF into a nursing home (or vice versa) is closer to starting over than remodeling. |
The core difference is medical intensity and licensure. Assisted living facilities provide personal care and supervision in a residential, non-medical setting. Nursing homes (also called skilled nursing facilities) provide 24-hour skilled nursing care ordered by a physician, for residents who need ongoing medical treatment, rehabilitation, or a level of clinical monitoring that a residential setting can't safely deliver. Medicare.gov describes nursing home care as covering people who need skilled nursing or rehabilitation services after a hospital stay, a distinctly different service model from residential assisted living [3]. In Virginia specifically, that separation is structural: DSS licenses ALFs, the Virginia Department of Health licenses nursing facilities, and the physical plant, staffing (including licensed nurse coverage), and survey process differ substantially between the two. | Feature | Assisted living facility | Nursing home |
Does Medicare cover assisted living facilities?
No, Medicare generally does not cover the cost of room and board or personal care services in an assisted living facility. Medicare.gov's long-term care coverage page states that Medicare does not pay for the non-medical, custodial care that assisted living residences provide, though it may still pay for Medicare-covered medical services (doctor visits, some therapy, durable medical equipment) a resident receives while living there [4]. What Medicare will pay for, separately, is short-term skilled nursing facility care after a qualifying hospital stay, under specific conditions and time limits, which is a nursing home benefit, not an assisted living benefit [3]. This distinction trips up a lot of families and new operators alike: Medicare's post-hospital skilled nursing benefit has nothing to do with paying an ALF's monthly rate. Medicaid is a different story, and a more complicated one. Some states, through Medicaid Home and Community-Based Services (HCBS) waivers, help cover services (not room and board) in assisted living settings for eligible low-income residents. Federal Medicaid HCBS regulation at 42 CFR 441.301 sets the framework states must follow when designing these waiver programs [5]. Whether Virginia's Medicaid program covers ALF services for a given resident, and under which waiver, depends on the specific program and current state plan; confirm current HCBS waiver availability and covered services with the Virginia Department of Medical Assistance Services or your state Medicaid agency, since waiver slots and covered services change.
How do I start a group home or assisted living facility?
Starting either one follows a similar arc, but the licensing agency, application forms, and specific standards differ by population and state. Broadly, expect these stages: figure out your population and license type, secure a compliant building, write your policies, hire and train staff, pass a pre-licensure inspection, then operate under ongoing renewal and inspection cycles. Step one is confirming which agency licenses your model. In Virginia, that's DSS for ALFs (22VAC40-73) or DBHDS for many IDD group homes. Don't guess; call the licensing division and describe your intended population and services before you sign a lease or start a business plan built on the wrong regulatory chapter. Step two is the physical plant. Assisted living regulations specify things like minimum square footage per resident, number of bathrooms per resident, fire and life safety systems (sprinklers, alarms, evacuation capability), and accessibility features. Your local fire marshal and building department sign off alongside the state licensing agency, so zoning and building code review often runs in parallel with your DSS application. Step three is your paperwork: policies and procedures manual, staffing plan with minimum ratios by shift and by resident acuity level, emergency and disaster plans, medication management protocols, admission and discharge criteria, and background check documentation for every staff member (Virginia requires criminal history and Central Registry checks for ALF staff under Title 63.2). Step four is the application itself, usually with a non-refundable fee that varies by facility size and is set by regulation, so confirm the current fee schedule with your state licensing agency rather than relying on a number you saw somewhere else. Step five is the pre-licensure inspection, where a DSS licensing specialist walks the building, reviews your files, and checks that staffing, training, and physical plant match what you submitted. Only after that inspection clears does DSS issue the initial license, which in Virginia is typically issued for a set term (commonly one to three years depending on compliance history) before renewal review starts again. If you're building this packet from scratch, a structured State Group Home Licensing Kit can save real hours by giving you the policy manual skeleton, staffing plan template, and application checklist in one place for $299, so you're not reverse-engineering a 22VAC regulation section by section on your own.
What staffing does Virginia require for assisted living facilities?
Virginia's ALF staffing rules under 22VAC40-73 tie required staffing levels to the acuity of residents in the building, not a flat number per bed. Facilities serving residents needing only minimal assistance can operate with lighter staffing than facilities serving residents at the intermittent or continuous care level, and any facility with residents needing continuous care must meet higher direct care staff-to-resident ratios and, in some cases, licensed nursing coverage [2]. Every ALF must have someone awake and on duty 24 hours a day. Administrators must meet Virginia's specific licensure or qualification requirements (education, experience, and in most cases a state administrator exam or DSS-approved training course) before they can run a facility. Direct care staff need documented training in first aid, CPR, infection control, and resident rights within specified timeframes after hire, and ongoing annual training hours are also required. Staffing plans get scrutinized hardest during inspections when there's a mismatch between what the facility's UAI assessments say about resident acuity and what the time sheets show for staff on the floor. If your assessed population skews toward higher-acuity residents but your staffing plan reads like a minimal-care facility, that gap is one of the fastest ways to draw a licensing violation.
What happens during a DSS assisted living inspection?
DSS conducts an unannounced pre-licensure inspection before issuing an initial license, and then annual renewal inspections plus complaint-driven visits after that. Inspectors (called licensing specialists) review the physical plant for life safety compliance, check resident records against staffing and care plans, verify staff training and background check files, and observe medication administration and meal service if timed right. Common citation areas nationally, and consistent with what state licensing agencies report, include incomplete or late resident assessments, medication management errors or missing documentation, staff training records that don't match required hours, and life safety issues like blocked egress paths or expired fire inspection certificates. None of these are exotic. They're mostly paperwork and follow-through failures, not conceptual gaps in how the facility runs. After an inspection, DSS issues a report noting any violations, and the facility has to submit a plan of correction with a timeline. Repeated or serious violations can lead to a summary suspension, a provisional license, or revocation, all of which are matters of public record with DSS. If you want the cleanest possible inspection history, build your compliance calendar (staff training renewals, fire drills, care plan review dates) into your operations from day one rather than scrambling before each visit.
How much does it cost to license an assisted living facility, and how long does it take?
Costs and timelines vary by state and by facility size. Virginia's specific fee schedule for ALF licensure is set by DSS regulation and can change, so confirm the current fee amount and any renewal fee with the Division of Licensing Programs directly rather than relying on a cached number. What's consistent across most states is the shape of the cost: an application fee, plus your own build-out or renovation costs to meet physical plant standards, plus staffing costs incurred before you have a single paying resident. Timeline-wise, expect the DSS review and pre-licensure inspection process to take a minimum of several weeks once a complete application is submitted, and realistically several months when you count the time to prepare policies, hire and train staff, and correct any physical plant deficiencies flagged during initial review. Incomplete applications are the single biggest cause of delay; DSS reviewers routinely bounce packets back for missing background check documentation, incomplete floor plans, or staffing plans that don't map to the regulation's acuity-based requirements. Nobody, including DSS, publishes a fixed timeline you can count on. Any source promising a fast-track path or an approval sure thing is not describing a real state licensing process. Build in buffer time, especially for your first location.
Frequently asked questions
What is assisted living?
Assisted living is a licensed residential care option for adults who need help with daily activities like bathing, dressing, and medication management, along with 24-hour supervision, but who don't need the skilled nursing care a nursing home provides. States, not the federal government, define and license assisted living, so specifics vary; in Virginia, DSS licenses it under 22VAC40-73.
What is a group home?
A group home is a residential setting, usually a house, where a small number of people needing shared support (developmental disability, mental illness, or recovery needs, for example) live together with staff. Licensing depends on the population served; in Virginia, DBHDS typically licenses IDD group homes while DSS licenses assisted living facilities for aged or disabled adults.
What is an assisted living facility?
An assisted living facility (ALF) is a licensed congregate residential setting providing personal care, 24-hour supervision, and coordinated health services for adults, typically four or more, who are aged, infirm, or disabled. Virginia's Code 63.2-100 defines it this way, and DSS regulates ALFs under 22VAC40-73.
What is assisted living vs nursing home?
Assisted living provides personal care and supervision in a residential setting for people who are relatively stable but need help with daily tasks. A nursing home provides 24-hour skilled nursing care ordered by a physician for people needing ongoing medical treatment or rehabilitation. Different agencies license each in Virginia: DSS for ALFs, the Department of Health for nursing homes.
What does assisted living provide?
At minimum, licensed assisted living provides help with activities of daily living, 24-hour staff supervision, meals, medication management appropriate to the resident's assessed need, housekeeping and laundry, and emergency response systems. Virginia ties the specific service level to a resident's Uniform Assessment Instrument (UAI) score under 22VAC40-73.
How do I start a group home?
Confirm which state agency licenses your intended population first (DSS, DBHDS, or another department, depending on state and population), secure a compliant building, write your policies and staffing plan, complete background checks, submit your application with the required fee, and pass a pre-licensure inspection before DSS or the relevant agency issues your license.
What is the difference between assisted living and nursing home licensing agencies?
In Virginia, assisted living facilities are licensed by the Department of Social Services under 22VAC40-73, while nursing homes are licensed by the Virginia Department of Health. The two agencies use different regulatory standards, inspection processes, and staffing requirements, so a facility built for one license type generally can't operate under the other without significant changes.
Does Medicare cover assisted living facilities?
No. Medicare does not cover room and board in assisted living, though it may cover specific Medicare-eligible medical services a resident receives there, like doctor visits or durable medical equipment. Medicare's skilled nursing facility benefit, which covers some short-term post-hospital care, is a separate, nursing-home-specific benefit, not an assisted living benefit.
How do I start a group home if I'm not sure which agency licenses it?
Call your state's Department of Social Services or equivalent human services agency and describe the population you plan to serve and the services you'll provide. Licensing jurisdiction depends on the resident population (seniors, IDD, mental health, recovery) and can span multiple agencies, so confirm before committing to a building or business plan.
Does Medicaid pay for assisted living in Virginia?
Medicaid may help cover services, not room and board, in some assisted living settings through Home and Community-Based Services waivers authorized under 42 CFR 441.301, but availability, eligibility, and covered services depend on the specific waiver program and current state plan. Confirm current details with the Virginia Department of Medical Assistance Services, since waiver programs and slots change over time.
What's the minimum number of residents that makes a home an assisted living facility in Virginia?
Virginia's Code 63.2-100 defines an assisted living facility as a setting serving four or more aged, infirm, or disabled adults needing personal care and supervision. Homes serving three or fewer may fall outside this specific licensure category, though other regulations could still apply depending on the arrangement and services provided.
How often does DSS inspect assisted living facilities?
DSS conducts a pre-licensure inspection before issuing an initial license, then typically at least one renewal inspection per licensing cycle, plus additional visits triggered by complaints or prior violations. Inspection frequency can increase for facilities with a history of compliance problems.
What training do assisted living staff need in Virginia?
Direct care staff generally need documented training in first aid, CPR, infection control, and resident rights within a set period after hire, plus ongoing annual training hours, under 22VAC40-73. Administrators must meet separate qualification requirements, which commonly include education or experience thresholds and a state-approved training course or exam.
Sources
- Code of Virginia, 63.2-100 (Definitions): Virginia's statutory definition of an assisted living facility as serving four or more aged, infirm, or disabled adults
- Virginia DSS, 22VAC40-73, Standards for Licensed Assisted Living Facilities: Virginia's ALF regulation covering required services, UAI assessment, and acuity-based staffing requirements
- Medicare.gov, Nursing Home Care: Nursing homes provide skilled nursing and rehabilitation care distinct from residential/assisted living settings, and Medicare covers short-term skilled nursing after a qualifying hospital stay
- Medicare.gov, Long-term care coverage: Medicare does not cover room and board in assisted living facilities
- 42 CFR 441.301, Home and community-based settings: Federal requirements governing Medicaid Home and Community-Based Services waivers that may cover services in assisted living settings
- Code of Virginia, 63.2-1721 (Criminal history and Central Registry background checks): Virginia requires criminal history and Central Registry background checks for assisted living facility staff