Last updated 2026-07-24
TL;DR
Virginia assisted living facilities (ALFs) are licensed by the Virginia Department of Social Services under 22VAC40-73 to provide housing, meals, supervision, and personal care to adults who can't live independently. They differ from group homes (behavioral health focus) and nursing homes (skilled medical care). Medicare does not pay for room and board in an ALF; Medicaid may cover care costs through the state's Assisted Living Facility waiver in some cases.
What is assisted living?
Assisted living is a residential care model for adults, usually seniors, who need help with daily activities like bathing, dressing, medication management, or meal prep but don't need round-the-clock skilled nursing. It sits between fully independent senior housing and a nursing home on the care spectrum. In Virginia, the formal license category is the "assisted living facility" (ALF), defined and regulated under Virginia Code § 63.2-100 and the licensing standards at 22VAC40-73. The Virginia Department of Social Services (VDSS) is the licensing agency for these facilities, not the Department of Health, which is a detail that trips up a lot of new operators coming from states where health departments run senior care licensing [1][2]. The practical version: assisted living gives someone their own room or apartment, staff on site, prepared meals, help with activities of daily living (ADLs), and a level of supervision matched to what a resident's individualized service plan says they need. It is not a hospital and it is not memory care by default, though many ALFs hold a specialized license to serve residents with dementia.
What is a group home (and how is it different from assisted living)?
A group home, in Virginia licensing terms, usually refers to a smaller residential setting serving people with intellectual/developmental disabilities (IDD), mental illness, or substance use disorders, often licensed through the Department of Behavioral Health and Developmental Services (DBHDS) rather than VDSS. Group homes tend to run under Medicaid waiver programs (like the Community Living or Family and Individual Support waivers) and focus on behavioral health support, skill-building, and community integration rather than age-related physical decline. Assisted living facilities, by contrast, are almost always aimed at older adults or adults with physical frailty, and licensing sits with VDSS under 22VAC40-73. The populations can overlap (an older adult with a long psychiatric history could technically qualify for either type of placement depending on need), but the licensing agency, staffing ratios, and reimbursement pathways are different animals entirely. If you're building a residential care business and you're not sure which lane you're in, the fastest gut check is: who is the resident population, and which state agency regulates that population's care in your state? For Virginia's disability and behavioral health group home rules specifically, check DBHDS's licensing pages directly rather than assuming ALF rules apply. Readers comparing the two models side by side may find our overview on assisted living facilities useful for sorting out overlapping terminology across states.
What is an assisted living facility?
An assisted living facility, under Virginia law, is "any congregate residential setting that provides or coordinates personal and health care services, 24-hour supervision, and assistance... for the maintenance or care of four or more adults who are aged, infirm or disabled" and who need that assistance as documented in an individualized service plan [1]. That four-or-more threshold matters: smaller adult care arrangements (fewer than four unrelated adults) generally fall outside ALF licensing and into different regulatory categories, like certain adult foster care arrangements. Virginia further splits ALFs into license tiers based on the level of care they're approved to provide: Assisted Living Care (auxiliary grant eligible) versus Residential Living Care, and facilities can also apply for an auxiliary grant designation and/or a specialized dementia care license. Each tier comes with different staffing, training, and physical plant expectations under 22VAC40-73 [2]. A one-time state fee, background check requirements for all staff and volunteers with resident contact, and a criminal history and central registry check are baseline requirements before VDSS will even schedule your initial licensing inspection. Exact fee schedules change periodically, so confirm current fees with VDSS directly rather than relying on older published numbers.
What is assisted living vs nursing home?
| VA Licensing agency | VDSS (22VAC40-73) | Virginia Dept. of Health |
|---|---|---|
| Medical staffing | Direct care staff, not necessarily licensed nurses | RN required 8 hrs/day, licensed nurse 24/7 [4] |
| Medicare coverage | Generally none for room/board | Up to 100 days per benefit period (post-hospital) [5] |
| Typical resident need | ADL help, supervision | Skilled nursing, rehab, complex medical care |
The short answer: assisted living is for people who need help with daily living tasks, nursing homes are for people who need ongoing skilled nursing or medical care. Nursing homes (called "nursing facilities" in Medicaid/Medicare terminology) are licensed in Virginia by the Virginia Department of Health, not VDSS, and they must meet federal Medicare/Medicaid conditions of participation under 42 CFR Part 483 if they accept those programs [3]. Staffing is the clearest structural difference. Nursing homes are required to have a registered nurse on duty for at least 8 consecutive hours a day, seven days a week, and licensed nursing staff (RN or LPN) on duty 24 hours a day under federal law [4]. Assisted living facilities in Virginia have no equivalent RN-on-site mandate; staffing is tied to resident acuity and the facility's approved level of care, with direct care staff required to be awake and on duty 24 hours a day, but not necessarily licensed nurses [2]. Cost and payer mix differ too. Nursing home stays are far more likely to be covered short-term by Medicare Part A (up to 100 days per benefit period, with a coinsurance requirement after day 20) following a qualifying hospital stay [5]. Assisted living has essentially no Medicare coverage for room and board, which is the single most common point of confusion for families and new operators alike. | Feature | Assisted Living Facility | Nursing Home |
What does assisted living provide?
At minimum, a licensed Virginia ALF must provide: a private or semi-private room, three meals a day plus snacks, help with ADLs (bathing, dressing, toileting, mobility, eating), medication administration or oversight, housekeeping and laundry, 24-hour staff supervision, and social/recreational activities, all documented in an individualized service plan updated based on resident condition changes [2]. Beyond the baseline, many facilities layer on services depending on their license tier: memory care programming for a specialized dementia unit, higher staff-to-resident ratios for residents needing more hands-on assistance, transportation to medical appointments, and coordination with outside home health or hospice agencies. What an ALF is explicitly not required or licensed to provide is ongoing skilled nursing care, IV therapy, or complex wound care beyond what's allowed under Virginia's delegation rules for unlicensed staff. One thing operators underestimate: the individualized service plan isn't paperwork theater, it's the document VDSS surveyors pull first during an inspection to check whether the care being delivered actually matches what was assessed and documented. If a resident's plan says they need two-person transfer assistance and the inspector observes one aide doing it alone, that's a citation waiting to happen.
Does Medicare cover assisted living facilities?
No. Medicare does not cover the cost of room, board, or personal care 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 what assisted living is classified as, regardless of state [6]. What Medicare will cover, even for someone living in an ALF, are the same medical services it covers anywhere: doctor visits, some home health services if the person qualifies, durable medical equipment, and short-term skilled nursing or rehab following a qualifying hospital stay (though that care typically happens in a nursing facility, not the ALF itself) [5][6]. Medicaid is a different story, but it's not simple either. Virginia does not use Medicaid to pay for the room-and-board portion of assisted living. Instead, income-eligible residents in ALFs may qualify for Virginia's Auxiliary Grant program, a state-funded supplement (not federal Medicaid) that helps cover the cost of care in an approved ALF, combined with the person's own Social Security/SSI income [7]. Separately, some personal care services in an ALF setting can be billed through Medicaid's Commonwealth Coordinated Care Plus (CCC Plus) waiver for people who qualify financially and functionally, but this covers care services, not the room and board itself . This distinction between Medicare, Medicaid, and state supplement programs is worth getting straight before you build a pro forma around expected payer mix.
How to start a group home or assisted living facility in Virginia
Starting a licensed ALF in Virginia runs through several fixed steps, and skipping ahead on any of them tends to cost more time later, not less. 1. Confirm which license you actually need. If your target population is seniors or adults needing ADL support, that's VDSS/ALF territory under 22VAC40-73. If it's IDD, mental illness, or substance use recovery in a smaller residential setting, that's likely DBHDS. Confirm this with the relevant state licensing agency before you sign a lease or buy property, because zoning, staffing rules, and the application itself are entirely different. 2. Check zoning and building/fire code fit. Local zoning ordinances vary by county and city in Virginia, and many jurisdictions treat ALFs as a distinct use category requiring a special use permit, especially for facilities above a certain bed count. Fire marshal approval and a Virginia Uniform Statewide Building Code inspection tied to the ALF occupancy classification happen before VDSS will issue a license, so loop in your local building and fire officials early. 3. Submit the license application to VDSS, including proof of financial solvency, an administrator who meets Virginia's ALF administrator qualification requirements (which include specific training/exam requirements under 22VAC40-73), staffing plans, a fire inspection report, a health inspection, and background checks (including a sworn disclosure statement) for the administrator and any staff with resident access [2]. 4. Pass the initial licensing inspection. VDSS conducts an on-site survey to verify the physical plant, staffing, policies, and records match what was submitted. Expect the inspector to review resident service plans, medication administration records, staff training files, and emergency preparedness plans. 5. Build your policy manual before you apply, not after. Surveyors expect a written medication management policy, emergency/disaster plan, admission and discharge criteria, resident rights disclosures, and grievance procedures on day one, not as a work in progress. Trying to write these from scratch during the application window is where a lot of first-time operators lose weeks. If you want a structured starting point instead of assembling every policy and form from a blank page, GroupHomePath's $299 State Group Home Licensing Kit gives operators a state-specific framework to work from, though you'll still need to confirm current Virginia-specific fee amounts and form versions directly with VDSS since those change over time. 6. Plan for ongoing compliance, more than the opening inspection. ALFs are subject to periodic unannounced inspections, complaint investigations, and annual re-licensure review. Build your staffing and documentation habits around the assumption that an inspector could walk in any given Tuesday.
How do I start a group home for IDD, mental health, or recovery populations?
If your intended population is adults with intellectual or developmental disabilities, serious mental illness, or substance use disorder recovery needs, you're generally not applying to VDSS for an ALF license. Virginia licenses these residential programs through DBHDS, and the rules differ meaningfully from ALF regulations, including different staff qualification requirements, different Medicaid waiver billing pathways (like the Community Living waiver or Family and Individual Support waiver), and different physical plant standards depending on program type. The process shape is similar in outline (confirm licensing category, secure a compliant property, build your policy and staffing framework, submit the application, pass inspection) but the specific regulations, forms, and even the state office you're dealing with are different from ALF licensing. Don't assume ALF paperwork or ALF staffing ratios transfer over; they don't. If you're weighing which population and license type fits your goals and local market, it's worth comparing options before committing to a property lease, since zoning approval for one license category doesn't guarantee approval for another even in the same building.
How much does assisted living cost in Virginia, and who pays?
Costs vary widely by region, level of care, and whether the facility holds specialized licenses like dementia care. There's no single authoritative statewide average maintained by VDSS, and industry cost surveys (like the ones some insurance and financial services companies publish annually) use different methodologies, so treat any single number you see as a rough regional estimate rather than a fixed figure. The safest approach for both operators and families is to request current fee schedules directly from individual facilities and cross-check against Virginia's Auxiliary Grant payment rate, which is a state-set figure updated periodically and is the closest thing to an official benchmark for the assisted-living portion of care costs for income-eligible residents [7]. Payer mix in most Virginia ALFs breaks into three buckets: private pay (the resident or family covers costs directly), Auxiliary Grant recipients (state-funded supplement for income-eligible residents in approved facilities), and residents receiving Medicaid CCC Plus waiver services for personal care while paying room and board privately or through the Auxiliary Grant [7]. Long-term care insurance, where a resident holds a policy, is a fourth but much smaller bucket in practice. For operators building a financial plan, the honest starting point is: assume most of your revenue will be private pay or Auxiliary Grant, verify current Auxiliary Grant rates with the Virginia Department for Aging and Rehabilitative Services or VDSS, and don't build a pro forma assuming Medicare will pay for anything beyond incidental medical services, because it won't [6].
What are the biggest compliance risks new Virginia ALF operators miss?
Medication management is the number one citation source in assisted living inspections nationally, and Virginia is no exception. Errors in documentation, staff administering medications without required training or delegation authority, and mismatches between the physician's orders and the medication administration record are common findings. Staffing ratio and awake-staff violations come next. Virginia requires direct care staff to be awake and on duty at all times, and inspectors check schedules against actual sign-in logs, more than the posted staffing plan. Individualized service plans that don't match observed care is the third big one, covered earlier in this piece. If a plan says a resident needs assistance with ambulation and staff are observed letting that resident walk unassisted with a documented fall risk, that's a direct discrepancy an inspector will flag. Finally, background check and training documentation gaps show up constantly in first-year facilities. Every staff member with resident contact needs the required criminal history check, central registry check, and initial/ongoing training documented in their personnel file before they start working unsupervised, per 22VAC40-73 [2]. Building these habits from day one, rather than scrambling to backfill files before a survey, is the difference between a routine inspection and a plan-of-correction spiral.
Frequently asked questions
What is assisted living?
Assisted living is residential care for adults who need help with daily activities like bathing, dressing, and medication but don't need full-time skilled nursing. In Virginia, it's a licensed category (ALF) regulated by VDSS under 22VAC40-73, providing housing, meals, supervision, and personal care based on an individualized service plan.
What is a group home?
A group home is a residential setting, usually smaller than an assisted living facility, that serves people with intellectual/developmental disabilities, mental illness, or substance use disorders. In Virginia these are typically licensed by DBHDS rather than VDSS, with different staffing and Medicaid waiver rules than assisted living facilities.
What is an assisted living facility?
Under Virginia Code § 63.2-100, an assisted living facility is a congregate residential setting providing personal and health care services and 24-hour supervision to four or more aged, infirm, or disabled adults who need that help under an individualized service plan. VDSS licenses ALFs under 22VAC40-73.
What is the difference between assisted living and nursing home?
Assisted living helps with daily living tasks and is licensed by VDSS; nursing homes provide skilled medical/nursing care and are licensed by the Virginia Department of Health. Nursing homes must have licensed nursing staff on duty 24/7 and an RN 8 hours a day under federal rules; ALFs have no equivalent RN mandate.
Does Medicare cover assisted living facilities?
No. Medicare does not pay for room, board, or personal care in an assisted living facility, per CMS guidance on long-term custodial care. Medicare will still cover medical services like doctor visits or short-term skilled rehab following a qualifying hospital stay, but not the assisted living stay itself.
Does Medicaid pay for assisted living in Virginia?
Not directly for room and board. Virginia uses a state-funded Auxiliary Grant to help eligible low-income residents afford approved assisted living facilities, and Medicaid's CCC Plus waiver can cover personal care services for qualifying residents, but neither program is traditional federal Medicaid paying the facility's full room-and-board rate.
How do I start a group home in Virginia?
First confirm whether your population fits ALF licensing (VDSS, seniors/ADL needs) or DBHDS licensing (IDD, mental health, substance use recovery). Then secure a compliant property, check local zoning and fire code, build required policies and staffing plans, submit your license application, and pass the initial on-site inspection.
How do I start an assisted living facility specifically?
Confirm your license category with VDSS, find a property that meets zoning and Virginia Uniform Statewide Building Code requirements for ALF occupancy, hire a qualified administrator meeting 22VAC40-73 training requirements, submit your application with staffing and policy documentation, and pass the initial licensing survey before admitting residents.
What does assisted living provide that a group home doesn't?
Assisted living focuses on age-related and physical-decline support: ADL help, medication management, meals, and supervision for older or physically frail adults. Group homes typically focus on behavioral health support, skill-building, and community integration for IDD or mental health populations, often funded through different Medicaid waivers.
What is the four-person threshold in Virginia ALF licensing?
Virginia law defines an assisted living facility as serving four or more unrelated adults needing personal or health care assistance. Settings serving fewer than four adults generally fall outside ALF licensing requirements and may be regulated under different adult care categories instead.
Who inspects assisted living facilities in Virginia?
The Virginia Department of Social Services (VDSS) licenses and inspects ALFs, conducting an initial licensing survey before opening and periodic unannounced inspections afterward. Local fire marshals and building officials also inspect the physical plant for fire and building code compliance as part of the licensing process.
Can I convert a house into an assisted living facility?
Sometimes, but zoning approval, local special use permits, and Virginia Uniform Statewide Building Code occupancy requirements for ALFs must all be met first, and requirements vary by county and city. Confirm with your local zoning office and VDSS before purchasing or leasing property for this purpose.
Sources
- Virginia Code § 63.2-100 (LIS): Definition of assisted living facility as serving four or more aged, infirm, or disabled adults
- Virginia Administrative Code 22VAC40-73 (Standards for Licensed Assisted Living Facilities): Licensing standards, staffing, administrator qualifications, and individualized service plan requirements for Virginia ALFs
- 42 CFR Part 483 (eCFR): Federal conditions of participation for nursing facilities
- 42 CFR § 483.35 (eCFR): Nursing home RN and licensed nurse staffing requirements
- Medicare.gov, Skilled Nursing Facility Care coverage: Medicare Part A covers up to 100 days per benefit period following a qualifying hospital stay
- Medicare.gov, Long-Term Care: Medicare does not cover long-term custodial care such as assisted living room and board
- Virginia Department for Aging and Rehabilitative Services, Auxiliary Grant Program: Auxiliary Grant is a state-funded supplement helping eligible residents afford approved assisted living facilities