How to Start an Assisted Living Facility in Maryland: OHCQ Licensing Guide

Starting an assisted living facility in Maryland is a regulated process that requires compliance with the Office of Health Care Quality (OHCQ) and adherence to COMAR 10.07.14, the Assisted Living Program rules. Unlike opening a general business, an assisted living facility must meet specific structural, staffing, and operational standards before you can admit residents. This guide walks you through the exact steps, costs, timelines, and requirements you need to know.

What Is an Assisted Living Facility in Maryland?

An assisted living facility (ALF) is a licensed residential setting that provides housing, meals, personal care, and support services to adults who need assistance with activities of daily living but do not require skilled nursing care. In Maryland, these facilities are regulated by OHCQ under the Department of Health.

An assisted living license is issued for a specified number of beds and a specified level of care. This means your license will state exactly how many residents you can serve and what type of care your facility is authorized to provide. Separate licenses are required if you operate programs on the same or separate premises, so you cannot run two ALFs under a single license even if they are connected buildings.

If you are planning to operate a group home or behavioral-health housing program, note that these are licensed separately through the Behavioral Health Administration (BHA), not OHCQ. Confirm the type of license your facility will need before proceeding.

The Three Levels of Care in Maryland

When you apply for an assisted living license, you must request one of three levels of care. Your choice determines what services you are authorized to provide and which residents you can accept. You specify the level at initial licensure, and changing it later requires amending your license.

• Level I. Ask OHCQ for the exact services and staffing the lowest level allows.
• Level II. Ask OHCQ for the exact services and staffing the middle level allows.
• Level III. Ask OHCQ for the exact services and staffing the highest level allows.

Your choice of level affects staffing requirements, training standards, and the types of residents you can admit. Choosing a level higher than your staff can safely manage is a common mistake that leads to licensing violations and resident harm.

Before You Apply: Pre-Licensing Requirements

OHCQ will not issue a license without evidence that you meet specific structural and operational requirements. Do not begin the formal application process until you have addressed these items.

Facility Requirements

• A physical building that meets fire safety codes, building codes, and accessibility standards. The facility must meet OHCQ's physical plant requirements for bedrooms, common areas, staff space, medication storage, and bathrooms, so ask OHCQ for the specifics. Your county building inspector must approve plans before construction.
• A valid Certificate of Occupancy for the building if it is new or substantially renovated. Existing buildings must pass a fire and building safety inspection by the State Fire Marshal's office.
• Proof of liability insurance. Confirm the required coverage with OHCQ before purchasing.
• A valid health permit from your county health department if your facility will serve meals on-site.

Staffing and Training

• A qualified assisted living manager who meets OHCQ's manager requirements. Confirm the current credential and training rules with OHCQ. The administrator oversees day-to-day operations and is responsible for compliance.
• Nursing staff (the number varies by level of care and occupancy). Confirm with OHCQ the nursing coverage your care level requires.
• Aides and caregivers trained in resident care, infection control, and emergency procedures. Confirm with OHCQ which background checks your staff must clear.
• Proof of the staff training OHCQ requires, such as CPR and first aid.

Resident Services and Policies

• A written residential services plan for each resident that documents their care needs, medication management, emergency contacts, and goals.
• A written medication management policy if your facility will handle resident medications. This must include storage, documentation, and oversight procedures.
• A written emergency preparedness plan covering fires, medical emergencies, utility failures, and other hazards.
• Policies on admission, discharge, grievances, and resident rights.

Step-by-Step Licensing Process

Step 1. Contact OHCQ and Confirm Your License Type

Call the Office of Health Care Quality at 410-402-8000 or visit the Maryland Department of Health website to confirm that an assisted living license (not a group home or behavioral health license) is what you need. Request the ALF licensing package and a list of current regulations. This call saves you time by ensuring you pursue the right license type.

Step 2. Complete Pre-Licensing Inspections

Before submitting an application, schedule inspections with your county building inspector, the State Fire Marshal's office (for fire safety), and the county health department (if applicable). These inspections are required, and deficiencies must be corrected before OHCQ will issue a license. Deficiencies are common; expect to make changes and reschedule inspections.

Step 3. Hire and Credential Your Administrator

Your facility must have a qualified administrator on staff or contracted before you apply. If you are the manager, verify with OHCQ that you meet the requirements. If you hire someone, ensure their credentials are current and that they have completed the training OHCQ requires.

Step 4. Develop Required Policies and Plans

Write or adopt residential services plans, medication management policies, emergency procedures, and resident rights statements. These documents must be in place and available for inspection. Do not leave these blank or generic. OHCQ will review them for completeness and compliance with regulations.

Step 5. Submit Your License Application

Obtain the ALF license application from OHCQ and submit it with the following documents:

• Proof of building ownership or a lease (if you rent).
• Certificates of Occupancy and building/fire safety inspection approvals.
• Your facility's floor plan with room layouts and square footage.
• Proof of liability insurance.
• Credentials and résumés for the administrator and key nursing staff.
• Your medication management policy, emergency plan, and resident services policies.
• A list of the number of beds and the level of care you are requesting (I, II, or III).
• Background check authorizations for all staff.
• Proof of health department permit (if applicable).

Submit the application to OHCQ by mail or via the agency's designated process. Keep copies for your records and request a receipt of submission.

Step 6. Attend the OHCQ Licensing Inspection

After you submit your application, OHCQ will schedule an on-site licensing inspection. During this inspection, surveyors will examine your facility, review policies, interview staff, and verify compliance with all regulations. Be present during the inspection, have all staff available, and have all required documents on hand.

Step 7. Address Deficiencies or Receive Your License

If no deficiencies are found, OHCQ will issue your license in writing. If deficiencies are cited, you have a specific period set by OHCQ to correct them and submit evidence of correction. Common deficiencies include staffing gaps, incomplete policies, fire safety issues, and documentation problems. Address deficiencies promptly. Failure to correct deficiencies can result in license denial.

Step 8. Maintain Compliance After Licensure

Once licensed, you must comply with all regulations, maintain policies, document all resident care, report incidents to OHCQ, and renew your license on OHCQ's schedule. OHCQ conducts routine inspections and can conduct unannounced inspections if complaints are filed.

Materials and Requirements Checklist

• Building inspection and fire safety certification
• Health department permit (if serving meals on-site)
• Proof of liability insurance
• Administrator credentials and current background check
• Nursing staff credentials and background checks
• Caregiver staff with CPR and first aid certifications
• Floor plan and square footage documentation
• Medication management policy
• Emergency preparedness plan
• Resident services plan template
• Resident rights and grievance policy
• Admission and discharge policies
• Staff training records and attendance logs

Licensing Fees and Timeline

OHCQ charges a license fee based on the number of beds in your facility. A 2016 fee summary reported amounts ranging from $50 for facilities with 1 to 4 beds up to $375 for facilities with 150 or more beds. However, these figures are not confirmed as current. Before budgeting, contact OHCQ directly at 410-402-8000 to confirm the exact fee for your bed count and whether fees have changed.

The licensing timeline varies. Ask OHCQ for current timelines for application review and the licensing inspection. Do not expect to admit residents until you hold a valid license in hand.

Common Mistakes to Avoid

• Choosing a care level you cannot support. Requesting Level III care without adequate nursing staff is a setup for violations and harm to residents. Be realistic about your staffing and start with a lower level if needed.
• Skipping pre-licensing inspections. Some operators skip building or fire inspections and discover deficiencies only after OHCQ inspection. This delays licensing and increases costs. Schedule inspections early.
• Incomplete or generic policies. OHCQ reviewers can spot boilerplate or incomplete policies quickly. Customize policies to your facility, your staff, and your residents' needs. Have an attorney review them.
• Inadequate background checks or credentialing. Any staff member with a criminal history or credential issues will delay or jeopardize your license. Verify every credential and clear every background check before staff start work.
• Assuming group homes and behavioral health housing follow the same rules. They do not. If you are opening a group home, apply for a BHA license, not an OHCQ ALF license. The rules and agencies are different.
• Starting resident admission before you are licensed. This is a violation that can result in fines, closure, and legal liability. Do not admit a single resident until your license is in hand.

Expected Timeline and Results

If you follow this process and meet all requirements, the time to licensure depends on your inspections and OHCQ's review, so ask OHCQ for current timelines. Your license will specify the number of beds, the level of care, and the conditions of licensure. You will be authorized to admit residents, operate your facility, and bill for services under the license.

Once licensed, your facility is subject to ongoing regulatory compliance. OHCQ may conduct unannounced inspections if complaints are filed. You must maintain all policies, document all resident care, report incidents, and renew your license on OHCQ's schedule.

When to Consult Professional Help

Assisted living licensing is complex and regulated. This guide provides an overview, but regulations change and individual circumstances vary. Before you begin, consult the following professionals:

• An attorney licensed in Maryland who specializes in health care or long-term care law. An attorney can review your policies, advise on liability, and represent you if OHCQ raises compliance issues.
• A certified health care administrator who has experience with assisted living licensing in Maryland. An administrator can help you develop policies, prepare for inspections, and ensure compliance.
• An accountant or CPA who understands long-term care financing, insurance, and tax obligations. ALF ownership has specific tax and financial implications.
• A licensed insurance agent who can advise on liability, property, and workers compensation coverage appropriate for an ALF.

Important Disclaimer

This article provides informational content about the process of obtaining an assisted living license in Maryland. It is not legal advice, tax advice, or regulatory guidance. The regulations, fees, and requirements described here are based on research current as of October 2026, but they may change. Before making any business decisions, consult with qualified professionals, including an attorney, accountant, and health care compliance expert. Contact the Office of Health Care Quality directly to confirm all current requirements, fees, and timelines.

Maryland Resources

• Office of Health Care Quality (OHCQ): 410-402-8000. Request the Assisted Living Program licensing package and COMAR 10.07.14 regulations.
• Maryland Department of Health: https://health.maryland.gov/
• State Fire Marshal's Office: For fire safety inspections and approvals.
• County Building Inspector: For building code compliance inspections. Contact your county's permit office.
• County Health Department: For health permits if you serve meals on-site.