Two options for senior living that rarely receive attention are board and care homes (BCHs) and adult foster homes (AFHs). While the two are very similar, the differences in terminology vary by state. Since all the different names for long-term care options can be confusing, it is preferable to focus on the size of the facility you are seeking and the services offered rather than on the name.

A Different Type of Assisted Living

One of the biggest reasons why BCHs and AFHs are so frequently overlooked is their size. Unlike large nursing homes and sprawling assisted living communities, BCHs and AFHs typically house 10 or fewer residents. The accommodations range from a residential home that has been adapted to meet seniors’ needs to small care facilities. Staff-to-resident ratios are also better, which means that residents may receive more one-on-one care. Both private and shared rooms are typically available.

Services Offered in Adult Foster Homes and Board and Care Homes

BCHs and AFHs essentially offer the same services that larger assisted living communities offer. This intermediate level of long-term care is unskilled, meaning that the staff mainly provides assistance with activities of daily living (ADLs), such as bathing, dressing, grooming and toileting. Some of these long-term care settings may be able to provide a limited amount of skilled care, but it varies by state.

Residents have access to assistance 24/7, but unlike assisted living, BCHs and AFHs do not require staff to be awake around the clock. This is because it is very common for the manager to live at the home with the residents.

Housekeeping Services

Board and care staff members are responsible for the general cleaning of common areas and residents’ rooms and bathrooms. They also provide supplies, such as toilet paper and soap. Laundry service for linens and residents’ clothing may be offered as well.


Activity programs are typically offered in AFHs and BCHs, but the options may be less extensive than those offered by larger assisted living facilities. Options usually include bingo, movies, crafts and outings. Some facilities encourage their residents to join neighborhood senior centers or other community programs for recreation and socialization opportunities.


Rides to doctor’s appointments and group outings are typically provided. Some residences may offer transportation to run errands, such as grocery shopping or filling prescriptions. This usually depends on the residents’ individual health and level of mobility.

Medication Management

Medication management is a highly regulated aspect of long-term care, and for BCHs and AFHs, regulations vary by state. Some states only allow staff to provide medication reminders unless they receive training and/or certification required to actually handle or administer medications. Furthermore, there are substantive differences among facilities in the methods used for storage and administration of medications as well as record keeping.


Obtaining proper nutrition is a major issue for many seniors. Often, they are unable or unwilling to shop and cook for themselves, and poor nutrition can aggravate existing health problems and contribute to new ones. Many state agencies that regulate these homes set specific nutritional requirements for meals, including the prominent posting of daily or weekly menus.

In addition to personal and cultural food preferences, a resident may have special dietary needs, which should be addressed prior to signing a contract and moving in. Most facilities cater to special diets, such as low-sodium or low-fat meals, when recommended by a resident’s healthcare provider. A facility will usually ask for documentation regarding any special diet necessitated by a medical condition.

Residents are free to eat out if they prefer, but the facility is not required to pay for meals taken elsewhere and does not provide refunds for uneaten meals when food is included in their board rate. Residents may usually arrange to have guests eat with them in the dining room, but generally advance notice is required and a fee may be charged.

Meal Supervision

Since a staff member is both cooking and serving meals to residents, they can easily pick up on changes in appetite that may indicate new health issues. In a large assisted living facility with hundreds of residents, it may be difficult for staff to notice that a particular resident has not been eating well. The more intimate setting of a BCH or AFH increases the likelihood that nutritional issues will be noticed and remedied in a timely manner.

Types of Facilities

Some facilities only admit elderly residents, while others have a mixed population. This is something to be aware of when considering a BCH or AFH. Non-elderly residents typically have a mental illness or physical disability that prevents them from living independently.

For some seniors, a mixed population may be beneficial. One advantage of facilities that serve other populations is that they often are required to have more staff onsite and/or provide a higher level of training for employees. Therefore, staff members are usually more alert to changes in health and behavior. Having multiple generations present also enhances the family-style environment.

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Licensing and Inspection

Board and cares and adult foster homes are licensed and inspected by state oversight agencies. It is usually the Department of Health that fulfills this function, but in some states it may be the Department of Social Services. The easiest way to find out which agency has this responsibility is to check a residence’s latest inspection or survey report. It is required that the most recent report be posted where it is easy for residents and visitors to view it.

Board and cares and adult foster homes are not accredited like hospitals and other health related-facilities. However, some of the larger facilities may be members of trade associations that have certain standards for membership. You can also check, enter your area, and find the information that way.

The Application Process

Prospective residents are required to complete an application form. It typically covers the person’s health, finances, likes and dislikes, and eating and sleeping habits. In addition to the application process, an interview and needs assessment will be conducted to determine if the facility is the right fit for this person’s needs and abilities. Hospital discharge planners, social workers, geriatric care managers and your local Area Agency on Aging can help arrange the needs assessment and provide referrals to the appropriate senior living facility.

Once both the prospective resident and the facility agree that the arrangement is a good fit, the next step is signing a contract called an admission agreement or a residency agreement. Clauses generally cover fees, what services the resident will receive for the fee, the circumstances under which a resident can be asked to leave or can be evicted, how long a bed will be held if a resident is hospitalized, and grievance procedures. Other topics that may be included are the facility’s right to inspect residents’ rooms, change room assignments and alter staffing levels. These agreements should be read carefully, and any confusing provisions should be made clear.

Increasing Levels of Care

Despite the requirement that residents in board and care facilities must be ambulatory and continent to be considered for admission, the time may come when the assistance and services offered there are no longer sufficient to provide for the needs of a resident. In some cases, this means that the resident must move to a facility that can meet these increasing needs, such as a memory care unit or a skilled nursing facility. However, in some states, a higher level of service can be brought to the resident instead of having them relocate. This can be arranged through a private agreement with a home care company, a Medicaid-funded assisted living program and certain VA programs for eligible veterans. Since each state differs, it is important to research available in-home care and funding options in the senior’s local area.

Visiting Senior Living Facilities

While visiting each prospective facility is important, don’t expect to learn everything in a single visit. Try to arrange several visits at different times of day to get a true picture of what life is like there. Take notes about what you see and hear, and jot down questions that arise. These notes will be helpful later for comparing facilities and making an informed decision.