Board and care homes are one of the least-discussed parts of the US mental health system, and one of the most consequential. Tens of thousands of adults with schizophrenia live in these small, privately operated residential facilities. The quality ranges from genuinely caring family-run homes to neglectful settings that periodically appear in newspapers. This guide covers the history, the current landscape, and the questions that separate a decent placement from a bad one.
Board and care homes are small, state-licensed residential facilities — usually 4 to 16 beds — providing room, meals, and basic supervision to adults who cannot fully live independently, including a substantial number of people with schizophrenia.
A brief history
Before the 1960s, most adults with severe mental illness in the US lived in state psychiatric hospitals. Deinstitutionalisation emptied those hospitals through a combination of new antipsychotic medication, civil-rights court rulings, and the promise of community-based care funded by Medicaid and a network of community mental health centres. The community-based care system was always under-funded, and one of the things that filled the gap was the small private residential facility — known by various names: board and care, adult residential facility (ARF), residential care facility for the elderly (RCFE), personal care home, adult care home, depending on the state.
By the 1980s and 1990s, board and care homes had become a quiet pillar of the housing system for people with serious mental illness. Many were — and are — run as small businesses by individual operators or families. Quality was uneven from the start.
What a board and care home looks like
A typical board and care provides:
- A bed in a shared or private room
- Three meals a day
- Help with personal care as needed
- Supervision — particularly around medication
- Laundry and basic housekeeping
- A common living area
What board and care homes generally do not provide is meaningful clinical care. Mental health treatment is usually delivered by an outside community mental health provider; the home itself is residential, not therapeutic. Staffing tends to be low — often a single caregiver during the day and night, with the operator living on the premises.
State variation
Board and care homes are licensed at the state level, which means rules vary enormously. California has thousands of Adult Residential Facilities and RCFEs, regulated by the Department of Social Services. Florida has Assisted Living Facilities with limited mental health licensure. Pennsylvania has Personal Care Homes. North Carolina has Adult Care Homes. The level of inspection, the staffing requirements, and the protections for residents vary state by state. Long-Term Care Ombudsmen in many states cover these settings; in others, oversight is thinner.
Who lives in board and care
Residents typically include:
- Adults with chronic schizophrenia or schizoaffective disorder, often in their 40s, 50s, or older
- Adults with intellectual or developmental disabilities
- Older adults with dementia
- Adults with chronic medical conditions who cannot live alone
- People exiting homelessness, jail, or psychiatric hospitalisation
The mix in a single home varies. Some homes specialise in mental illness; others house mixed populations.
How it is paid for
Most residents pay for board and care with their monthly SSI cheque, a state SSI supplement (where one exists), and sometimes a contribution from family. The federal SSI rate plus a typical state supplement covers the monthly room-and-board fee in many states with little left over. Medicaid does not generally pay for the residential portion in most states, though some states have started to fund tenancy supports through HCBS waivers.
The economics are tight. An operator who depends on the SSI cheque is under continual financial pressure — which can affect food quality, staffing, and maintenance.
The quality picture
Board and care homes range from excellent to dangerous. The good ones are warm, well-kept, and staffed by people who know their residents and care about them. The bad ones — periodically exposed in investigative reporting — are over-crowded, under-fed, poorly maintained, and sometimes outright abusive. The 2018 investigation by ProPublica and Frontline into California's RCFEs, and many similar regional reports over the years, have documented serious failings in some homes.
Research from the academic literature has consistently found that residents of board and care often have worse health outcomes than residents of more structured supported housing — partly because of low staffing, partly because of the population's medical complexity, and partly because of the limited integration with mental health services.
Locked rooms, residents who appear over-medicated or unkempt, missing inspection reports, refusal to allow unannounced visits, controlled access to a resident's mail or money, blanket "no visitor" rules, or any sign that residents' SSI cheques are being managed without authority. Any of these warrant a call to the state licensing agency or ombudsman.
How to evaluate a home
- Verify the licence with the state agency that oversees these settings (Department of Social Services, Department of Health, Department of Aging — varies by state).
- Check the inspection history. Many states post past inspections online. Look for repeated deficiencies, especially in food, sanitation, medication management, or resident care.
- Visit unannounced. Walk the home. Look at the kitchen and bathrooms. Eat a meal if you can. Notice resident appearance and engagement.
- Ask about medication management. Who passes medication? How is a refusal handled? Is there a Medication Administration Record?
- Ask about clinical coordination. Does the home work with a community mental health team? What happens if a resident decompensates?
- Ask about money. How is the SSI cheque handled? How much personal-needs allowance does the resident keep? Are residents allowed to manage their own money if able?
- Talk to current residents and other families. Their experience is more reliable than marketing materials.
- Read the agreement carefully. Pay attention to discharge criteria and the process for raising concerns.
Rights of residents
Board and care residents retain rights even in low-staffed settings. Most state regulations require:
- The right to refuse medication outside an emergency
- The right to receive visitors at reasonable times
- The right to private mail and phone calls
- The right to keep personal money and belongings
- The right to file complaints without retaliation
- Reasonable notice before discharge
Long-term care ombudsmen in most states will investigate concerns. Local NAMI chapters can also be a useful starting point for family members who are trying to evaluate or improve a placement.
Where the field is going
Many states are gradually moving toward more integrated Permanent Supportive Housing and Housing First models that emphasise tenants' own apartments with wraparound services, rather than congregate residential facilities. The shift is slow because the demand for low-cost residential settings is real and the alternatives are not always available. Board and care will be part of the housing landscape for the foreseeable future, even as policy attention shifts to other models.
For more, see group homes for adults with schizophrenia and supported housing models for schizophrenia.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.