How to Fill Out Form LIC 622

Table of Contents

LIC 622 at a glance
A filled-in LIC 622 example: one resident's Part I and Part II
How to fill out LIC 622, box by box
Sources

LIC 622 at a glance

What it is: In this form, Part I is CENTRALLY STORED MEDICATION and Part II is MEDICATION DESTRUCTION RECORD.

A filled-in LIC 622 example: one resident's Part I and Part II

LIC 622 example filled out, example: one resident's Part I and Part II — A resident's medication record at Example Care Home, a made-up facility that is neither an RCFCI nor an RCFE, so the paragraph for facilities other than RCFCI and RCFE applies. The picture under this story shows Part I; Part II, with the signatures, is pictured under Part II in Box by box. Part I lists three medications. The example writes the resident's name on the Name line; the form does not say whose name that line holds. The form does not say what to write under Instructions Control/Custody, so the example uses a short made-up note. Page 2 prints the same ten column headings for more medications. When the resident's services end, Sample Tablet A goes with the resident, and the other two medications are destroyed in the facility on 04/02/26 by the administrator, Jordan Example, and witnessed by Casey Example, an adult who is not a client or resident, and Part II records them. The form prints the same two signature boxes for every kind of facility; for RCF-CIs it names the facility manager as the second person but does not say which box the manager signs. The example copies Strength/Quantity from Part I; the form does not say whether Part II shows the amount filled or the amount destroyed. The form prints no date format, so the example uses MM/DD/YY. The two signatures are drawn as handwriting because the form's own signature boxes are too small to show a name. Every name, date, number and facility in the example is made up. Open the picture to see it full size.

How to fill out LIC 622, box by box

Tap a group of boxes to open it, and a picture to see it full size.

Part I: Instructions, Facility and Name

Centrally stored medications shall be kept in a safe and locked place that is not accessible to any person(s) except authorized individuals. Medication records for each client/resident shall be maintained for at least one year.

In Part I, write the Facility Name and the Facility Number.

Fill in Name (Last First Middle), Admission Date, Attending Physician and Administrator.

Part I: the medication boxes

In each row, fill in Medication Name, Strength/Quantity, Instructions Control/Custody, Expiration Date, Date Filled, Date Started, Prescribing Physician, Prescription Number, No. of Refills and Name of Pharmacy.

Part II: Destruction Record and signatures

In Part II, MEDICATION DESTRUCTION RECORD, fill in Medication Name, Strength/Quantity, Date Filled, Prescription Number, Disposal Date and Name of Pharmacy in each row.

Each row of Part II has two signature boxes: Signature of Administrator or Designated Representative, and Signature of Witness Adult Non-Client/Resident.

For facilities other than Residential Care Facilities for the Chronically Ill (RCFCI) and Residential Care Facilities for the Elderly (RCFE), prescription medication that is not taken with a client or resident when services are terminated or otherwise disposed of must be destroyed in the facility by the administrator or designated representative and witnessed by one other adult who is not a client or resident. Medication destruction records must be retained for at least one (1) year.

For RCF-CIs: Prescription medication that is not taken with a resident when placement is terminated or which is not to be retained must be destroyed by the administrator and the facility manager. Medication destruction records must be retained for at least three (3) years.

For RCFEs: Prescription medications which are not taken with a resident when services are terminated, not returned to the issuing pharmacy, not retained in the facility as ordered by the resident's physician and documented in the resident's record, not disposed of according to the established procedures of a hospice agency, or not otherwise disposed of must be destroyed by the administrator and one other adult who is not a resident of the RCFE, in the RCFE. Records documenting destruction of medication must be retained for at least three (3) years.

Sources

[1] LIC 622 (9/19), Centrally Stored Medication and Destruction Record, California Department of Social Services (the Official source link on this page).

LIC 622 PDF Details

Medication records for each client/resident shall be maintained for at least one year.

Other facilities: medication destruction records must be retained for at least one (1) year.

RCF-CIs and RCFEs: medication destruction records must be retained for at least three (3) years.

RCF-CIs: medication not taken with a resident when placement is terminated or not to be retained must be destroyed by the administrator and the facility manager.

Signatures: signature of administrator or designated representative; signature of witness, adult non-client/resident.

Question	Answer
Form Name	LIC 622
Form Length	4 pages
Fillable?	Yes
Fillable fields	388
Avg. time to fill out	60+ min
Other names	LIC 622, LIC622, LIC 622A, Centrally Stored Medication and Destruction Record
Edition	9/19
Issuing agency	California Department of Social Services
Matches the agency's file	Yes, checked October 1, 2026
Official source	LIC 622 (Rev 9/19), California Department of Social Services

LIC 622: California Centrally Stored Medication and Destruction Record