LIC 622A — Medication Administration Record (MAR)
LIC 622A is the California CDSS form titled "Medication Administration Record (MAR)". Documents every scheduled and PRN dose administered to a resident.
Official PDF
The current LIC 622A is published by the California Department of Social Services. We link to the live source rather than hosting a copy, so you always get the latest revision.
Open LIC 622A on cdss.ca.govWho completes it and when
The facility prepares this form and files the completed original in the appropriate record.
Maintained every month for each resident receiving medication assistance.
How to complete LIC 622A
- 1Download the current revision of the form directly from CDSS so you are not working from an outdated copy.
- 2Fill in facility and resident identifying information exactly as it appears in your licensing and resident records.
- 3Complete every section — evaluators read blanks as missing documentation.
- 4Obtain the required signatures and dates before filing.
- 5File the completed form in the resident or facility record. Maintained every month for each resident receiving medication assistance.
Mistakes evaluators flag
- Using an old revision of the form after CDSS published an update.
- Sections left blank with no explanation.
- Signature or date lines missed on the final page.
Questions about LIC 622A
When is LIC 622A used?
Maintained every month for each resident receiving medication assistance.
Is LIC 622A required for an RCFE?
LIC 622A is part of the documentation set an RCFE is expected to keep on file. Confirm the current requirement with the form instructions and your licensing analyst.
Fill this form from data you already have
- Resident, staff, and facility details populate the form fields automatically.
- Track which forms are on file, which are missing, and which are about to expire.
- Incident reports draft the LIC 624 narrative and finalize an immutable PDF.
Related medical forms
RCFE OS is not affiliated with the California Department of Social Services. This guide is operational information for licensees, not legal advice. Always follow the current form instructions and guidance from your licensing analyst.