Corrective Action Plans

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Finding 555735 (2024-001)
Significant Deficiency 2024
a. Comments on the Finding and Each Recommendation Management agrees that when the PRAC renewal for 2024 was submitted, they failed to include a return to HUD the balance of the residual receipts above $250 per unit. This is accounted to the recent Management Agent transition on 7/1/2024 and transit...
a. Comments on the Finding and Each Recommendation Management agrees that when the PRAC renewal for 2024 was submitted, they failed to include a return to HUD the balance of the residual receipts above $250 per unit. This is accounted to the recent Management Agent transition on 7/1/2024 and transition of software and accounts. b. Action(s) Taken or Planned on the Finding Current management has submitted a 9250 to HUD for approval of release of Residual Receipt funds above $250 per unit to be returned to HUD. As part of the PRAC renewal process, current management will follow HUD guidelines that require a submission of a 9250 residual receipt request with the renewal submission.
a. Comments on the Finding and Each Recommendation Management agrees that when prior Management agent submitted the PRAC renewal for 2024, they failed to include a return to HUD the balance of the residual receipts above $250 per unit. ...
a. Comments on the Finding and Each Recommendation Management agrees that when prior Management agent submitted the PRAC renewal for 2024, they failed to include a return to HUD the balance of the residual receipts above $250 per unit. b. Action(s) Taken or Planned on the Finding Current management has submitted a 9250 to HUD for approval of release of Residual Receipt funds above $250 per unit to be returned to HUD. As part of the PRAC renewal process, current management will follow HUD guidelines that require a submission of a 9250 residual receipt request with the renewal submission.
a. Comments on the Finding and Each Recommendation Management agrees that when prior Management agent submitted the PRAC renewal for 2024, they failed to include a return to HUD the balance of the residual receipts above $250 per unit. b. Action(s) Taken or Planned on the Finding Current management ...
a. Comments on the Finding and Each Recommendation Management agrees that when prior Management agent submitted the PRAC renewal for 2024, they failed to include a return to HUD the balance of the residual receipts above $250 per unit. b. Action(s) Taken or Planned on the Finding Current management has submitted a 9250 to HUD for approval of release of Residual Receipt funds above $250 per unit to be returned to HUD. As part of the PRAC renewal process, current management will follow HUD guidelines that require a submission of a 9250 residual receipt request with the renewal submission.
Condition: The District’s quarterly report was not submitted within 40 days of quarter-end. Plan: The District acknowledges the timelines in the quarterly reports and will continue to review its procedures to ensure the quarterly report to be submitted within 40 days of quarter-end. Anticipated Date...
Condition: The District’s quarterly report was not submitted within 40 days of quarter-end. Plan: The District acknowledges the timelines in the quarterly reports and will continue to review its procedures to ensure the quarterly report to be submitted within 40 days of quarter-end. Anticipated Date of Completion: The District anticipates completion during the 2024-2025 fiscal year.
Condition: The District’s supporting documentation for the expenses incurred for staff and contractors that provide direct medical services did not get reported appropriately in the quarterly submissions. Plan: The District acknowledges the discrepancies in the quarterly reports and will continue to...
Condition: The District’s supporting documentation for the expenses incurred for staff and contractors that provide direct medical services did not get reported appropriately in the quarterly submissions. Plan: The District acknowledges the discrepancies in the quarterly reports and will continue to review its procedures for compiling and submitting the quarterly financial submissions to ensure that all salaries, benefits, and contracted costs are properly reported in the SBS Medicaid system. Anticipated Date of Completion: The District anticipates completion during the 2024-2025 fiscal year.
1. Implement pre-approval controls; require date validation for all expenses against the award' s period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitatio...
1. Implement pre-approval controls; require date validation for all expenses against the award' s period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitations. 3. Perform periodic reviews; monitor compliance quarterly to detect outliers.
1. Implement pre-submission controls; require Date validation for all expenses against the award's period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitati...
1. Implement pre-submission controls; require Date validation for all expenses against the award's period of performance. Program Director or Executive Director or Accounting Director to review and approve. 2. Conduct training; educating staff on 2 CFR requirements and period-of-performance limitations. 3. Perform periodic reviews; monitor compliance quarterly to detect outliers.
1. Implement pre-submission controls; require all draw requests to have written review and approval. Program Director or Executive Director or Accounting Director to review and approve. 2. Documentation Requirements: require written confirmation when payments are received from both the program and t...
1. Implement pre-submission controls; require all draw requests to have written review and approval. Program Director or Executive Director or Accounting Director to review and approve. 2. Documentation Requirements: require written confirmation when payments are received from both the program and the bank. 3. Perform periodic reviews; monitor compliance quarterly to detect outliers.
Finding 2024-001: The Property paid expenses totaling $6,702 on behalf of another property without HUD approval. Comments on the Finding and Each Recommendation: Management should seek reimbursement for these transactions from the other property. Action(s) taken or planned on the finding: Manageme...
Finding 2024-001: The Property paid expenses totaling $6,702 on behalf of another property without HUD approval. Comments on the Finding and Each Recommendation: Management should seek reimbursement for these transactions from the other property. Action(s) taken or planned on the finding: Management concurs with the finding and agrees with the auditor's recommendation. On February 11, 2025, a reimbursement from the other property totaling $6,702 was deposited into the Property's operating account.
View Audit 354222 Questioned Costs: $1
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current ...
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and RecommendationsFinding 2024-002: The Corporation made a payment to LAHD in the amount of $15,483 and did not obtain the required HUD approval. Comments on the Finding and Each Recommendation: The Corporation should request retroactive HUD approval to make the payment or request reimbursement from the lender. Action(s) taken or planned on the finding: Management has requested approval from HUD. As of the report date, no response has been received.
View Audit 354160 Questioned Costs: $1
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current ...
Name of auditee: Lime House Senior Housing, Inc. HUD auditee identification number: 122-EE136-WAH-NP Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended December 31, 2024 CAP prepared by Name: Ana Ponce Position: President Telephone number: 323-231-1104 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2024-001: The Corporation's required deposit of $30,965 to the residual receipts account per the December 31, 2023 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Comments on the Finding and Each Recommendation: Management should make all required residual receipt deposits per the annual Computation of Surplus Cash, Distributions and Residual Receipts within 90 days after fiscal year end. Action(s) taken or planned on the finding: Management deposited $30,965 into the residual receipts fund on December 20, 2024. No further action is required.
View Audit 354160 Questioned Costs: $1
Finding 555439 (2024-005)
Significant Deficiency 2024
Views of Responsible Officials and Planned Corrective Action The County has a written policy regarding Federal Grants that was passed by the Grant County Commissioners in January 2025. Finding resolution timeline: Resolved. Designation of employee position responsible for meeting this deadline: ...
Views of Responsible Officials and Planned Corrective Action The County has a written policy regarding Federal Grants that was passed by the Grant County Commissioners in January 2025. Finding resolution timeline: Resolved. Designation of employee position responsible for meeting this deadline: Andrea Montoya, Deputy County Manager
The Town agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
The Town agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
View Audit 353928 Questioned Costs: $1
The Town agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
The Town agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
View Audit 353928 Questioned Costs: $1
The Town agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
The Town agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
View Audit 353928 Questioned Costs: $1
The Town agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
The Town agrees with the finding and has established policies and procedures to ensure that expenditures are only charged to one federal program.
View Audit 353928 Questioned Costs: $1
The District recognizes the importance of supervisory review in ensuring the accuracy of meal count documentation and reimbursement claims. To address this, the District will implement a standardized review process across all schools requiring supervisory personnel to sign or initial daily meal cou...
The District recognizes the importance of supervisory review in ensuring the accuracy of meal count documentation and reimbursement claims. To address this, the District will implement a standardized review process across all schools requiring supervisory personnel to sign or initial daily meal count sheets. In addition, we will institute a reconciliation step to verify that reported counts align with reimbursement claims. Training will be provided to ensure compliance with these procedures. Anticipated Date of Completion: A review and determination will be completed in fiscal year 2025. Contact Person: Joe Barker, CSBO.
Finding 555196 (2024-002)
Significant Deficiency 2024
Finding 2024-002 Corrective Action Plan The College reassigned the duties within its business office to ensure remittances to students or parent borrowers of credit balances are executed in accordance with the timeline mandated by the U.S. Department of Education. Gratz College notes that this was ...
Finding 2024-002 Corrective Action Plan The College reassigned the duties within its business office to ensure remittances to students or parent borrowers of credit balances are executed in accordance with the timeline mandated by the U.S. Department of Education. Gratz College notes that this was the only instance of noncompliance and resulted from turnover in Gratz College’s business office staff. Anticipated Completion Date The corrective action plan was completed June 1, 2024 Names of Contact People Responsible for Corrective Action Thomas R. Cipriano, Jr. – Manager of Business Operations and Facilities Ross Holgado – Manager of Financial Reporting Karen West – Senior Accounting Associate and Coordinator of Student Billing
Identifying Number: 2024-005 Finding: Material Weakness: Cash Management Context: Drawdown on reimbursement requests were submitted to the grantor prior to the System incurring qualifying expenditures. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Mana...
Identifying Number: 2024-005 Finding: Material Weakness: Cash Management Context: Drawdown on reimbursement requests were submitted to the grantor prior to the System incurring qualifying expenditures. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdwn requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.
View Audit 353775 Questioned Costs: $1
Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director ...
Identifying Number: 2024-004 Finding: Material Weakness: Period of Performance Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were incurred prior to the budget period start date. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Implementing organizational changes such as updated policies and/or procedures b. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices during the Grant management process c. Oversight of drawdown requests by the Director of Sponsored Programs to ensure accuracy of request Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. - Oversight of all drawdown requests, ensuring complete and accurate supporting documentation. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limted to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.
View Audit 353775 Questioned Costs: $1
Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office...
Identifying Number: 2024-002 Finding: Material Weakness: Allowable Costs/Cost Principles Context: Expenditures were included on the 2024 Schedule of Expenditures of Federal Awards, however, the expenditures were not incurred until 2025. Corrective Actions Taken or Planned: The Director of the Office of Sponsored Programs and the Manager of Sponsored Programs will develop a standardized document checklist for all high-value expenditures. This checklist will require all Sponsored Programs analysts to submit complete documentation with expense reports and proof of payment and have their respective immediate supervisor/manager review for compliance before final approval by the Director. a. Correcting the gaps between invoicing processes and collecting the Departments/AP proof of payment b. Returning overpayments, if applicable c. Implementing organizational changes such as updated policies and/or procedures d. Educating the team(s) and/or Department(s) on internal controls, processes and accuracy best practices duing the Grant management processes. Planning Process: Compliance with Regulations: The Director and Manager from Sponsored Programs will ensure the corrective actions align with applicable federal grant regulations and guidelines. We will create: - Create processes in which we will adopt verification procedures for invoices and collections. - Create/update Standard Operating Procedures (SOPs) - Provide our team with updated training material (working practice guidelines - WPGs), so they have clear expectations and understand our compliance mechanism. - Implement internal controls, with the Director and Manager from Sponsored Programs developing checks and balances at the end of each month to ensure compliance in all the grant's portfolio. Communication: The Director and Manager from Sponsored Programs will communicate the corrective action plan to all relevant staff and stakeholders. Follow-up: The Director and Manager from Sponsored Programs will regularly monitor progress and adjust to resolve any inefficiencies. Training: The Director and Manager from Sponsored Programs will work on the development and delivery of mandatory training sessions for all Sponsored Programs relevant staff. This will include (not limited to): - Retrain on updated policies and procedures (OSP team, Departments and stakeholders, if applicable) - Retrain on workflows and system (OSP team, Departments and stakeholders, if applicable) - Retrain on process improvement (OSP team, Departments and stakeholders, if applicable) Policy Updates: Revision of existing policies or creation of new ones to clarify procedures. System Enhacements: Implementing new software/program that improves data accuracy and compliance in all Federal/State and Local Grants throughout Nicklaus Children's Hospital. Monitoring and Oversight: The Director and Manager from the Sponsored Programs will monitor transactions and reporting processed more frequently. Deadline for Implementation: Immediate Action: The Director of Sponsored Programs transitioned the staff member responsible for the findings to an area where their expertise is most valuable. This CAPA will take effect immediately and be fully implemented within six weeks by April 07, 2025, allowing time to create/revise SOPs, Working Practice Guidelines (WPGs), Checklists and training/retraining sessions for stakeholders and OSP team members.
View Audit 353775 Questioned Costs: $1
The Organization will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hir...
The Organization will implement the following corrective actions for the fiscal year ending June 30, 2024 to remediate the finding and address the cause of the finding. The Organization has hired staff with higher technical accounting skills than the previous staff. The following staff have been hired full-time or will be hired soon: Payroll and Benefits Specialist, Grant Accountant, Senior Staff Accountant, Accounts Payables and Receivables Specialist, and a Purchasing Specialist. • The Organization’s Human Resources has implemented quarterly audits on all new staff to verify each new staff member hired within the last year has a signed employee offer and appropriate backup support to support each employee’s annual salary. • The Organization has implemented a new accounting system – Sage Intacct. Additionally, we have implemented a grants project tracking module to better help with grants and contracts reporting and compliance. • The Organization has implemented a new payroll and human resources IT solution – UKG. All manual and onboarding processes have been implemented within the system for tracking and auditing purposes. • The Organization will implement an established month-end checklist for all monthly entries to be completed by assigned finance staff. We will ensure that all staff are trained adequately to handle any assigned task. All monthly entries are required to be reviewed and approved by the Chief Financial Officer prior to posting to the general ledger within our new Accounting Software. All appropriate backup documentation will be saved and stored within the accounting software. • All grant related year-end audit procedures has been transitioned to the Grant Accountant who has experience with audits, compliance, and reporting for City, State, and Federal grants. • The Organization has documented accounting policies and procedures to reflect the new month-end processes and provide training to staff on current and future policies. • The Organization will ensure that Finance personnel receive a minimum of twenty-five (25) hours of training annually of relevant accounting topics including updates to generally accepted accounting principles, generally accepted government accounting principles, nonprofit and governmental financial reporting, and other related accounting trainings. • The Organization will ensure that any personnel involved in financial reporting have the technical expertise to help with the preparation, review, and analysis of the financial statements and supplementary information. The target date for implementation is April 2025. The responsible party for the planned resources will be Raheel Shahzad, Chief Financial Officer (708) 288-7897. Our address is 340 E. 51st St., Chicago, IL 60615.
Audit Finding 2024-001: Condition: The tenant security deposit cash account was insufficient to cover the tenant security deposit liability. - Response: The reserve for replacement has ample funds to request reimbursements of qualified expenditures for the last two years to catch up on outstanding...
Audit Finding 2024-001: Condition: The tenant security deposit cash account was insufficient to cover the tenant security deposit liability. - Response: The reserve for replacement has ample funds to request reimbursements of qualified expenditures for the last two years to catch up on outstanding payables and fund the deficiency in the security deposit account. Management is going to request a Budget Based Rent increase for the property since the OCAF increases for the last few years to not keep up with the extraordinary escalation of operating costs of the last three years. Management believes that with these steps it will be able to return to its previous cash flow position. - Name and Title of contact person responsible for corrective action: - Linda Holder, Executive Director – Houston Housing Management Corporation - PO Box 1819 - Houston, TX 77002 - 713-526-9470
Finding 2024-003 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities All...
Finding 2024-003 Federal Agency Name: Department of the Health and Human Services Program Name: Rural Health Care Services Outreach, Rural Health Network Development and Small Health Care Provider Quality Improvement Federal Financial Assistance Listing #93.912 Compliance Requirement: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Finding Summary: BHD, LLC calculated their indirect cost rate based on the total grant budget and claimed an equal amount of indirect costs per month instead of calculating the indirect cost rate per direct expenditures for each month. Responsible Individuals: Valarie Howard, Chief Financial Officer Corrective Action Plan: Historically, the indirect cost received by this grant has not been dependent of the direct expenditures. Based on verbal conversations with the HRSA grant project manager, requesting reimbursement for the indirect costs evenly over the year based on the budget submitted was acceptable. Therefore, the accounting treatment has been reflective of that. However, management agrees that recording the indirect cost based on the direct cost expenditures monthly is reasonable and appropriate and will make the change accordingly. Anticipated Completion Date: March 31, 2025.
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Reimbursement requests should be reviewed by the CFO for all grants before submission to the grantor ...
Health Center Program Cluster (Community Health Centers, Migrant Health Centers, Health Care for the Homeless, and Public Housing Primary Care) -Assistance Listing No. 93.224 /93.527 Recommendation: Reimbursement requests should be reviewed by the CFO for all grants before submission to the grantor to ensure that employees charged to the grants are different, in addition, timesheets should be reviewed during the grant reimbursement process to ensure time supports the specific grant and allowable costs. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The CFO will review all grant submissions based on personnel costs each month and ensure that there are no duplicate billings and that timesheets appropriately reflect staff involvement. Name(s) of the contact person(s) responsible for corrective action: Jeff Forman, CFO. Planned completion date for corrective action plan: March 21, 2025
View Audit 353547 Questioned Costs: $1
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