Corrective Action Plans

Management agrees with this finding. The SSS director and staff will review the key line-item data at the point of entry to ensure the completeness and accuracy of information input into the Blumen system. Training will also be provided for the new administrative assistant. Prior to submitting the APR, a download of all data categories will be reviewed for accuracy and completeness.

Finding No. 2024-003 Department(s): New York City Administration for Children’s Services and Department of Education Program(s): Assistance Listing Number 93.575, Child Care and Development Block Grant Corrective Action(s): ACS: The City is planning to transition to the New York State IT system once it is fully developed and implemented by the New York State Office of Children and Family Services and New York State Information Technology for the Child Care Assistance Program. The State IT system will be programmed to reflect current State policy on authorized hours, mitigating the risk of this error in the future. In the interim, The City will implement a short-term, manual solution that will ensure enrollments match authorized hours with regard to full time or part time enrollment and days of enrollment. The first step of the manual solution requires a feasibility analysis to see if it is possible to add a field for recording authorized hours into The City's IT system of record. DOE: The DOE will continue working with ACS to ensure compliance with internal controls, applicable state and federal statutes, regulations, requirements and guidelines. The internal controls include a quality assurance check process on submitted eligibility applications. Anticipated Completion Date: ACS: August 2025 and ongoing DOE: Ongoing Person(s) Responsible for Implementation: ACS: Shari Gruber, Associate Commissioner, Policy and Compliance, Division of Child & Family Well-Being, shari.gruber@acs.nyc.gov, (212) 393-5109 DOE: Meg Barboza, Senior Director of Program Enrollment, mbarboza@schools.nyc.gov, (212) 287-1996 Jodina Clanton, Eligibility and Senior Director of Policy, jclanton@schools.nyc.gov, (212) 287-1927

Finding No. 2024-004 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Number 14.871, Housing Voucher Cluster: Section 8 Housing Choice Vouchers Corrective Action(s): During the COVID 19 pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of adverse actions. Although HPD continued to request recertification packages during the period the waivers, February 2020 through December 2021, HPD did not penalize families who did not submit complete recertification packages at that time until more recently. HPD continues to make progress in addressing this substantial backlog through the implementation of technological and streamlined program improvements. HPD increased its HUD reporting rate of actions taken on household cases by 34% from FY23. Although there has been significant progress towards on time recertifications, HPD anticipates it will continue to take time until the agency achieves pre-pandemic overall submission levels as HPD ensures that any enforcement action the agency takes is taken as a last resort. HPD’s COVID-era policies involving adverse action have ceased and normal processes are in effect. However, it takes intensive tracking and follow up to ensure participants comply with requirements to submit annual certifications or have due-process before terminating subsidy for failing to respond. As a result, there is a lag between the re-implementation of HPD’s policy to take enforcement actions and ensuring every active participant has a completed certification. 1. Continue to build on existing systems to more closely track recertifications that are mailed and not returned. 2. Build on the more robust digital operations that were started during the pandemic to track the submission of documents improving reporting capabilities that help track overdue recertifications. 3. Create a streamlined process for referring overdue cases for Community Based Organizations that can assist participants complete and return recertification package 4. Continue to provide automated reminders for participants at risk of termination of assistance because of their failure to submit a recertification package. 5. Invest in a training team to meet the training needs of new staff Anticipated Completion Date: Implemented as of March 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

Finding No. 2024-005 Department(s): New York City Housing Preservation & Development Program(s): Assistance Listing Numbers: 14.249, Section 8 Project-Based Cluster: Section 8 Moderate Rehabilitation Single Room Occupancy 14.856, Section 8 Project-Based Cluster: Lower Income Housing Assistance Program – Section 8 Moderate Rehabilitation Corrective Action(s): During the COVID 19 pandemic, HPD adopted HUD CARES Act waivers, intended to minimize health and safety risks to applicants, participants, owners and staff, and which included the temporary suspension of adverse actions. Although HPD continued to request recertification packages during the period the waivers, February 2020 through December 2021, HPD did not penalize families who did not submit complete recertification packages at that time until more recently. HPD continues to make progress in addressing this substantial backlog through the implementation of technological and streamlined program improvements. HPD increased its HUD reporting rate of actions taken on household cases by 34% from FY23. Although there has been significant progress towards on time recertifications, HPD anticipates it will continue to take time until the agency achieves pre-pandemic overall submission levels as HPD ensures that any enforcement action the agency takes is taken as a last resort. HPD’s COVID-era policies involving adverse action have ceased and normal processes are in effect. However, it takes intensive tracking and follow up to ensure participants comply with requirements to submit annual certifications or have due-process before terminating subsidy for failing to respond. As a result, there is a lag between the re-implementation of HPD’s policy to take enforcement actions and ensuring every active participant has a completed certification. 1. Continue to build on existing systems to more closely track recertifications that are mailed and not returned. 2. Build on the more robust digital operations that were started during the pandemic to track the submission of documents improving reporting capabilities that help track overdue recertifications. 3. Create a streamlined process for referring overdue cases for Community Based Organizations that can assist participants complete and return recertification package 4. Continue to provide automated reminders for participants at risk of termination of assistance because of their failure to submit a recertification package. 5. Invest in a training team to meet the training needs of new staff Anticipated Completion Date: Implemented as of March 2025 Person(s) Responsible for Implementation: Dinsiri Fikru, Assistant Commissioner, Division of Program Policy and Innovation, Office of Housing Access and Stability FIKRUD@hpd.nyc.gov

Finding No. 2024-007 Department(s): New York City Human Resources Administration Program(s): Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s): HRA implemented the corrective actions noted in our response to the Fiscal 2023 Single Audit findings. In November of 2023, HRA hired an Executive Director for the Home TBRA program, updated the quality assurance evaluation tool and trained staff on the differences of budgeting the “gross” and “net” income. Note that HRA began closing out the TBRA tenants with renewal lease dates starting on 8/1/2023, as the program fully closed and transitioned to the City Fighting Homelessness and Eviction Prevention Supplement (“CityFHEPS”) by the 6/30/24 HRA- Housing Preservation and Development Memorandum of Understanding expiration date. Although the rental assistance portion of the HOME TBRA program began phasing out, the following corrective actions were implemented as part of the Fiscal 2023 Single Audit recommendation: • Supervisory staff were retrained on case review and instructed to do a thorough and comprehensive review of the budget and documentation received to inform case decisions. There have been on-going team and individual meetings, informational sessions and trainings with staff involved with TBRA to improve performance and outcome. Anticipated Completion Date: Not Applicable. As noted above, the Rental Assistance portion of the program has been taken over by CityFHEPS. Person(s) Responsible for Implementation: Jordan Worrell, HTBRA Executive Director worrellj@hra.nyc.gov (929)-252- 5403

Corrective action: There is a process in Banner that creates a file containing graduates for degree verification submission to the National Student Clearinghouse. There was a systematic error with that process in Spring 2024 rendering the process unable to generate a file. The error was not resolved until May 2024, which is when the submission for these students was completed. This was a one-time specific system failure occurrence which has been resolved and the process has been working correctly since May 2024. The Offices of the Registrar and Student Financial Services are working in conjunction with the University compliance team and Office of Institutional Research to enhance review and checks/balances of reporting deadlines to ensure that files are submitted within the required deadlines. Further, the Office of the Registrar will work with internal IT staff to research and implement backup reporting procedures for creating enrollment and graduation files in the event of another system issue. Proposed Completion Date: May 31, 2024

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Allowable Activities and Allowed Costs Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County has policies and procedures as well as systematic processes and oversight set up to ensure accurate assessments and determinations are made regarding the Federal or Non-Federal Eligibility of youth in the Foster Care system. It is Solano County’s policy to conduct these assessments at the onset of the case and ensure quality documentation. In addition, the Foster Care unit has a Lead worker and Supervisor who conduct periodic reviews of open cases to ensure accuracy of documentation and adherence to timelines are met. The specific corrective actions identified in this audit found errors related to the migration of data to the CalSAWS program in 2023, where an identified payment was incorrectly identified (Non-Federal to Federal) due to errors or information which existed in CalWin and were transferred improperly to CalSAWS. These conversion errors occurred automatically. As a result, the Foster Care Eligibility Unit has implemented the following changes. • Correction to identified payment: o The identified case was corrected immediately, and all payments adjusted as appropriate. • Changes to workflow to ensure accuracy: o The entire caseload of open Foster Care Eligibility cases will be reviewed to ensure that the original determination or as found in the FC3 or FC3A and granting comments, is correctly input in CalSAWS, and any payment errors corrected as needed. o The case aid code (noting eligibility type) will be included next to the youth’s name to ensure that it shows in the workload report in CalSAWS to ensure the information is easily accessible and any future errors can be identified. o Cases will be reviewed to ensure the above changes are completed through the unit supervisor’s ongoing qualitative review of cases. • The Foster Care Eligibility Supervisor will discuss the findings and requirement with subordinate staff in the following ways: o Unit meeting communication regarding Corrective Action findings and Agency steps to remediate. o Issue a reminder to all staff regarding the above remediation plan. Responsible Individual(s): Kim McDowell, Social Services Manager Neely McElroy, Deputy Director, Child Welfare Services Anticipated Completion Date: May 31, 2025

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Foster Care Federal Assistance Listing Number: 93.658 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/24 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County has policies and procedures as well as systematic processes and oversight set up to ensure accurate assessments and determinations are made regarding the Federal or Non-Federal Eligibility of youth in the Foster Care system. It is Solano County’s policy to conduct these assessments at the onset of the case and ensure quality documentation. In addition, the Foster Care unit has a Lead worker and Supervisor who conduct periodic reviews of open cases to ensure accuracy of documentation and adherence to timelines are met. The specific corrective actions identified in this audit found errors related to the migration of data to the CalSAWS program in 2023, where two cases were inadvertently converted from Non-Federal to Federal cases due to errors or information which existed in CalWin and were transferred improperly to CalSAWS. These conversion errors occurred automatically. As a result, the Foster Care Eligibility Unit has implemented the following changes. • Corrections to identified cases: o The two identified cases were corrected immediately, and all payments adjusted as appropriate. • Changes to workflow to ensure accuracy: o The entire caseload of open Foster Care Eligibility cases will be reviewed to ensure that the original determination or as found in the FC3 or FC3A and granting comments, is correctly input in CalSAWS, and any payment errors corrected as needed. o The case aid code (noting eligibility type) will be included next to the youth’s name to ensure that it shows in the workload report in CalSAWS to ensure the information is easily accessible and any future errors can be identified. o Cases will be reviewed to ensure the above changes are completed through the unit supervisor’s ongoing qualitative review of cases. • The Foster Care Eligibility Supervisor will discuss the findings and requirement with subordinate staff in the following ways: o Unit meeting communication regarding Corrective Action findings and Agency steps to remediate. o Issue a reminder to all staff regarding the above remediation plan. Responsible Individual(s): Kim McDowell, Social Services Manager Neely McElroy, Deputy Director, Child Welfare Services Anticipated Completion Date: May 31, 2025

Federal Agency: U.S. Department of Agriculture Program/Cluster: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number: 10.557 Pass‐through: California Department of Public Health Award No. and Year: 22-10294 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Condition #1. Five (5) instances out of 60 cases were missing all eligibility documentation. This included the documentation of the determination of eligibility and redetermination in the period under audit. The missing documentation included the records to evidence compliance with the eligibility criteria. Condition #2. Two (2) instances out of 60 cases were missing the Self Declaration Statement form when the applicant was unable to provide acceptable documentation for proof of income, proof of address, or proof of identification. Response to Condition #1 Per California Department of Public Health, Women, Infant, Children division (CDPH/WIC), the categories of non-breastfeeding, breastfeeding, and partially breastfeeding women files remain accessible to the local agency. For children five years of age, the files are purged six months after the fifth birthday. The WIC WISE records for the 5 files were not available due to the file purge by CDPH/WIC, therefore the auditor was unable to determine compliance to eligibility requirements for each of the five files. The auditor suggests the local agency retain eligibility documents. According to the California WIC Policy and Procedure Manual, WIC WISE Forms JOB AID section, eligibility documents provided by an applicant or a re-certifying client are not required to be retained by the local agency. The County has communicated this finding to CDPH/WIC and the risk it presents. At this time, the County is working with CDPH/WIC to address this finding. Specific Corrective Plan Procedures addressing Condition #1 Staff participate in a robust Quality Assurance (QA) plan which involves periodic file reviews and observations as documented in Solano County’s Continuous Quality Improvement (CQI) Monitoring Plan. Additionally, CDPH/WIC conducts a Program Monitoring Visit (PMV) every two years which includes a random record review of the agency’s compliance to eligibility policies. Solano County WIC program will continue to conduct the QA plan, and participate with the CDPH/WIC PMVs. Response to Condition #2 Solano County agrees with the finding. This use of the Self Declaration Statement (SDS) is a specific consideration in the QA plan. The WIC Supervisor was aware of the matter as it was discovered that both SDSs were missing from the family file as part of a regular QA review. The error was addressed with the employee shortly after the mistake occurred. Specific Corrective Plan Procedures addressing Condition #2 Staff participate in a Quality Assurance (QA) plan which involves periodic file reviews and observations as documented in Solano County’s Continuous Quality Improvement (CQI) Monitoring Plan. Additionally, CDPH/WIC conducts a Program Monitoring Visit (PMV) every two years which includes a random record review of the agency’s compliance to eligibility policies. Solano County WIC program will continue to conduct the QA plan, and participate with the CDPH/WIC PMVs. Responsible Individual(s): Christopher Husing, Senior Health Services Manager, Solano Public Health Anticipated Completion Date: April 1, 2025

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Health Care Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County agrees that eligibility determinations and redeterminations including obtaining documentation and verifications should be performed annually to determine if individuals are eligible in accordance with the compliance requirements of the program. There are overdue redeterminations in our system due to the Medi-Cal expansion and increasing need for IHSS services in our communities without a substantial increase in staffing to support this service need. This year, we continue to have uncovered caseloads related to Social Worker job transition or leave, fair hearing and the growing complexity of our client population requiring more case management throughout the year. In FY 2024-25, we were granted seven additional social workers. We are anticipating these additional social workers will reduce the number of overdue redeterminations. We also have hired two Extra Help Social Workers who will focus on overdue redeterminations. We participate in State level discussions related to advocacy and increased IHSS administrative funding to support the growing number of IHSS clients. Responsible Individual(s): Gwendolyn Gill, Health Services Administrator Bela Matyas, Chief Deputy Director Anticipated Completion Date: July 1, 2025

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Eligibility and Special Tests and Provisions Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: CW 2.1: Solano County has policies and procedures as well as systematic processes set up to ensure the required collection and documentation of the applicant’s intent to cooperate with child support. It is Solano County’s policy that the Child Support Questionnaire (CW 2.1Q) and Notice and Agreement (CW2.1NA) be processed in accordance with regulations, which require workers to: • Conduct an interview either via telephone, or in-person with the applicant, print the forms, and document the County Use Section which requires worker’s signature and date. • Mail the forms to the applicant for a wet signature or collect the signature via electronic means. • Ensure the CW2.1 forms are received and complete. • Initiate the required case action(s) based upon information provided on the forms. Solano County has a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent this error in the future: • A post-Audit meeting will be held with all stakeholders to discuss the specific audit findings and action steps needed. • The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the applicable eligibility handbook with verbiage to emphasize the following: o The requirement to review and collect the information needed to complete the notice and agreement (form CW2.1) for child, spousal, and medical support from the applicant. o That the case be authorized according to program rules only after required forms are received by the county, reviewed to ensure that the case is updated with the correct information, documented in the case journal, and the form(s) scanned into the document imaging system. o Highlight these requirements when training this topic. • The CalWORKs Program Specialist will address the findings and requirements as follows: o Present at the Monthly Program Support Forum conducted with managers, supervisors, and lead workers. o Written guidance and reminder will be published in the Monthly Program Support Newsletter to all staff. o Present and discuss this requirement with lead workers at the Lead Worker Coordination Meeting, and with supervisors at the Division Coordination Meeting. • In addition to regular case reviews, focused case reviews will be added to review for completion of the Notice and Agreement for Child, Spousal, and Medical Support (form CW 2.1). SAWS 2A SAR: Solano County has policies and procedures as well as systematic processes set up to ensure the worker has reviewed the Rights and Responsibilities (SAWS 2A SAR) with the applicant/recipient and obtain their signature. It is Solano County’s policy that the SAWS 2A SAR be processed at application and redetermination which require workers to: • Conduct an interview either via telephone, or in-person with the applicant, print the form, and document the worker’s signature and date. • Mail the form to the applicant for a wet signature or collect the signature via electronic means. • Ensure the completed form is on file prior to authorizing benefits. Solano County has a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent this error in the future: • A post-Audit meeting will be held with all stakeholders to discuss the specific audit findings and action steps needed. • The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the applicable eligibility handbook with verbiage to emphasize the following: o That the case be authorized according to program rules only after the signed SAWS 2A SAR form is received by the county, documented in the case journal, and the form(s) scanned into the document imaging system. o Highlight these requirements when training this topic. • The CalWORKs Program Specialist will address the finding and requirement in the following ways: o Present at the Monthly Program Support Forum conducted with managers, supervisors, and lead workers. o Written guidance and reminder will be published in the Monthly Program Support Newsletter to all staff. o Present and discuss this requirement with lead workers at the Lead Worker Coordination Meeting, and with supervisors at the Division Coordination Meeting. • In addition to regular case reviews, focused case reviews will be added to review for completion of the Rights and Responsibilities (SAWS 2A SAR). Responsible Individual(s): Daniel Horel, Employment and Eligibility Services Administrator Thomas West, Employment and Eligibility Services Manager Diana Hernandez, Employment and Eligibility Services Manager Jennifer Stephenson, Employment and Eligibility Services Manager Anticipated Completion Date: May 31, 2025

Student Financial Assistance Cluster - Assistance Listing No. No. 84.268 Recommendation: We recommend the University review its process around sending exit counseling information to students to ensure this information is received and the University is performing required procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has hired additional staff, enhanced training efforts, and established a standard procedure to send loan exit counseling notifications to students at the end of each term, ensuring regulatory compliance. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: June 2025

Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public and Indian Housing and Section 8 Housing Choice Vouchers Programs to ensure that established internal control policies are being followed on a timely basis. Julio Marenco, Interim Executive Director, will be responsible to implement this corrective action by June 30, 2025.

2024-004. Inadequate Procedures to Identify Healthcare Providers with Expired Licenses State Agency: Department of Health and Human Services Federal Agency: Department of Health and Human Services Out-of-state providers and the provider whose license expired during the PHE. During the PHE an expired license report was not properly monitored. Prospectively, DHHS will ensure license expiration notifications are reviewed on a monthly basis. Additionally, DHHS will work with the PRISM contractor to explore pathways to identify all providers (out-of-state and in-state) whose licenses may have already expired. DHHS will follow the current license expiration process and close those providers as appropriate. Provider initially granted eligibility in the legacy system. In any future event involving data conversion, DHHS will ensure that all relevant data from the existing system is thoroughly collected and reviewed prior to the conversion process. This will help guarantee data integrity and minimize the risk of issues arising during the transition. Implementation Date: July 31, 2025 Contact: Shandi Adamson, Director, Office of Medicaid Operations, shandiadamson@utah.gov

2024-010. HTF Project Does Not Meet Eligible Income Requirements State Agency: Department of Workforce Services Federal Agency: Department of Housing and Urban Development The Housing and Community Development Division is in the process of completing a full HTF policy and procedures rewrite with a robust internal controls process. This will include an updated HTF monitoring checklist and a quality control check of said monitoring checklist by the Program Manager. Anticipated correction date: March 31, 2025 Responsible person: Daniel Murphy, HCD Program Manager, 385-630-8368

2024-009. Unallowable Cash Medical Assistance Benefit Issuances State Agency: Department of Workforce Services Federal Agency: Department of the Treasury All cases cited in error have been reviewed, and all corrective actions have been completed. One-on-one meetings with individual staff who took approval actions on these cases will be scheduled to discuss what led to the incorrect decision and review the policy and procedure for learning. In addition, all eligibility workers who manage refugee programs will receive training on common error elements. All one-on-one meetings and team training will be completed by April 30, 2025. Anticipated correction date: April 30, 2025 Responsible person: Muris Prses, Division Director, Eligibility Services Division, 801-889-9712

Management agrees with the auditors and has initiated the necessary corrective action plan to mitigate the deficiency from occuring again. The plan is to implement new procedures to ensure the reporting to the NSLDS is done on a timely basis.

Name of Responsible Individual: Brandon Rhone, Analyst, Financial Aid Systems, and Chad Wick, Director Financial Aid Corrective Action: During the 2024 fiscal year, the Financial Aid office experienced several staffing changes, including hiring of a new Director of Financial Aid. The University transitioned from a manual awarding process to an automated process after last year’s audit but not in time to change some of the 23-24 awards. In the past FSEOG funds were used to assist students to pay off balances allowing them to register for the next semester. This practice in no longer being followed beginning with the 24-25 academic year. In addition, the Financial Aid office will review all 2024-2025 FSEOG awards to ensure that FSEOG is only awarded to Pell recipients. Anticipated Completion Date: March 31, 2025

Name of Responsible Individual: Vice President of Enrollment Management (Dr. Stacey Sowell), Director of Financial Aid (Dr. Ojebe Ifegwu) Corrective Action: The University concurs with the finding. In selecting among eligible students for FSEOG in each award year, the office of Financial Aid will select first those students with the lowest expected family contribution and the highest need who also received Federal Pell Grants in that year. Management will implement and document an internal audit review. A monthly reconciliation will be completed to ensure Pell recipients are awarded FSEOG, based on the guidance provided by the Federal handbook. Anticipated Completion Date: June 30, 2025

Management agrees with the finding regarding Cheshire Medical Center’s eligibility and allowable costs. Management will implement a control starting with the month ending April 30, 2025, to conduct a retrospective review of patient service revenue charges incurred during that month and allocate costs in a manner that aligns with the eligibility and income requirements of the award. Using this methodology, management will identify the eligible population and appropriately incur allowable expenses associated with the award. Management will initiate a bi-weekly process to review upcoming appointments and the most recent eligibility check on recurring patients. If, during this process, a patient is identified who requires an eligibility check based on award criteria (i.e., whichever is later: four weeks or the individual's next appointment), Management team will perform re-enrollment procedures to validate that the individual is still eligible. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

Views of Responsible Officials and Planned Corrective Action: Quincy Asian Resources, Inc. agrees with the finding and will develop and implement policies and procedures to ensure that all participant information is retained and for management to perform and document periodic reviews of eligibility determinations. As required to maintain the Organization’s Pending Recognition status with the Diabetes Prevention Recognition Program (DPRP), Quincy Asian Resources, Inc. has complied with all data collection and reporting requirements.

Reference Number: 2024-001 Name of Contact Person: Kelly Nakamura Phone: 530-642-7167 Email: Kelly.nakamura@edcgov.us Corrective Action: • Increasing Staffing Levels: o By April 1, 2025, the County will have 11 newly trained Eligibility Specialists who are fully trained to process Medi-Cal applications. o Ongoing recruitment efforts will continue to fill vacant positions, including the hiring additional trainees to build capacity for timely eligibility determinations. • Improving Internal Processes: o The County is conducting a review of workflows to identify inefficiencies and implement streamlined processes that eliminate bottlenecks. o Digital tools and automation are being introduced to enhance efficiency and accuracy case processing. • Providing Additional Support: o Overtime opportunities are being offered to eligibility specialists to expedite the processing of pending cases. o Applications are being assigned to Eligibility Specialists on a weekly basis to ensure consistent progress in reducing the backlog. • Enhancing Monitoring and Reporting: o Administrative staff are generating weekly reports from CalSAWS to track the status Medi-Cal pending applications and monitor progress. o Weekly meetings are being held with supervisors to review performance, discuss challenges, and adjust strategies as needed. • Strengthening Internal Controls: o The County is improving its internal controls to prevent future delays, including increased use of system reports to identify applications nearing the 45-day processing requirement, regular audits of the eligibility determination process and enhanced compliance training for staff. • Ongoing Evaluation and Adaptation: o Progress will be assessed weekly to ensure the implemented measures are effective. Adjustments will be made as needed to maintain compliance with the 45-day requirement. Proposed Completion Date: The county has already implemented this process and expects it to be completed by July 31, 2026.

Identification and Review • Conduct an internal audit of all financial aid awards for the affected students to determine the extent of the overaward • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year. • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies. • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed. Process and Policy Improvements • Implement a cross-check system for all financial aid components and strengthen internal controls to ensure total aid does not exceed COA before disbursement • Implement additional system checks and alerts in the financial aid management system to flag overawards automatically. • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent overawards • Train financial aid staff on COA regulations and best practices for awarding aid Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 2/25/25

Identification and Review • Identify all students who received incorrect loan amounts (Completed) • Make appropriate adjustments to loan disbursements (Completed) • Notify affected students and provide guidance on next steps (Completed) Policy and Procedure Enhancements • Develop clear, written procedures for verifying loan amounts prior to disbursement • Implement a two-step verification process for loan packaging System Controls • Collaborate with IT to implement automated system checks to flag discrepancies • Enhance reporting tools for regular audits and monitoring Staff Training • Conduct comprehensive training sessions for financial aid staff on federal regulations regarding Direct Loans • Provide ongoing refresher courses and updates as federal policies change Monitoring Continuous Improvement • Establish a quarterly audit process to ensure compliance • Monitor loan discrepancies detected and correct as needed • Conduct regular audits to confirm compliance with federal loan regulations. • Collect feedback from staff on the effectiveness of training Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 03/03/25

Identification and Review • Immediately review and recalculate the subsidized need for the affected students. (Completed) • Identify the sources of aid contributing to the excess amount and whether any adjustments can be made within the same academic year • Adjust the loan amounts as necessary and return any excess funds to the Department of Education. (Completed) • Review packaging procedures to pinpoint the cause of the discrepancy (e.g., late outside scholarships, system errors, or manual adjustments Student Award Adjustments • Reduce or cancel institutional or federal aid (such as loans, Federal Work-Study, or certain grants) in accordance with federal regulations and institutional policies • If the excess aid cannot be adjusted within the same academic year, follow federal guidelines to return any over awarded federal funds through the Common Origination and Disbursement (COD) system • Notify students of any changes to their financial aid package and provide guidance on alternative funding options if needed System Enhancements • Implement system-level edits and warnings in the financial aid software to flag over-awards before disbursement. • Schedule regular audits of loan disbursements to ensure ongoing compliance Policy and Procedure Update • Update the financial aid packaging policy to include stricter controls for verifying subsidized need calculations. • Implement a cross-check system for all financial aid components before loan disbursement • Require timely reporting of external scholarships and third-party payments to prevent adjustments after disbursement Monitoring and Compliance • Conduct training sessions for financial aid staff on loan eligibility calculations. • Conduct periodic reconciliation of student aid packages throughout the academic year to prevent over awards • Provide guidance on using the financial aid management system's tools to avoid over-awards Responsible Person for Correction Action Plan: Alexis Brown, Director of Financial Aid Implementation Date for Corrective Action Plan: 02/25/25