Corrective Action Plans

2025-001 - Missing Information from Tenant Files Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing

2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing

2025-001 - Missing Information from Tenant Files Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing

2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing

2025-001 - Missing Information from Tenant Files Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing

2025-002 - Missing Evidence Tenant Files Reviewed by Supervisor Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing

2025-001 - Missing Information from Tenant Files Corrective Action: Findings were related to required information missing from the tenant files. Corrective action has been implemented in ensuring the check list was revised to ensure all documentation is kept for each item of documentation needed to be included in the tenant files and additional corrective action has been implemented in ensuring checklist form will be reviewed and initialed by another staff member so there will be a cross check. Controls continue and remain in place to assure compliance, including, but not limited to, centralization of files, improved orientation procedures and periodic internal reviews conducted by Finance staff. Assigned to: Kenneth P. Parent, Director of Residential Leasing

a. Finding 2025-001; Supportive Housing for the Elderly, Federal Assistance Listing Number 14.157 i. Comments on the Finding a. Management concurs with the finding that the Corporation should ensure annual tenant recertification Form 50059’s are completed timely and EIVs are run timely. ii. Planned Corrective Action a. Management has communicated with the staff the importance of timely annual tenant recertifications and EIV reporting. On a going forward basis, management will enhance its monitoring of compliance with these requirements to ensure that annual tenant recertifications are completed and EIVs are run within an appropriate time frame. iii. Anticipated Completion Date a. Corrective actions have been completed.

a. Finding 2025-001; Supportive Housing for the Elderly, Federal Assistance Listing Number 14.157 i. Comments on the Finding a. Management concurs with the finding that the Corporation should ensure annual tenant recertification Form 50059’s are completed timely and EIVs are run timely. ii. Planned Corrective Action a. Management has communicated with the staff the importance of timely annual tenant recertifications and EIV reporting. On a going forward basis, management will enhance its monitoring of compliance with these requirements to ensure that annual tenant recertifications are completed and EIVs are run within an appropriate time frame. iii. Anticipated Completion Date a. Corrective actions have been completed.

The District will review its procedures related to application approvals.

Management’s View: During the recent audit, a finding was identified within the Sliding Fee Discount Program (SFDP) related primarily to data entry errors, incomplete documentation, and lack of proper review. Errors included incorrect or missing income calculations, misclassification of SFDP categories, and inaccuracies entered into the EHR. These discrepancies were attributed to inconsistent staff performance, insufficient oversight, and gaps in training. Since the audit, the former Office Manager and two front desk employees responsible for SFDP data entry have left the organization. Proposed Corrective Action: 1. Strengthening Oversight & Accountability Office Manager Signature Required on ALL SFDP Forms signifying they have reviewed for accuracy, completeness, verified income documentation, ensure calculations are correct, and confirm appropriately and accurately entered into Athena software. 2. Updated Workflow & Process Improvement 3. Training & Competency Development - Annual Refresher Training (All Front Office Staff) The next training has already been scheduled for the week of December 8th. 4. Onboarding Process for New Front Office Employees A strengthened onboarding process will ensure new hires understand the SFDP accurately from day one. 5. Ongoing Monitoring & Quality Assurance Monthly Internal Reviews The Office Manager will audit a percentage of SFDP applications monthly, they will be documented and accuracy rates will be documented for all frontdesk staff. The Director of Administration will ensure these are maintained monthly. 6. Reinforcing the Importance of SFDP Accuracy Anticipated Completion Date: No later then December 31, 2025 Responsible Official: Diana Salcedo, Director of Administration

View of Responsible Officials and Planned Corrective Actions: Management agrees with the other matter. Corrective action has been taken. On October 23, 2025, Management informed the applicable staff member regarding the undocumented sliding fee scale applications identified during the audit. The staff member acknowledged the undocumented sliding fee scale applications. The staff member has been retrained on the sliding fee scale documentation requirements. Management will supervise and monitor the staff member to ensure the other matter has been resolved.

Recommendation: We recommend that the District implement procedures and controls to ensure that all paper applications are being reviewed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure that all paper applications are being reviewed. Official Responsible for Ensuring CAP: Tanner Spawn, Business Manager. Planned Completion Date for CAP: June 30, 2026.

Management's Response/Planned Corrective Action: The Organization's Director overseeing these programs will provide training to staff on policies. The Organization has recently implemented internal chart audits to aid in verifying compliance with funder regulations and identifying any deficiency in supporting document retention and will continue this practice going forward.

HHC was in the process of adding a new site in the Steelton area, due to additional need that had been identified for our services. HHC had been the recipient of a Federal Grant- American Rescue Act- Capital Grant and had identified several options for the use of such funds; however, none of those options resulted in a viable use of these funds. It was determined late in the Steelton building project to utilize the American Rescue Act- Capital Grant funds to support this project. Due to the timing and the fact that the General Contractor had already been selected and work had already started on the project, HHC did not proceed with an Exclusion List check to ensure that none of the individuals on the project (contractors and sub-contractors) were not prohibited from being involved in this project. HHC’s Procurement Policy does require review of the Exclusions List for all projects supported by Federal Grant Funds. HHC has reviewed our Procurement Policy and determined that no revisions of the policy are required at this time. HHC has already completed a retroactive review of the Exclusions List of all Contractors and Sub-contractors that were involved in the Steelton Project and found that there were no identified exclusions. This review was completed in September 2025. HHC is committed to future compliance with the review of the Exclusions List for all capital projects whether or not they are supported by Federal Grant funds.

RE: Finding Reference Number: 2025-001 Corrective Action: Sea Mar will implement a compliance worksheet that will be used by staff to ensure they have collected all necessary documentation for each tenant. This tool will assist in tracking income verification documents and move-in/move-out dates and will be included as a cover sheet for each tenant file. Sea Mar will also provide staff with additional training on eligibility determination for qualifying applicants in alignment with applicable program guidelines. This will be completed by 3/31/2026. Name of Contact Person Responsible for Implementation: John Clerkin, Housing Director Sincerely, John Clerkin Housing Director P: (206) 788-3399 E: johnclerkin@seamarchc.org Proudly serving the community since 1978

Response: According to the student sampling conducted as part of the audit, several withdrawal records were reported incorrectly. The source of the inconsistencies was unknown at the time of notification by the auditors. However, progress had been made since the 2023-24 audit when little to no withdrawal records were being reported correctly. The purpose of this report submitted to NSLDS through NSC, is to notify lenders of students who have dropped below half time status and therefore should be entering their six month grace period prior to loan repayment. All students are included in the withdrawal report, regardless of whether they have a loan with Vernon College or any other institution. It is important to note, internal records are accurate and loan processes are in compliance. Vernon College is pleased to report that recently the Registrar’s Office has discovered the source of the withdrawal reporting errors and has implemented a solution. The source and subsequent solution involve entering certain dates in designated areas in our student information system, Colleague. If errors occur in the future, the Registrar’s Office has developed a backup manual review process to use to ensure reporting will remain consistent and correct. The Registrar’s Office will run an “Enrollment Activity Report” to identify all course withdrawals within a designated time period as outlined by the NSC First of Term and Subsequent Term reports. The reporting official will then audit the Colleague produced NSC report against the Enrollment Activity Report to ensure accuracy and update manually as needed. This will occur prior to submission to the NSC/NSLDS. Moving forward, the manual process will only be used if needed.

Corrective Action Plan: The District will ensure free and reduced meal applications with a case number in Step 2 of the application are part of a program that makes them immediately qualify for free or reduced meals. In addition, approved applications will be reviewed by a 2nd party to ensure accurate approval has taken place. Anticipated Corrective Action Plan Completion Date: December 2025 Contact Information: For additional information regarding this finding please contact Erica Pickett, Director of Business Services, at 608-877-5011.

Western Wyoming Community College experienced a transition in leadership within the Financial Aid Office, resulting in a change in the Director of Financial Aid position. This transition caused disruptions in communication and process continuity between the Financial Aid, Registrar, and Institutional Effectiveness offices. As a result, inconsistencies were identified in the timing and accuracy of enrollment reporting to the National Student Clearinghouse (NSC) and the National Student Loan Data System (NSLDS). Corrective Action Plan 1. Leadership and Process Realignment a. A new Director of Financial Aid has been appointed and is collaborating with the Institutional Effectiveness Office and the Registrar to define clear processes and timelines for Records & Registration and Financial Aid operations. b. The Director of Financial Aid and Registrar will maintain continuous communication to ensure timely and accurate enrollment reporting and prompt correction of any identified discrepancies. c. The Director of Financial Aid and Registrar will work together to develop a Standard Operating Process (SOP) to ensure if any future attrition occurs in either department that anyone else in those departments will be able to step in and continue processing without interruption ensuring timely and accurate enrollment reporting continues. 2. Implementation of Controls for Third-Party Reporting a. Recognizing the benefits and responsibilities of using the National Student Clearinghouse (NSC) for enrollment reporting, the institution has implemented controls to verify the accuracy of data transmitted through this third-party servicer. b. The Assistant Director (or the Director of Financial Aid in the Assistant Director’s absence) will generate the Summary Return of Funds Report (ROFS) from Colleague each term and provide a copy to the Registrar for enrollment verification and reconciliation. 3. Quarterly Reconciliation and Internal Review a. The Financial Aid Office will conduct a quarterly comparison between Colleague and NSLDS records to ensure consistency of enrollment and status dates. b. Any discrepancies identified will be communicated to the Registrar for prompt resolution. c. Results of the quarterly reviews will be documented and used for internal compliance monitoring and training. 4. Updated End-of-Term Procedure To ensure ongoing accuracy and compliance, the following revised steps will be followed each term: a. The Director or Assistant Director of Financial Aid will run an All F Report after final grades are posted. b. The Director and Assistant Director of Financial Aid will jointly calculate Return to Title IV (R2T4) funds. c. The Return of Funds Report (ROFS) will be provided to the Registrar monthly to verify last date of attendance and withdrawal dates against Colleague records. d. The Registrar will verify subsequent semester enrollments and continuously monitor student enrollment, reporting any changes to Financial Aid leadership. e. The Registrar will submit end-of-term enrollment data to the National Student Clearinghouse as usual, and one week before the next term begins, will submit the end-of-term R2T4 list to prevent overwriting by subsequent semester reporting. 5. Training and Internal Audit Enhancement a. The Financial Aid and Registrar’s Offices will use findings from this audit to develop staff training on identifying and correcting data discrepancies during the quarterly reconciliation process. b. The Director of Financial Aid will review 80% of R2T4 files during each semester for accuracy in reporting and documentation. 6. Graduation Data Accuracy a. The Registrar’s Office utilizes the Update Academic Credentials File (UACF) in Colleague to batch post student degrees and certificates three times per year (end of spring, summer, and fall terms). b. It was determined that the automatic graduation date populates correctly only when students have a single program with no changes. For students with multiple programs or program changes, the graduation date must be entered manually to ensure accuracy. c. The Registrar will oversee the upload of graduates and verification of accurate credential dates, ensuring these dates are correctly reflected in NSC and the Director or Assistant Director of Financial Aid will make sure the dates are correctly reflected in the NSLDS system. d. The Registrar and Director of Financial Aid will conduct joint reviews to verify that all graduation and enrollment data are reported correctly. Anticipated Completion Date: June 30, 2026 Contact Persons: DeeAnna Archuleta, Director of Financial Aid, and Kayla Miller, Registrar

Condition During our testing over direct loan disbursement notifications, we found that for twenty out of twenty students tested, City Colleges could not provide evidence that notifications were sent within the required timeframe informing the student, or parent, that a credit will be made to the student’s account for a direct loan disbursement. While City Colleges demonstrated that its system was configured to automatically send notification letters and confirmed that notifications were issued, City Colleges could not provide documentation showing the specific date each notification was sent in relation to the loan disbursement. Cause City Colleges’ system is designed to record the date notifications are sent to students; however, it does not retain a copy of the actual notification content that was transmitted. Corrective Action Taken or Planned City Colleges’ IT team, in collaboration with a consultant, will configure the system to bring all Direct Loan communication letters into the Financial Aid (FA) Status pages. Integrating these letters directly into the FA Status page will ensure they are easily accessible for FA staff. As part of this enhancement, City Colleges will be able to view a timestamp indicating when each communication was sent to the student, as well as view the information required to be communicated by 34 CFR 668.165. Contact Person: Leticia Garcia, District Director of Student Financial Aid Anticipated Completion Date: December 13, 2025

Management agrees with the finding identified and is in process of implementing the recommendation. The District will implement procedures to ensure all vendors paid with Federal awards are reviewed for suspension and debarment prior to payment and that evidence of the review is documented and maintained in the proper files. It will be the responsibility of the Director of Business Services and accounts payable personnel to impelement these procedures.

U.S. Department of Housing and Urban Development: The Housing Authority of the County of Contra Costa respectfully submits the following corrective action plan for the year ended March 31, 2025. Auditor: Novogradac and Company, LLP Certified Public Accountants 1144 Hooper Avenue Suite 203 Toms River, New Jersey 08753 The findings from the March 31, 2025 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Findings – Federal Award Program Audit Finding 2025-001 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Titles: Housing Voucher Cluster Assistance Listing Number: 14.871, 14.879 and 14.EHV Noncompliance – E. Eligibility – Tenant Files Non Compliance Material to the Financial Statements: Yes Material Weakness in Internal Control over Compliance for Eligibility Criteria: Tenant Files. The PHA must do the following: As a condition of admission or continued occupancy, require the tenant and other family member to provide necessary information, documentation, and releases for the PHA to verify income eligibility (24 CFR sections 5.230, 5.609, and 982.516). These files are required to be maintained and available for examination at the time of audit. Condition: Based upon inspection of the Authority’s files and on discussion with management, there were documents that were unavailable for examination at the time of audit. Context: There are approximately 11,032 units. Of a sample size of sixty-nine (69) tenant files, the following was noted: - Declaration of Section 214 Status form was missing in one (1) file - HUD-9886 Authorization for Release of Information was missing in six (6) files - Lead based paint form was missing in one (1) file - HUD-50058 Form applicable to the audit period was missing in seven (7) files Our sample size is statistically valid. Known Questioned Costs: $168,325 Cause: There is a material weakness in internal controls over the compliance for the eligibility type of compliance related to the maintenance of tenant files. The Authority has not properly considered, designed, implemented, maintained and monitored a system of internal controls that assures the program is in compliance. Effect: The Housing Voucher Cluster is in material non-compliance with the eligibility type of compliance related to the maintenance of tenant files. Recommendation: We recommend the Authority design and implement internal control procedures that will assure compliance with the Uniform Guidance and the compliance supplement.. Views of responsible officials and planned corrective action: We agree with the Auditor’s observations on the inspection of the tenant files and will implement internal control procedures that will ensure compliance of federal regulations. HACCC identified two primary causes of the deficiency and has outlined corrective measures to address them. Firts, HACCC recognized the need for improved training on supervisory tools used to monitor recertification deadlines. Management was retrained in November 2025 on the use of WorkQueue oversight tools and on conducting daily team stand-up meetings to reinforce production goals. Key performance indicators from these meetings flow to management reports and executive leadership for ongoing monitoring. Second, HACCC'S HCV program partnered with Paul Edwards Management and Consulting (PEM) on May 1, 2024. This partnership provided HACCC's HCV program with technical assistance and coverage of positions which had remained vacant from 2021 until recently. Ingrid Layne, Director of Assistance Housing, will be responsible to implement this corrective action by March 31, 2026.

Finding 2025-001. The management company is required to use the Enterprise Income Verification for eligibility determination per the compliance supplement. There are numerous reports required to be created and reviewed by management on a periodic basis. (1) Recommendation: The management company should acquire access to the HUD EIV, and begin producing and reviewing the required reports within required timeframes. The organization should further establish procedures that will ensure ongoing compliance. These procedures should include training and monitoring of responsible staff. (2) Actions Taken: Management has worked with HUD to obtain access and will begin performing this responsibility. The appropriate reports will be produced and reviewed once management has access to the HUD EIV system. Procedures are being implemented to assure that this process is taking place.

Finding 2025.002 - Sliding Fee Scale Discount Recommendation The Organization should strengthen internal controls in place to effectively ensure that patients receive the correct sliding fee discount. Action Taken • Monthly Audits o The Front Office Coordinators at each location will routinely audit sliding fee verification on a monthly basis to verify that information has been captured and recorded correctly and all proof of income documentation is received. These monthly audits will be adopted as standard protocol and procedure for front office operations, effective January 2025. Any findings through the audit process will be reported to the COO. At least five patient charts will be audited monthly. o In addition, the Revenue Cycle Manager will also review audit findings or summaries to ensure adequate adjustment to patient accounts to correlate with the patient's eligibility status. • Staff Training o Although Heartland has offered periodic sliding fee scale procedure training, administration will be scheduling additional training with a focus on required documentation and proper analysis and implementation of sliding fee discounts. o COO and Revenue Cycle Manager will review, implement and update standard operating procedure for sliding fee scale verification. o Employees will receive a copy of the sliding fee scale policy and sign that they have read the material. o Front office employees at all locations will complete a sliding fee schedule competency check-off sheet that will be reviewed by the Front Office Coordinators and Revenue Cycle Manager.

Finding Number: 2025‐001 Program Name/Assistance Listing Title: Temporary Assistance for Needy Families (TANF) Assistance Listing Number: 93.558 Contact Person: Elise Lopez – Vice President, Organizational Operations Anticipated Completion Date: January 31, 2026 Planned Corrective Action: The TANF Cash Assistance eligibility for each client served is one of the dozens of data points that Emerge tracks as part of our requirements for the Arizona Department of Economic Security (ADES) funding. The categorization of whether clients are eligible for TANF Cash Assistance, while a reporting requirement, is not tied to our contract billing. In other words, the accuracy of this categorization does not affect Emerge’s funding in any manner, and reporting errors regarding this categorization has not – and cannot – result in over‐billing for service units within the contract. Nevertheless, Emerge takes its reporting obligations very seriously and strives to always provide the most complete and accurate data to funders and the community. In regard to determining a client’s eligibility for TANF Cash Assistance or other government benefits, Emerge collects information and assesses eligibility for two reasons: 1) as a means of supporting our case management services and efforts to connect clients with appropriate resources, and 2) in order to comply with ADES requests to report whether or not we serve TANF‐eligible clients. While Emerge and its employees are not trained by ADES in determining individual’s eligibility for TANF Cash Assistance or other government benefits that we do not administer, we do provide our own internal training to employees about the factors that go into determining eligibility. Historically, this information has been provided as a stand‐alone document and noted during new hire training. In researching the client files which were selected for audit, it was determined that, in some instances, clients were categorized incorrectly, or that qualifying information was not sufficiently documented as it pertains to the client’s TANF Cash Assistance eligibility. Overwhelmingly, this was a result of one or both of the following factors: (1) clients whose TANF eligibility changed during the year, but whose status was not updated in our system, and/or (2) inconsistencies in how a client’s children had been documented in our client information system (eg. clients whose children are not enrolled in Emerge’s services do not appear in this system, but staff may have marked the client eligible for TANF based on verbal information without documenting the children in their notes). Our internal inquiry into this issue also revealed that TANF income eligibility charts were not correctly updated in all areas of the client information system, which may have led to confusion among staff regarding client eligibility status changes throughout the year. To mitigate future errors, we have taken immediate steps to begin the process of updating our client information system to ensure the correct TANF eligibility charts are reflected in the appropriate areas. We also have a plan to update TANF eligibility chart updates annually, which will include a quality assurance check by the Vice President of Operations to ensure the information has been updated in all appropriate areas of the client data managements system. As of November 28, 2025, we have developed an internal performance improvement plan. This plan includes conducting an internal audit of our client information system files for 2025 to ensure accuracy, re‐training staff on TANF eligibility and documentation, and conducting monthly quality assurance checks through the end of FY26. Additionally, greater time and focus related to the details surrounding the TANF assessment process will be built into the curriculum for new hire trainings moving forward. These corrective actions, while ongoing, are expected to be fully implemented by 01.31.2026