Corrective Action Plans

CORRECTIVE ACTION PLAN Breakthrough Phase I, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Purkey, Carter, Compton, Swann, & Carter, PLLC PO. Box 727 Morristown, Tennessee 37815 Audit period: July 1, 2021 ?June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS ? FINANCIAL STATEMENT AUDIT None FINDINGS ? FEDERAL AWARD PROGRAMS AUDITS FINDING NO. 2022-001: Ineffective operation of internal controls by management Management did not conduct recertifications of the Project?s tenants during the ?scal year under audit. Criteria: According to the HUD Handbook 4350.3, owners must conduct a recertification of family income and composition at least annually by the tenant?s recertification anniversary date. Owners must then recompute the tenants? rents and assistance payments, if applicable, based on the information gathered. If a new recertification is not submitted within 15 months of the previous year?s recertification anniversary date, HUD will terminate assistance payments. Cause of Condition: Management had difficulties setting up the One Site Leasing software in order to conduct the recertifications in a timely manner. Recommendation: Auditor recommends management review HUD Handbook 4350.3 and put proper internal controls in place to ensure recertifications are completed as required by HUD. Action Taken: Personnel at Breakthrough Corporation that are handling the operations of the Project have gone through HUD?related training. The Board is working closely with Breakthrough Corporation to ensure the Project is complying with HUD requirements and completing training annually to stay up to date with HUD compliance. The difficulties with the leasing software has been resolved and recertifications have been completed after year end.

Management agrees with this finding. Management believes that the cost of additional staff time and training to prepare these items outweighs the benefits to be received. Management will continue to review the schedules of expenditures of federal and state awards and other information.

Carbondale Senior Housing Corporation Phase IV, dba Crystal Meadows IV (?CSHC Phase IV?) respectfully submits the following corrective action plan for the year ended June 30, 2022. CSHC Phase IV agrees that the surplus cash calculation for June 30, 2021 is correct and that the required deposit was not made to a separate bank account. Moving forward, management will review and calculate surplus cash following the close of each fiscal year to ensure the deposit, if applicable, is made within the 60-day period as required by HUD. Jerilyn Nieslanik, Executive Director In August 2022, a new bank account for CSHC Phase IV was opened, with the June 30, 2021 calculated surplus cash transferred. No additional deposit is required for the June 30, 2022 fiscal year end.

The Housing Authority of the City of Bessemer recognizes the need for satisfactory internal controls. The Housing Authority has hired a compliance officer to conduct file review and audits on all program files. Reports are prepared and submitted to executive management upon completion. This process was instituted January 1, 2023 and has proved to be an upgrade in our internal control environment.

The Housing Authority of the City of Bessemer agrees with the identified deficiencies and a plan or action has been developed to strengthen internal controls. The Housing Authority of the City of Bessemer recognizes the need for satisfactory internal controls. The identified deficiency was a result of interruption in inspections due to an unprecedented pandemic. Although, inspections were reinstated, the Housing Authority failed to complete all catch-up inspections. The Housing Authority hired a third-party vendor to conduct all inspections as a result of this deficiency. We have also hired a compliance officer to conduct file audits and confirm that all HUD required policies are met in all programs. We believe that these adjustments will ensure that our internal control environment is greatly improved.

FINDINGS - MAJOR FEDERAL AWARD PROGRAM AUDIT Department of Housing and Urban Development Finding 2022-001: Major Programs: Section 8 Housing Assistance Payments Program, Assistance Listing 14.195 RECOMMENDATION The auditor recommends ensuring all disbursements are thoroughly reviewed prior to authorizing the expense to be paid. ACTION TAKEN The Project will be reimbursed by the other project for the expense paid on its behalf.

Finding Number: 2022-001 Condition: HUD requires the Corporation to refund the security deposit to tenants within 30 days of the move out. The Corporation failed to monitor the deposit refund requirements for the security deposits as specified by the regulatory agreement and failed to return security deposits within 30 days. Planned Corrective Action: Management acknowledged the errors that occurred during the year ended September 30, 2022 and has taken measures to change their process of issuing refunds to reduce the likelihood of late refunds. Contact person responsible for corrective action: Jill Kolb, Vice President ? Housing Accounting Completion Date: September 27, 2022

Finding Number: 2022-001 Condition: HUD requires the Corporation to refund the security deposit to tenants within 30 days of the move out. The Corporation failed to monitor the deposit refund requirements for the security deposits as specified by the regulatory agreement and failed to return security deposits within 30 days. Planned Corrective Action: Management acknowledged the errors that occurred during the year ended September 31, 2022 and has taken measures to change their process of issuing refunds to reduce the likelihood of late refunds. Contact person responsible for corrective action: Jill Kolb, Vice President ? Housing Accounting Completion Date: March 25, 2022

CORRECTIVE ACTION PLAN March 31, 2023 United States Department of Housing and Urban Development PCM Senior Housing, Inc. d/b/a Shady Park Place, respectfully submits the following corrective action plan for the year ended December 31, 2022. Name and address of independent public accounting firm: Maher Duessel, CPA?s 503 Martindale Street, Suite 600 Pittsburgh, PA 15212 Audit period: January 1, 2022 ? December 31, 2022 The finding from the December 31, 2022 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT No matters were reported FINDINGS? FEDERAL AWARD PROGRAMS AUDITS Finding 2022-001 Department of Housing and Urban Development Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects Program ALN Number 14.155 Recommendation: Procedures should be implemented to ensure the Property makes the required deposits to its residual receipts account within the 90 days following year end. Action taken: Diana Bobak, Director of Finance will double check all audit requests for residual receipt deposits 60 days after the financials are issued with all staff. If the Department of Housing and Urban Development has questions regarding this plan, please call Diana Bobak at 412-349-3942. Sincerely yours, Diana Bobak Director of Finance Brandywine Agency, Inc.

Finding 2022-001 Significant Deficiency in Internal Control over Compliance Corrective Action Plan: The corrective plan is to examine all applicant and participant files for accuracy using a file checklist for forms such as Section 214 Declaration of Citizenship during the eligibility process and annual reexamination period. Management has decided not to purge tenant files for the current program participants. For the participants who are not in the program, the file will not be purged for a minimum of three years. In this specific instance, the participant entered the program in 2012 and ended program participation on March 31, 2022. The original file had been purged. Name of Responsible Person: Cherrie Escobar, Director of Section 8 Projected Completion Date: March 31, 2023

HARVARD SUPPORTIVE HOUSING, INC. HUD PROJECT NO. 071-HD154 CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Harvard Supportive Housing, Inc. respectfully submits the following corrective action plan for the year ended June 30, 2022. Name and address of independent public accounting firm: Hinrichs & Associates, Ltd. 1000 Shelard Parkway, Suite 110 Minneapolis, MN 55426 Audit Period: June 30, 2022 The findings from the June 30, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS - FINANCIAL STATEMENT AUDIT NONE FINDINGS - FEDERAL AWARD PROGRAMS AUDIT DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2022-001: SECTION 811, ASSISTANCE LISTING NUMBER 14.181 The Project failed to comply with the repayment terms of a HUD approved, replacement reserve loan. Recommendation: The Project should deposit $5,606 into the replacement reserve account. Action Taken: The Project agrees with the finding. Management will deposit $5,606 to the replacement reserve account as soon as possible. If the Department of Housing and Urban Development has questions regarding this plan, please call Les Russo at 847-424-5601.

Jackson MHA completed the required inspection, but we were unable to provide the completed inspection report generated by our software company. After speaking with our software company, they were also unaware why the software did not have the inspection report under the inspections tab. The software does show the inspection was completed under the occupancy tab. JMHA was unable to provide a copy of the inspection report. Going forward, the Executive Director and staff will ensure that all required inspection documentation will be printed and placed in the tenant files immediately following the unit?s inspection. If we are unable to print the inspection documentation, we will immediately contact our software company to address the situation and not wait until the documentation is requested. All tenant files will be inspected and reviewed by staff monthly to ensure that all pertinent documentation is in place.

Third party employment verifications were provided to the housing authority by the tenants. Staff were able to verify the provided employment documents. Staff were able to ensure that the tenants met the mandatory income limits. Upon transferring of job descriptions, in the office, between staff documents were misplaced. Going forward, the Executive Director and staff will place a high emphasis on ensuring that all third-party verifications are stamped with the date received and placed in tenant files upon receipt of the documents. All tenant files will be inspected and reviewed by staff monthly to ensure all pertinent documentation is in place.

2022-001 Auditee's response and Planned Corrective Action Planned Implementation Date of Corrective Action: All annuals, interims, and rent increases being processed after March 1, 2023. Person Responsible for corrective Action: Margaret Dooling - HCV Housing Manager The Exeter Housing Authority has changed the policy of documenting rent reasonableness. Going forward all files will document the rent reasonableness by filling out the point system chart at the bottom of each inspection report on bottom of the rent reasonableness point total page. This will be compared to the Rent Reasonableness Chart for the particular year that is supplied by NHHFA on the price range based on the total points. A copy of the NHHFA chart will also be attached in the file as well. This will be done for every new admission, annual inspection, as well as rent increase request.

Finding #2022-001- Segregation of Duties Criteria: Segregation of duties is an aspect of internal control intended to prevent or decrease opportunities of intentional and unintentional errors and fraud. Duties and responsibilities are properly segregated if no single individual either has control over all phases of a transaction or can both make and conceal an error, whether such error is intentional or unintentional. Condition: A properly designed system of internal control includes adequate staffing, policies, and procedures to properly segregate duties. All internal control duties can be classified into four broad categories: authorization, custody, recordkeeping, and reconciliation. No one person should have control of two or more of these four categories for any one cycle. There are key controls related to significant transaction cycles that are important in reducing the risk of errors or irregularities. Currently, there are the following overlapping duties: - Both Accounting Specialists have the authority to enter invoices into the system, print checks, and have access to the electronic signatures. Preferably, the check cutting process would separate the entering of payment information into the system and the ability to print signed checks. - One Accounting Specialist creates deposits and makes deposits with the bank. Although not the standard procedure, the Accounting Specialist has the authority to collect cash receipts. Ideally, separate individuals would collect cash and make deposits. - The Housing Authority Executive Director opens the mail, creates deposits and takes deposits to the bank. The Executive Director also enters invoices into the system and prints checks. The Board of Commissioners approves disbursements and all checks require dual signatures. Effect: Errors or intentional fraud could occur and not be detected timely by other employees in the normal course of their responsibilities because of the lack of segregation of duties. Cause: Limited number of personnel. Recommendation: We recommend that the City consider the benefits of implementing additional policies and procedures to address key controls related to its significant transaction cycles as noted. Response: We agree with this finding but do not believe it is cost effective to increase personnel to bring about a more effective segregation of duties.

Comments on Findings and Recommendation: The Corporation's required deposit into the residual receipts account per the June 30, 2021 Computation of Surplus Cash, Distributions and Residual Receipts was not deposited within 90 days of the fiscal year end. Management should make all required residual receipts deposits per the annual Computation of Surplus Cash, Distributions and Residual Receipts within 90 days after the fiscal year end. Action(s) taken or planned on the finding: Agree. Management deposited $10,879 into the residual receipts fund on May 2, 2022.

Identifying Number: 2022-001 Finding: The Organization did not deposit cash surplus into the residual receipts account in a timely manner. Contact Person Responsible for Corrective Action: Richard Manall, CFO Corrective Action Taken or Planned: Review of the financial statement now includes the process of making the cash surplus cash transfer into the residual receipts account. Anticipated Completion Date: September 14, 2022.

Finding 2022-001 Federal Agency Name: Department of Housing and Urban Development, Passed through Hearth Connections Program Name: Continuum of Care CFDA # 14.267 Finding Summary: Identified five instances where the participant?s file did not have documentation that the rent reasonableness test was performed in a timely manner. In addition, we identified 19 instances where the participant?s file did not have documentation that the rent reasonableness test was reviewed. Creating Inadequate internal controls over compliance could result in noncompliance with the federal program. Responsible Individuals: Paul Bloomer, VP of Finance Corrective Action Plan: A complete review and policy and procedures along with proper training for new staff. The findings occurred during position vacancy and onboarding training. Additional steps are taken to ensure training is completed and random spot checks of client files. Anticipated Completion Date: Ongoing in nature.

Finding No. 2022-014 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.241, Housing Opportunities for Persons with AIDS Corrective Action(s) The auditors selected a non-statistical sample of nineteen (19) units that were subject to an initial inspection by HRA during fiscal 2022 and noted that for three (3) selections, HRA was unable to provide a copy of the inspection checklist that was completed by the QA Inspector prior to assistance being provided for the unit. Unfortunately, during the height of the COVID-19 pandemic, many housing vendor staff were working remotely, and a few documents may have been mislaid. To ensure continual compliance with federal HOPWA grant requirements, HRA will enhance its efforts to confirm that housing vendors properly maintain a copy of inspection checklists completed prior to initial move in. Monitoring visits conducted by HRA will include a review of the checklists. Anticipated Completion Date April 2023 and ongoing Person(s) Responsible for Implementation Pamela Xiomara Farquhar Assistant Deputy Commissioner FarquharX@hra.nyc.gov

Finding No. 2022-011 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.239, HOME Investment Partnerships Program Corrective Action(s) HRA is committed to better understand the Housing Quality Standards (HQS) inspection process and strengthen our monitoring to ensure future compliance. Corrective Actions: ? Hire an Executive Director for the TBRA. ? Advance HRA understanding of the inspection process, deliverables and compliance including intentional notifications and requesting, collecting, and maintaining of documentation. ? Review and update, as determined, HRA procedures to strengthen monitoring of HQS inspections and ensure appropriate documentation is maintained. Anticipated Completion Date May 2023 and ongoing Person(s) Responsible for Implementation Dori Hopkins-Figeroux Director, TBRA (929) 252-6089 Dwana Abraham Assistant Deputy Commissioner (929) 221-6726

Finding No. 2022-003 Department(s) New York City Human Resources Administration Program(s) Assistance Listing Number 14.231, Emergency Shelter Grants Program Corrective Action(s) Because the ESG expense construct had to be vetted and approved before obligating the total grant amount, we were unable to do so within the prescribed 180 days. We will ensure in the future that we strengthen our internal controls to ensure that 100% of the total ESG grant amount is obligated within 180 days of the signed grant agreement. This will include an added layer of review by the Associate Commissioner of Homeless Policy and Innovation, who oversees the unit that obligates the funds in IDIS. Anticipated Completion Date April 2023 and ongoing Person(s) Responsible for Implementation Kristen Mitchell Associate Commissioner, Homeless Policy & Innovation MitchellKr@dss.nyc.gov

Finding 2022-022 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Provider Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will amend the managed care contracts to require that signatures are obtained on the Provider Screening Information Collection Tool (PSICT) forms when contracts and waivers are renewed and extended. Annually, MDHHS will send a reminder to the managed care entities to report any change in ownership to MDHHS within 35 days. In addition, MDHHS has incorporated a review of provider agreements as part of their monitoring process conducted for all MI Choice Waiver Program (MI Choice) entities. Anticipated Completion Date MDHHS will send the annual reminder to managed care entities beginning August 2023. MDHHS anticipates that signatures will be obtained on the PSICTs effective October 2023 for the fiscal year 2024 contract cycle. MDHHS expects to complete its current review of provider agreements for MI Choice entities by July 2023 and reviews will be ongoing. Responsible Individual(s) Elizabeth Gallagher, MDHHS Latina McCausey, MDHHS

2022-002 Tenant Files: Eligibility Program: U.S. Department of HUD: Section 8 Housing Choice Vouchers (CFDA 14.871) Type of Finding: Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2021-001 from September 30, 2021 (Other Matter and Significant Deficiency in Internal Control over Compliance). Originally reported as finding 2019-001 from September 30, 2019 (Material Weakness in Internal Control and Material Noncompliance) Statement of Condition: Out of a total tenant population of approximately 1,114 vouchers, 25 files were selected for testing. Exceptions were noted as follows: ? 1 tenant file had the following errors: o The tenant?s annual recertification application is missing. o The tenant?s signed 9886 form is missing. o The wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting this error would cause the HAP rent to increase by $9. o The tenant?s signed HAP contract is missing. ? 1 tenant file had the following errors: o The name and social security number for one of the tenant?s dependents was reported incorrectly on the 50058 form. o The tenant?s utility allowance was calculated correctly but was reported incorrectly on the 50058 form. Correcting this error would cause the HAP rent to increase by $56. ? 1 tenant file had the following errors: o The lease agreement was not signed by the tenant. o The tenant?s assets was reported in error. Correcting this error would cause the rent to increase by $8. ? 2 tenant files where the tenants? income was miscalculated. Correcting the errors would cause the HAP rent for one of tenant files to decrease by $12 and the other to increase by $181. ? 2 tenant files where the wrong utility allowance schedule was used to calculate the tenants? utility allowance. Correcting these errors would cause the HAP rent for one of the tenant files to decrease by $13 and the other to increase by $14. ? 1 tenant file where the family?s assets was reported in error. Correcting the errors had no effect on the HAP rent. ? 1 tenant file where a member of the household moved but was reported on the 50058 form. ? 1 tenant file where the tenant?s signed HAP contract is missing. ? 1 tenant file where the EIV report was never generated or was misplaced. In addition to the above, we noted the following during our new admissions testing (out of a total of 118 new admission, 18 files were selected for testing.): ? 1 tenant file where the member of the household did not checkmark the checkbox on the 214-affidavit form indicating that they are a U.S. Citizen or permanent resident. However, the member?s birth certificate confirms that the member is a U.S. Citizen. ? 1 tenant file where the tenant?s signed 214-affidavit is missing. However, the member?s birth certificate confirms that the member is a U.S. Citizen. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing quality control review process on the entire tenant population to ensure proper compliance with the requirements related to tenant eligibility. Ongoing staff training and timely management reviews should be utilized to ensure staff is aware of acceptable procedures. In addition, the Authority should review staffing levels, skill sets and case load. Action Taken: The Authority concurs with this finding. The Authority has an established review, oversight and training process and will continue to improve its review, oversight, and training process to ensure proper procedures are being followed. All audit findings of the files tested will have been corrected. The Authority has implemented a quality control system so that every file receives a quality review for appropriate third-party verification and upfront income and assistance is determined. The agency has created a Family Worksheet and an HCV Computation Worksheet to help staff identify errors in calculations and to check for accuracy prior to completing Annual Reexaminations and Interim Recertifications. The agency has changed its filing system to enable staff to thoroughly review all forms prior to admission and during regular recertification and interim adjustment processing. The agency created an Other Adult packet to ensure 214 forms and other pertinent are completed for all adult household members. The HCV Counselor caseloads have been distributed equitably amongst Counselors to promote efficiency and accuracy while working on each HCV participant?s file. The Counselor?s caseload is divided alphabetically and assigned by multifamily developments to track and monitor counselors? strength and weaknesses, and to determine if additional training and/or monitoring is needed. Internal file reviews are being completed and management will continue to conduct a 10% review for each Counselor?s processing of annual recertifications. This percentage may increase if work product indicates a need for more stringent review. To further ensure compliance and accuracy, the HCV Program Manager will review at least 1 out of every 5 intake files. The Authority has had a significant turnover in the HCV department over the past 24 months. All HCV staff will attend Voucher Specialist training and Nan McKay HCV Rental Calculation Certification training. Effective Date: June 20, 2023 Contact Information Gwendolyn B. Dawson, CEO Ocala Housing Authority 1629 NW 4th Street Ocala, Florida 34475 (352) 369-2636

2022-006 Special Tests and Provisions ? Internal Control and Compliance over Obligation, Expenditure, Payment Requirements City?s Corrective Action Plan: When invoices from subrecipients are received, they are reviewed thoroughly by staff. Documentation sent may range from a few pages to several hundred pages. The larger the packet submitted, the longer the review process. In the review process, it may be determined that the information sent is not sufficient to support the claim/amount for reimbursement. This initiates a back and forth between staff and the subrecipient that could take up to several weeks to resolve. The department continuously holds workshops with all vendors/subrecipients on best practices, and invoicing procedures to cut down on the time spent reviewing invoices. The department makes great effort in working with all subrecipients to expedite documentation review and payment process and continues to make great improvement in this area. Staff will also maintain records of any delays in processing as a result of insufficient documentation submitted by the subrecipient. Responsible Person: Julisa Villalobos (Program Admin), Raquel Chavarria (Fiscal) Expected Implementation Date: July 2023

Corrective Action Plan Year Ended December 31, 2022 Name and Number of Project: Cedar Lane Senior Living Community I, Inc. HUD Project Number 052-11225 Auditor/Audit Firm: PKF O?Connor Davies LLP Audit Period: December 31, 2022 Finding 2022-001 ? Use of Project Funds Federal Assistance Listing Number Name of Federal Programs 14.155 Mortgage Insurance for the purchase or Refinancing of Existing Multifamily Housing Projects 14.195 Section 8 Project-Based Cluster Section 8 Housing Assistance Payments Program A. Comments on Finding and Recommendations Recommendation ? We recommend that management reconcile and repay intercompany activity in a timely manner. B. Actions Taken or Planned The Entity has instituted policies and procedures to reconcile and rectify intercompany activities timely and is working with their HUD representative to consolidate their Federal Programs which will rectify the issue and simplify the intercompany activity. C. Status of Corrective Action on Prior Findings N/A Eric Golden, President and CEO Cedar Lane Senior Living Community I, Inc.