Corrective Action Plan - Audit Finding 2024-002 Reportable finding considered a significant deficiency - Inadequate support for distribution of donated food 1. Documentation Procedures The Organization has updated its policies in 2025 to ensure all food distributions—including goods received, distri...
Corrective Action Plan - Audit Finding 2024-002 Reportable finding considered a significant deficiency - Inadequate support for distribution of donated food 1. Documentation Procedures The Organization has updated its policies in 2025 to ensure all food distributions—including goods received, distributed, used for on site meal preparation, and leftover items transferred to partner nonprofits—are supported by appropriate documentation. A standardized set of templates will be used to record: • Distribution logs at each location • Congregate Aggregate Feeding Reports • Documentation of leftover or transferred goods All documentation will be retained in a centralized repository accessible to program and compliance staff. ________________________________________ 2. Distribution Tracking Controls The Organization has implemented strengthened controls to ensure accurate and complete tracking of all food commodities. These controls include: • Required completion of distribution logs at all partner locations • Mandatory retention of Congregate Aggregate Feeding Reports • Reconciliation of monthly distribution activity to the Monthly Distribution Report • Documentation of discarded or transferred goods A compliance checklist is being developed to verify that all required documents are collected each month. ________________________________________ 3. Designation of Responsibility A Chief Operating Officer has been assigned responsibility for ensuring that all distribution documentation is collected, retained, and reviewed. Program staff and site partners will receive ongoing training to ensure consistent adherence to the updated tracking requirements. ________________________________________ 4. Review and Approval A formal review and approval process has been established. Monthly Distribution Reports will be reviewed by: • The Chief Operating Officer • The Warehouse Manager Any discrepancies or missing documentation will be investigated and resolved prior to monthly reporting. ________________________________________ 5. Monitoring and Follow Up Beginning in 2025, the Organization implemented ongoing monitoring procedures, including periodic internal audits of distribution files. Quarterly compliance reviews will be performed to assess adherence to documentation requirements and to identify additional training needs. The Warehouse Manager will report quarterly to senior leadership on distribution documentation compliance. Management will continue refining the new processes and providing ongoing training to ensure full, consistent adoption across all distribution sites. The Organization anticipates that these corrective actions will fully address the documentation gaps identified in the audit and strengthen internal controls moving forward. ________________________________________ Implementation Timeline All corrective action steps were initiated in 2025, and full implementation of updated procedures is ongoing. The Organization anticipates complete adoption across all distribution sites by December 31, 2026. ________________________________________ Responsible Personnel • Chief Operating Officer-Food Bank Operations: Thomas Deramore • Warehouse Manager-Food Bank Operations: Sean Conner • Chief Financial Officer: Kate Stefan • Executive Director: Timothy Hawkins ________________________________________ This Corrective Action Plan is designed to address the auditor’s findings, recommendations and prevent recurrence of similar issues to ensure compliance with Uniform Guidance documentation standards and internal control requirements ________________________________________ Signature: ________________________________________ Kate Stefan, Chief Financial Officer Community Action Agency of Butte County, Inc.