Corrective Action Plans

Finding 1205054 (2025-001)

Material Weakness 2025

MA

Reporting Internal Control / Segregation of Duties § 200.512

The Authority agrees with the finding and will strengthen its internal procedures to ensure timely submission of the Federal Audit Clearinghouse reporting package going forward.

View Audit 396698

Finding 1205046 (2025-002)

Material Weakness 2025

Human Resource Development Institute

IL

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Finding 2025-002 Material Weakness in Internal Control Over Special Tests and Provisions Compliance Requirements Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of He...

Finding 2025-002 Material Weakness in Internal Control Over Special Tests and Provisions Compliance Requirements Assistance Listing Numbers 93.224 Health Center Program 93.527 Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program Federal Agency U.S. Department of Health and Human Services, Health Resources and Services Administration Passthrough Agency N/A Award Number/Year 2025 Criteria FFHC is responsible for keeping adequate supporting documentation of the calculation of patient service fees for those patients who qualify for discounted fees based on family size and household income. FFHC is also required to apply discounted fees accurately based on an approved sliding fee scale that meets federal compliance requirements. Views of Responsible Officials and Planned Corrective Actions Friend Family Health Center Inc. and Affiliates (Organization) will implement the following corrective actions for the fiscal year ending June 30, 2025 to remediate the finding and address the cause of the finding. The Organization will implement the following corrective actions for fiscal year 2026 to remediate the finding and address the cause of the finding. •The Chief Financial Officer (CFO) will be responsible for the implementation of the corrective action plan and will oversee all related finance activities. •FFHC will enforce its current policy and related internal control procedures to ensure that supporting documentation of family size and household income is maintained for all patients that receive discounted patient service fees in relation to the Health Centers Program and Affordable Care Act (ACA) for New and Expanded Services Under the Health Center Program. •FFHC will enforce its current policy and related internal control procedures to ensure that discounted patient service fees are properly calculated and charged based on the applicable approved sliding fee scale. The target date for full implementation of these corrective actions is June 30, 2026. The responsible party for the planned resources will be Wendy Thompson, Chief Executive Officer (312) 682-6110. Our address is 800 East 55th Street, Chicago, IL 60615.

View Audit 396687

Finding 1204982 (2025-002)

Material Weakness 2025

Ou Medicine, Inc.

OK

Reporting Internal Control / Segregation of Duties

As part of the Uniform Guidance audit, OU Health will submit and provide copies of the Federal Financial Reports and progress reports, as applicable. To ensure reporting is compliant under current audit standards, OU Health will utilize a Corporate Reporting Deadlines calendar to ensure timely filin...

As part of the Uniform Guidance audit, OU Health will submit and provide copies of the Federal Financial Reports and progress reports, as applicable. To ensure reporting is compliant under current audit standards, OU Health will utilize a Corporate Reporting Deadlines calendar to ensure timely filings. The grant accounting team within the finance department will coordinate with the grant manager(s) to ensure timely and accurate filings of required reporting. Copies of these reports will be retained within the applicable Grant Folders and Audit Folder.

View Audit 396655

Finding 1204977 (2025-002)

Material Weakness 2025

Puerto Rico Medical Services Administration

PR

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.510

Create a standardized SEFA template that includes all required fields: Assistance Listing Number, Federal Program, Federal Agency (Pass-through Agency), and total expenditures. Implement a monthly reconciliation between the general ledger (GL) and federal drawdowns to ensure the SEFA data is updated...

Create a standardized SEFA template that includes all required fields: Assistance Listing Number, Federal Program, Federal Agency (Pass-through Agency), and total expenditures. Implement a monthly reconciliation between the general ledger (GL) and federal drawdowns to ensure the SEFA data is updated in real-time throughout the year. Establish a policy requiring the SEFA to be completed and reviewed by the Director of Finance 30 days prior to the start of the annual audit. Implement a "double-check" system where the Federal Programs Director verifies that all active federal grants are included in the draft SEFA before submission. Provide specialized training for the finance team on 2 CFR 200.502 (Uniform Guidance) requirements for SEFA preparation and reporting.

View Audit 396649

Finding 1204971 (2025-002)

Material Weakness 2025

County of Fresno

CA

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs

Management concurs with the finding. After the Fiscal Year 2024 monitoring finding last year, the Department developed a comprehensive certification for property owners to complete and a list of required files to be provided to the County on an annual basis. In 2025, Department staff confirmed with ...

Management concurs with the finding. After the Fiscal Year 2024 monitoring finding last year, the Department developed a comprehensive certification for property owners to complete and a list of required files to be provided to the County on an annual basis. In 2025, Department staff confirmed with the County’s HUD representative that the new monitoring documents and plan would satisfy the HUD’s monitoring requirements. Staff are providing technical assistance to the property owners, as preliminary records reviewed indicate all units are still maintained as affordable, but the owners’ provision of all documentation is still in progress. The physical inspections of the property exteriors in October 2025 indicated broadly that housing quality standards are still being maintained. The Department continues to seek out training for staff on HOME requirements and will continue efforts to update monitoring policies and procedures, as necessary, to address all current regulatory requirements. The Department’s multifamily monitoring for all projects in the HOME period of affordability for calendar years through 2024 will be completed prior to August 30, 2026. Although not due in Fiscal Year 2024-25, the Department is moving forward with monitoring for calendar year 2025, which is anticipated to be completed timely, prior to December 31, 2026. As part of the monitoring process, the Department will collect or create documents demonstrating a property’s annual or semi-annual (as relevant) compliance with HOME requirements, review for adherence to regulations, draft and issue a report of findings, and require owners of projects with deficiencies to prepare and submit a satisfactory corrective action plan. The Department will continue to follow up regularly with property owners until all corrective actions are implemented. Staff’s recommendation to facilitate ongoing, decades-long monitoring requirements include the creation of a master omnibus amendment to all existing property agreements to ensure concrete requirements for recordkeeping and monitoring are clearly outlined and accompanied by explicit deadlines. This amendment will be pursued as time permits and after lessons learned from current monitoring activities are integrated into the monitoring process. Anticipated Completion Date August 2026 Contact Information of Responsible Official Name: Augustine Ramirez Title: Division Manager, DPWP Community Development Division Phone: 559-600-4266

View Audit 396642

Finding 1204960 (2025-001)

Material Weakness 2025

City of South El Monte

CA

Reporting Internal Control / Segregation of Duties § 200.303 § 200.510

The City is taking corrective action in response to this finding by strengthening its grant management procedures. The Director of Community Development and Public Works is responsible for overseeing these improvements, which include enhancing coordination among the Public Works Analyst, Grants Coor...

The City is taking corrective action in response to this finding by strengthening its grant management procedures. The Director of Community Development and Public Works is responsible for overseeing these improvements, which include enhancing coordination among the Public Works Analyst, Grants Coordinator, and the City's contracted engineering firm to clearly distinguish between federally and state-funded Highway Safety Improvement Program (HSIP) activities and ensure that program information aligns with current federal award documents. Key measures include requiring identification of funding sources in Staff Reports submitted to City Council prior to grant application submission, assigning unique project numbers and classifications within the City's financial system (Incode), implementing a reconciliation process to accurately align project expenditures with their funding sources before inclusion in the Schedule of Expenditures of Federal Awards (SEFA), and providing targeted staff training along with a standardized SEFA preparation checklist. All corrective actions are set for implementation effective March 18, 2026. Personnel responsible for implementation: Gerardo Marquez Position of personnel responsible: Director of Community Development and Public Works Expected date of implementation: March 18, 2026

View Audit 396633

Finding 1204950 (2025-001)

Material Weakness 2025

Innovative Health Solutions

CA

Reporting Significant Deficiency Internal Control / Segregation of Duties

Finding 2025-01 Internal Control Over Financial Reporting: Revenue Recognition Management concurs with the finding. The condition cited was an oversight and was missed during the transition process of bringing the accounting function in-house, which was previously outsourced to an outside firm. We w...

Finding 2025-01 Internal Control Over Financial Reporting: Revenue Recognition Management concurs with the finding. The condition cited was an oversight and was missed during the transition process of bringing the accounting function in-house, which was previously outsourced to an outside firm. We will perform a review of all promises to give transactions prior to closing the books to ensure proper revenue recognition.

View Audit 396574

Finding 1204946 (2025-001)

Material Weakness 2025

Chief Leschi Schools, Inc.

WA

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.430

15.047 Indian Education Facilities, Operations, and Maintenance – Assistance Listing No. Recommendation: To implement a stronger system of review for ensuring that all changes in employee payroll are properly implemented and approved. Explanation of disagreement with audit finding: There is no disag...

15.047 Indian Education Facilities, Operations, and Maintenance – Assistance Listing No. Recommendation: To implement a stronger system of review for ensuring that all changes in employee payroll are properly implemented and approved. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Human Resources (HR) is working with Finance to process retroactive compensation for the full underpaid amount owed. Associated DRS contributions will also be reviewed and corrected to ensure full compliance. Moving forward, HR will implement an enhanced verification control at the beginning of each fiscal year. This includes documented confirmation of pay accuracy for a minimum of two employees per department following salary schedule implementation and prior to the first payroll. Ideally, this control will be performed jointly by HR and Finance to ensure segregation of duties and consistency. Name(s) of the contact person(s) responsible for corrective action: Beth Wilde, Director of Human Resources Planned completion date for corrective action plan: July 1, 2026

View Audit 396562

Finding 1204931 (2025-002)

Material Weakness 2025

Wellspace Health

CA

Subrecipient Monitoring Internal Control / Segregation of Duties

Corrective Action Plan: The organization will continue with its ongoing implementation of several measures to ensure accuracy and compliance in the sliding fee process. Monthly audits will continue to be conducted to review all sliding fee application forms from the previous month for accuracy and v...

Corrective Action Plan: The organization will continue with its ongoing implementation of several measures to ensure accuracy and compliance in the sliding fee process. Monthly audits will continue to be conducted to review all sliding fee application forms from the previous month for accuracy and verifying information in NextGen. Skills assessments will continue to be conducted in January and July to identify staff needing refresher training. A sliding fee wage training video has been added to Relias and will be required for all staff involved in the process, providing guidance on wage calculation. This training will be distributed twice a year. Additionally, sliding fee monthly audit results will be reported quarterly at QA/QI meetings. To enhance accountability, the organization has implemented an expiration policy for applications lacking supporting documentation within 30 days. The system will automatically expire these applications on day 31, prompting staff to have the patient reapply. Patients who fail to provide the required documentation within the timeframe will receive an invoice or statement for all services rendered during the 30-day period. Estimated completion date: September 30, 2026 Contact person: Jessica Dana, Vice President of Strategy

View Audit 396538

Finding 1204926 (2025-001)

Material Weakness 2025

Elizabethtown College

PA

Student Financial Aid Subrecipient Monitoring Internal Control / Segregation of Duties

Finding 2025-001 Condition During our audit, 1 out of 3 employees selected for testing received a bonus payment for achieving first year enrollment goals. The College then determined 2 employees received such bonuses and additional testing confirmed a total of 2 out of 27 employees who were involved...

Finding 2025-001 Condition During our audit, 1 out of 3 employees selected for testing received a bonus payment for achieving first year enrollment goals. The College then determined 2 employees received such bonuses and additional testing confirmed a total of 2 out of 27 employees who were involved in the College's admissions/recruiting, financial aid and registrar offices received bonuses based on their contributions towards enrollment performance. These bonuses were paid from internal College funds and not from Title IV funds. Corrective Action Plan Corrective Action Planned: The college implemented a policy on incentive pay citing the restrictions and banning incentive pay for specific job duties. The policy and a standard form for awarding additional compensation have been reviewed and approved by senior leadership and posted to the college’s human resources website. Name(s) of Contact Person(s) Responsible for Corrective Action: Amanda Stahl, Vice President for Finance and Ann Eckert, Assistant Vice President for Human Resources will be responsible for ensuring adherence to the policy and review of any awarding of additional compensation. Anticipated Completion Date: The policy and forms were approved and completed September 30, 2025.

View Audit 396527

Finding 1204917 (2025-001)

Material Weakness 2025

City of Madera

CA

Subrecipient Monitoring HUD Housing Programs Period of Performance

Finding 2025-001 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet cri...

Finding 2025-001 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet criteria specified in the regulations that would exempt or exclude them from environmental certification requirements. For projects where the environmental review was not performed, a written documentation that the review was not required must be prepared. Condition and Context: The City could not provide support that there was pre-award or post-award review of grant projects to determine if a project requires an environmental review or is categorically excluded from the environmental review requirements. The City did not have adequate internal controls to ensure compliance with the special test – environmental review requirements. Testing was performed over each requirement for the City. Out of a total population of twelve (12) projects, we selected a sample of four (4) projects to test for environmental reviews. Four (4) out of the four (4) projects tested did not have an exemption report prepared in a timely manner. The sample was not intended to be, and was not, a statistically valid sample. City’s Corrective Action Plan: The City will reinforce its standard operating procedure concerning Environmental Reviews (ER) and will reinsure that environmental reviews are properly completed for every awarded grant project. Corrective Action Plan (Continued) Contact person responsible for corrective action: Michael Lima, Finance Director Anticipated completion date: June 30, 2026

View Audit 396513

Finding 1204912 (2025-002)

Material Weakness 2025

Kildahl Park Pointe Cooperative

MN

Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 396512

Finding 1204911 (2025-001)

Material Weakness 2025

Kildahl Park Pointe Cooperative

MN

Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempts...

Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempts to maximize the segregation of duties in all areas within the limits of the staff available. Planned Completion Date: Not Applicable.

View Audit 396512

Finding 1204907 (2025-001)

Material Weakness 2025

Town of Westport, Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.1

Finding 2025-001 Condition: Expenditures were not reconciled to the general ledger for reporting submitted to the U.S. Department of the Treasury and Bristol County, Massachusetts. Corrective Action Planned: To ensure the accuracy of ARPA reporting, and all Federal Grants, a reconciliation process w...

Finding 2025-001 Condition: Expenditures were not reconciled to the general ledger for reporting submitted to the U.S. Department of the Treasury and Bristol County, Massachusetts. Corrective Action Planned: To ensure the accuracy of ARPA reporting, and all Federal Grants, a reconciliation process will be implemented and followed by all involved. Anticipated Completion Date: April 30, 2026 Contact: Nicole Pearsall, Town Accountant

View Audit 396509

Finding 1204904 (2025-008)

Material Weakness 2025

County of Ventura

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirements...

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: VCPH Management agrees with the recommendation for the Department to strengthen its policies and procedures to ensure all required reports are reviewed, approved and retained as evidence in the applicable grant folder. View of Responsible Officials and Corrective Action: VCPH Management will implement a requirement that all applicable reports must include documented review and approval (e.g. email approval, signed cover sheet, or workflow confirmation) before submission and retention of such approval evidence in the applicable grant folder location. Name of Responsible Persons: Maria Macias, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: April 2026

View Audit 396507

Finding 1204902 (2025-006)

Material Weakness 2025

County of Ventura

CA

Special Tests & Provisions Cash Management Material Weakness § 200.303

Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Materia...

Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Material Weakness in Internal Control over Compliance and Material Non-Compliance Department’s Management Response: Health Care Agency (HCA) management agrees and acknowledges the findings related to the application and review of sliding fee discounts under the Self-Pay Discount Program. The Department recognizes the importance of consistent application of sliding fee discount schedules and proper documentation of review processes to ensure full compliance with federal requirements. The Department is committed to maintaining strong internal controls and ensuring adherence to all applicable policies, procedures, and regulatory standards governing the Sliding Fee Discount Program. View of Responsible Officials and Corrective Action: HCA Management agrees with the finding and will implement corrective actions to strengthen internal controls and ensure consistent application of the sliding fee discount program. The following actions will be taken: • Reinforcement of Policies and Procedures: Re-educate all applicable staff on existing sliding fee discount program policies, including proper calculation and application of discounts. First re-education session was held on February 4, 2026. • Standardization of Workflow: Update and implement standardized workflows and job aids within the registration and billing processes to ensure discounts are applied accurately and consistently. Standardized workflows completed on February 2, 2026. • Enhanced Review and Oversight: Establish a formalized secondary review process for sliding fee discount determinations, including required documentation and supervisory sign-off. Supervisor sign off on sliding fee applications by April 1, 2026. • Ongoing Training: Incorporate sliding fee discount program requirements into onboarding and annual refresher training for relevant staff beginning April 1, 2026. • Audit and Monitoring: Conduct monthly internal audits of sliding fee discount applications to monitor compliance and identify any trends or gap by May 1, 2026. These corrective actions are designed to ensure compliance with federal requirements, improve consistency in application, and strengthen overall internal controls. Name of Responsible Persons: Octavius Gonzaga, Ambulatory Care CFO – Establishes sliding fee discount program policy, procedures, and fee schedules. Erika Herincx, Ambulatory Care Revenue Cycle Manager – Responsible for the oversight of the training program and ensures the listed activities in the Corrective Action Plan are executed. Implementation Date: February 4 - March 30, 2026 – Training of front-end staff and clinic management. April 1, 2026 – Implementation of supervisor sign off for each sliding fee application. April 1, 2026 – Re-Training of Medical Billing Specialists on adjustments. May 1, 2026 – Monthly sampling of encounters December 1, 2026 – Year-to-date report and internal audit

View Audit 396507

Finding 1204900 (2025-005)

Material Weakness 2025

County of Ventura

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Program: Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii Assistance Listing No.: 14.228 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Pass-Through California Department of Housing and Community Development Award No.: 17-MITP...

Program: Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii Assistance Listing No.: 14.228 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Pass-Through California Department of Housing and Community Development Award No.: 17-MITPPS-21029, 18-DRWD-23003, 21-CDBG-HK-0010 Award Year: 2022, 2024 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: Management agrees with the recommendation to revise its procedures to include evidence documenting the individual who reviewed and approved required reports prior to submission. View of Responsible Officials and Corrective Action: a. With regards to the CDBG-CV2 and CDBG-MIT reports managed by the County Executive Office Community Development Division, procedures were revised beginning in April 2025 due to prior year findings 2024-007 and 2024-008 to incorporate documented review and approval requirements for all applicable federally required reports. These enhanced internal controls are being phased in across all relevant reporting processes, with full implementation completed by the end of June 2025. These changes are intended to ensure that evidence of review and approval is consistently retained and that reporting is accurate, complete, and compliant with federal requirements. The reports identified in the finding were completed prior to the stated corrective action. b. With regards to the VC Heal Activity reports managed by Ventura County Workforce Development (VCWD) management, the required reports were prepared by the subrecipient (Career TEAM) using the standardized HCD format and underwent multiple levels of review, the County acknowledges that documentation of the specific individual review and approval prior to submission was not consistently retained. To strengthen internal controls to ensure all required reports include documented evidence of review and approval prior to submission, VCWD management will: • Implement a standardized review and approval protocol requiring documented sign‑off by designated VCWD management prior to submission. • Require Career TEAM to use a formal certification or routing process identifying the preparer and reviewer. • Maintain centralized documentation identifying the report preparer, reviewer/approver, and date of review. • Incorporate these requirements into internal procedures and contractor guidance. • Conduct periodic internal monitoring to verify compliance. Name of Responsible Persons: a. Kimberlee Albers, Deputy Executive Officer b. VCWD staff responsible for the CDBG program Career TEAM (Subrecipient – Report Preparation) Implementation Date: a. April – June 2025 b. April 2026

View Audit 396507

Finding 1204890 (2025-003)

Material Weakness 2025

County of Ventura

CA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Finding 2025-003 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...

Finding 2025-003 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC-06-0507, B-24-UC-06-0507, 95-6000807 Award Year: 2024 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: The County Executive Office Community Development Division agrees with the recommendation to revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. View of Responsible Officials and Corrective Action: Procedures were revised beginning in April 2025 due to prior year findings 2024-007 and 2024-008 to incorporate documented review and approval requirements for all applicable federally required reports. These enhanced internal controls are being phased in across all relevant reporting processes, with full implementation completed by the end of June 2025. These changes are intended to ensure that evidence of review and approval is consistently retained and that reporting is accurate, complete, and compliant with federal requirements. The reports identified in the finding were completed prior to the stated corrective action. Name of Responsible Persons: Kimberlee Albers, Deputy Executive Officer Implementation Date: April – June 2025

View Audit 396507

Finding 1204883 (2025-002)

Material Weakness 2025

County of Ventura

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Finding 2025-002 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: A...

Finding 2025-002 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Activities Allowable or Unallowed and Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: HCA’s Ventura County Public Health (VCPH) Management agrees with the recommendation to strengthen the established policies and procedures to ensure all timecards consistently document evidence of supervisor approval. View of Responsible Officials and Corrective Action: The timesheet identified during this audit were submitted in the County’s payroll system prior to the completion of the 2024 fiscal year audit and related finding 2024-003; therefore, the related corrective actions had not yet been implemented at the time of submission. In response to the prior year’s finding, VCPH Management implemented enhanced controls to ensure compliance with timecard approval requirements moving forward from that date. Payroll staff now sends reminder notifications to supervisors, managers, and VCPH Management before and after each pay period closing to identify and resolve unapproved timecards. Management has also reinforced expectations through additional training for supervisors and managers. When a primary supervisor is unavailable, the established alternate approver process will be used to ensure timely approvals. VCPH Management will continue monitoring compliance with these procedures, and these requirements will be reviewed again with all supervising staff at the next scheduled WIC Supervisor Meeting. Name of Responsible Persons: Laura Flores, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: May 1, 2025 – Instructions were provided to all supervisors at the WIC Supervisor Team Meeting May 7, 2026 – Timecard instructions will again be discussed at the WIC Supervisor Team Meeting

View Audit 396507

Finding 1204851 (2025-002)

Material Weakness 2025

City of Sumner

IA

Internal Control / Segregation of Duties

We will review procedures and plan to make changes to improve internal control when possible.

View Audit 396484

Finding 1204850 (2025-001)

Material Weakness 2025

City of Sumner

IA

Internal Control / Segregation of Duties

We will review procedures and plan to make changes to improve internal control when possible.

View Audit 396484

Finding 1204846 (2025-007)

Material Weakness 2025

Stevenson University, Inc.

MD

Student Financial Aid Internal Control / Segregation of Duties Special Tests & Provisions

FINDING 2025-007 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We have revised our award period start and end dates to align or fall within range of our loan period code start and end dates when reporting to COD. This alignment ensures that all reported disb...

FINDING 2025-007 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We have revised our award period start and end dates to align or fall within range of our loan period code start and end dates when reporting to COD. This alignment ensures that all reported disbursements meet federal timing requests and reduces the risk of COD rejects or compliance findings. Anticipated Completion Date: March 31, 2026

View Audit 396468

Finding 1204843 (2025-006)

Material Weakness 2025

Stevenson University, Inc.

MD

Internal Control / Segregation of Duties Period of Performance Reporting

FINDING 2025-006 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: To resolve the finding of loan period academic end dates being inaccurately reported, we now utilize system forms that allow us to identify and batch-correct any student record with incorrect dat...

FINDING 2025-006 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: To resolve the finding of loan period academic end dates being inaccurately reported, we now utilize system forms that allow us to identify and batch-correct any student record with incorrect dates. This process enhances data accuracy, ensures proper reporting, prevents COD rejects and reduces the risk of future compliance issues. Anticipated Completion Date: Already completed

View Audit 396468

Finding 1204842 (2025-005)

Material Weakness 2025

Stevenson University, Inc.

MD

Student Financial Aid Internal Control / Segregation of Duties Eligibility

FINDING 2025-005 Name of Responsible Individual: Chad Wick, Director of Financial Aid Corrective Action: We have implemented a new Quality Assurance Measure for Auditing all students with a C-Flag. The process begins with the FA advisor team. They are responsible for ensuring all documents have been...

FINDING 2025-005 Name of Responsible Individual: Chad Wick, Director of Financial Aid Corrective Action: We have implemented a new Quality Assurance Measure for Auditing all students with a C-Flag. The process begins with the FA advisor team. They are responsible for ensuring all documents have been received and all steps have been completed to clear the C-Flag. In Colleague the advisor will then mark the file is ready for audit. Chad Wick, Director, Financial aid or Brandon Rhone, Systems Administrator, will review all documents and steps needed to clear C-Flag and then update the communication code to audited and make any adjustments if needed to the FAFSA. Anticipated Completion Date: Already completed

View Audit 396468

Finding 1204835 (2025-003)

Material Weakness 2025

Stevenson University, Inc.

MD

Internal Control / Segregation of Duties Student Financial Aid Matching / Level of Effort / Earmarking

FINDING 2025-003 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We implemented a process which assigns communications management codes based on transmittal activity of each federal direct loan. On the same day a loan is disbursed, our system applies the appro...

FINDING 2025-003 Name of Responsible Individual: Brandon Rhone, Systems Administrator Corrective Action: We implemented a process which assigns communications management codes based on transmittal activity of each federal direct loan. On the same day a loan is disbursed, our system applies the appropriate code to the student record. These codes are then automatically selected for the correct loan disbursement notification to be sent either to the student or parent based on the federal loan type. Anticipated Completion Date: Already completed

View Audit 396468

Corrective Action Plans

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