Corrective Action Plans

Finding 505441 (2023-003)

Significant Deficiency 2023

Calhoun Liberty Hospital Association INC

FL

Questioned Costs Material Weakness Reporting

Calhoun-Liberty Hospital Association, Inc., D/B/A Calhoun-Liberty Hopsital, (Hospital), respectfully submits the following corrective action plan for the year ended December 31, 2023. The finding from the December 31, 2023, Schedule of Findings and Questioned Costs is discussed below. The finding is...

Calhoun-Liberty Hospital Association, Inc., D/B/A Calhoun-Liberty Hopsital, (Hospital), respectfully submits the following corrective action plan for the year ended December 31, 2023. The finding from the December 31, 2023, Schedule of Findings and Questioned Costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FEDERAL AWARD PROGRAMS AUDIT FINDING Significant Deficiency - Noncompliance (2023-003) Recommendation: The Hospital should continue to improve its understanding of the reporting requirements as specified in the applicable loan document and create a process to ensure all USDA requirements are met. Planned Corrective Action: As of September 30, 2024, the Hospital will open a bank account with the Hospital's current banking relationship. This account will be a restricted account dedicated to holding the required reserve as described in the existing USDA loan documents. The required reserve balance will be recorded on the Hospital's trial balance. The reconciliation for such balance will be provided upon request. Emily Brown Chief Executive Officer

View Audit 328121 Questioned Costs: $1

Finding 505353 (2023-101)

Material Weakness 2023

Booker T. Washington Child Development Center, Inc.

AZ

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles

Person Responsible: Josie Ayon Estimated Completion Date: 12/31/2024 Planned Corrective Action: Due to the COVID relief money received, there was no time to acquire additional in-kind donations. The Organization will continue to emphasis the importance of in-kind volunteer hours by parents and has ...

Person Responsible: Josie Ayon Estimated Completion Date: 12/31/2024 Planned Corrective Action: Due to the COVID relief money received, there was no time to acquire additional in-kind donations. The Organization will continue to emphasis the importance of in-kind volunteer hours by parents and has implemented a new program to track parent volunteer hours which will facilitate the gathering of accurate records.

View Audit 328011

Finding 505229 (2023-003)

Significant Deficiency 2023

National Council for Community Development, Inc.

NY

Subrecipient Monitoring Reporting Significant Deficiency

Finding No. 2023-003 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-t...

Finding No. 2023-003 - Reporting – Significant Deficiency Name of Federal Agency: U.S. Department of Treasury Federal Program Name: COVID-19: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Federal Award Identification Number and Year: Not available Name of Pass-through Entity (if applicable): City of Scranton Condition: During our testing, we noted that the Organization did not provide the required monthly reports to the City of Scranton. Recommendation: We recommend that the Organization establish policies, procedures, and controls to ensure that the required information is submitted on a timely basis. Action Taken: Management has incorporated procedures into our grant compliance and administration policies and procedures to ensure that a Project Director reviews, understands and takes the necessary steps to comply with reporting requirements or other, as set forth by the client agreements. This step includes but is not limited to the Project Director completing a Grant Award File Checklist. Anticipated completion date: Immediately.

View Audit 327833

Finding 505128 (2023-011)

Material Weakness 2023

City of Long Beach

CA

Reporting Matching / Level of Effort / Earmarking § 200.303 § 200.502 § 200.510

Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Finding: 2023-011 Contact Person: Sarah Castillo Grants Accounting Officer Emergency Operations Center (EOC) Finance Division Phone: (562) 570-5479 Email: Sarah.Castillo@longbeach.gov Planned Actions: The Emergency ...

Program: Disaster Grants - Public Assistance (Presidentially Declared Disasters) Finding: 2023-011 Contact Person: Sarah Castillo Grants Accounting Officer Emergency Operations Center (EOC) Finance Division Phone: (562) 570-5479 Email: Sarah.Castillo@longbeach.gov Planned Actions: The Emergency Operations Center (EOC) Finance division acknowledges there has been deficiencies in the manner we report expenditures related to a declared disaster on the SEFA, which will be addressed by issuing a Financial Management Disaster Procedure Manual that will include a narrative on this specific matter. The manual will be published on our City Intranet and utilized for all City Staff as a resource for all future disasters that occur. Revisions to the Procedure Manual will be made as needed to ensure we are up to date with the latest compliance changes. Expected Completion Date: 12/31/2024

View Audit 327788

Finding 505125 (2023-009)

Material Weakness 2023

City of Long Beach

CA

Questioned Costs HUD Housing Programs Eligibility § 200.303

Program: Section 8 Housing Choice Vouchers Finding: 2023-009 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To address delays in reexamination processes, in fiscal yea...

Program: Section 8 Housing Choice Vouchers Finding: 2023-009 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To address delays in reexamination processes, in fiscal year 2024, HACLB has contracted with an agency to assist in processing overdue reexaminations, and HACLB has submitted recruiting requisitions to its Human Resources department to hire additional housing specialists to improve upon its management of the high volume of HCV program participants, documentation and processes, and to meet various requirement deadlines. Regarding the testing of HUD-50058 forms, the HUD-50058 form is generated after information is inputted into HUD’s system. Error warnings are produced from the system if information is missing. Accuracy is based on the information inputted. HACLB will provide additional training to staff inputting the information, and reviews will continue to be done by the supervisor. To further improve upon the process, HACLB implemented new housing software in August 2024, which enhances reporting and tracking of payments, of HUD-50058 forms and of contract amendments. Housing Assistance Coordinators will use these reports to identify and address discrepancies. Regarding the City’s control with the HAP register’s required signatures, HACLB’s internal procedures do not require all six Housing Coordinators to approve the check run/HAP register, as KPMG assumed. There are only three assigned Housing Assistance Coordinators that have designated staff who are allowed to make adjustments and review the check-run adjustment register to confirm the work of their respective teams. If one of the approvers is absent, another approver may review and approve the adjustments that can be completed via email. No further change or action is necessary for this process. Furthermore, supervisors will continue to review completed files and train staff on errors identified in the review process. Expected Completion Date: 9/30/2024

View Audit 327788 Questioned Costs: $1

Finding 505123 (2023-008)

Material Weakness 2023

City of Long Beach

CA

HUD Housing Programs Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles § 200.303

Program: Section 8 Housing Choice Vouchers Finding: 2023-008 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To ensure that required repairs are completed within the 30-...

Program: Section 8 Housing Choice Vouchers Finding: 2023-008 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To ensure that required repairs are completed within the 30-day time period, in fiscal year 2024, HACLB has implemented a process to ensure reinspection dates occur before the expiration of the 30-day remediation period. By January 31, 2025, HACLB will also establish clear criteria and standards for the Inspections Housing Assistance Coordinator who is responsible for timely abatement entries, ensuring compliance with operational and regulatory requirements. The Inspections Housing Assistance Coordinator will receive additional training on abatement procedures to enhance their skills and understanding by May 2025, or earlier, depending upon the availability of training opportunities. Furthermore, by January 1, 2025, the Housing Assistance Coordinator will conduct weekly reviews of deficiencies that exceed the 30-day remediation period to ensure timely action for abatement or proration. Regarding the City’s control with the HAP register’s required signatures, HACLB’s internal procedures do not require all six Housing Coordinators to approve the check run/HAP register, as KPMG assumed. There are only three assigned Housing Assistance Coordinators that have designated staff who are allowed to make adjustments and review the check-run adjustment register to confirm the work of their respective teams. If one of the approvers is absent, another approver may review and approve the adjustments that can be completed via email. No further change or action is necessary for this process. Expected Completion Date: 1/1/2025

View Audit 327788

Finding 505119 (2023-006)

Material Weakness 2023

City of Long Beach

CA

Questioned Costs Allowable Costs / Cost Principles HUD Housing Programs § 200.303

Program: Section 8 Housing Choice Vouchers Finding: 2023-006 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: The Housing Authority and the City of Long Beach already has...

Program: Section 8 Housing Choice Vouchers Finding: 2023-006 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: The Housing Authority and the City of Long Beach already has a multi-step review and approval process in place for the processing and posting of journal entries and their support documentation. Moreover, for upcoming fiscal years 2024 and after, the City has changed its indirect costs allocation methodology, in that the City will be directly charging HACLB’s funds its share of overhead costs thereby eliminating the Health and Human Services Department indirect cost allocation plan and related indirect cost charges. However, HACLB will still review the accuracy of the charged overhead costs. Effective fiscal year 2024, September, 30, 2024, HACLB will review the affected general ledger accounts at fiscal year-end, with the new allocation methodology and will verify the charged overhead costs. Expected Completion Date: 9/30/2024

View Audit 327788 Questioned Costs: $1

Finding 505117 (2023-005)

Material Weakness 2023

City of Long Beach

CA

HUD Housing Programs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Program: Section 8 Housing Choice Vouchers Finding: 2023-005 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To address delays in recertification processes, in fiscal ye...

Program: Section 8 Housing Choice Vouchers Finding: 2023-005 Contact Person: Jennifer Saatjian Accounting Services Officer Health & Human Services Department Phone: (562) 570-4022 Email: Jennifer.Saatjian@longbeach.gov Planned Actions: To address delays in recertification processes, in fiscal year 2024, HACLB has contracted with an agency to assist in processing the overdue recertifications, and HACLB has submitted recruiting requisitions to its Human Resources department to hire additional housing specialists to improve upon its management of the high volume of HCV program participants, documentation and processes, and comply with various deadlines. Regarding the Intake forms, HUD does not require an Intake/Eligibility sheet be completed. However, HACLB has typically included an Intake/Eligibility sheet to help ensure quality control. Recently, this was not consistently done, due to staffing shortages. To maintain this internal control in the process, staff will be reminded to ensure that an approved Intake/Eligibility sheet is included in the participant’s file. Effective November 29, 2024, a reminder will be sent to staff to ensure that an approved Intake/Eligibility sheet is included in the participant’s file. Expected Completion Date: 12/31/2024

View Audit 327788

Finding 505112 (2023-004)

Material Weakness 2023

City of Long Beach

CA

Matching / Level of Effort / Earmarking Subrecipient Monitoring HUD Housing Programs § 200.303

Program: HOME Investment Partnerships Program (HOME) Finding: 2023-004 Contact Person: April Apodaca Administrative & Financial Services Bureau Manager Community Development Department Phone: (562) 570-6611 Email: April.Apodaca@longbeach.gov Planned Actions: This issue is related to Finding 2023...

Program: HOME Investment Partnerships Program (HOME) Finding: 2023-004 Contact Person: April Apodaca Administrative & Financial Services Bureau Manager Community Development Department Phone: (562) 570-6611 Email: April.Apodaca@longbeach.gov Planned Actions: This issue is related to Finding 2023-003, and should be considered in the context of that response. Housing Quality Inspection times were impacted in 2023 due to staff shortages and the need to address a significant backlog that occurred as a result of the COVID-19 pandemic. Despite these challenges, the City remained committed to ensuring the health and safety of affordable housing by maintaining an overall inspection rate of 19.65% in Fiscal Year 2023. Furthermore, the Community Development Department is taking comprehensive measures to address the needed maintenance completion timeframe following the required inspection, and the goal is to ensure repairs are completed within thirty days. Expected Completion Date: 12/31/2024

View Audit 327788

Finding 505107 (2023-003)

Material Weakness 2023

City of Long Beach

CA

Matching / Level of Effort / Earmarking § 200.303

Program: HOME Investment Partnerships Program (HOME) Finding: 2023-003 Contact Person: April Apodaca Administrative & Financial Services Bureau Manager Community Development Department Phone: (562) 570-6611 Email: April.Apodaca@longbeach.gov Planned Actions: The Community Development Department ...

Program: HOME Investment Partnerships Program (HOME) Finding: 2023-003 Contact Person: April Apodaca Administrative & Financial Services Bureau Manager Community Development Department Phone: (562) 570-6611 Email: April.Apodaca@longbeach.gov Planned Actions: The Community Development Department has faced challenges in meeting its inspection goals, primarily due to resource limitations, staff redeployment and the impact of COVID-19. It is taking steps to address these issues by forming an in-house inspection team and adopting elements from HUD’s yet-to-be-released NSPIRE system. For example, three full-time positions have been filled as of May 2024 to assist with the Housing Quality Standards (HQS) efforts. The Community Development Department is now taking more systematic, proactive measures to improve the inspection process, particularly through filled vacancies, in-house inspections conducted by department staff, and an active log indicating inspection targets. As a result, during the current fiscal year, there has been a smoother, more data-driven, systematic approach to meeting HQS requirements, as evidenced by the substantial decrease in backlog. The Department is on track to ensure that every project will meet an inspection target that meets the NSPIRE standards (as currently drafted). The Community Development Department will continue to monitor HUD’s proposed NSPIRE standards and will rely on in-house inspections and continued alignment with those until they are finalized. HUD has indicated that the standards will not be finalized until 10/1/2025. Expected Completion Date: 9/30/2024

View Audit 327788

Finding 505102 (2023-002)

Material Weakness 2023

City of Long Beach

CA

Matching / Level of Effort / Earmarking § 200.303

Program: HOME Investment Partnerships Program (HOME) Finding: 2023-002 Contact Person: April Apodaca Administrative & Financial Services Bureau Manager Community Development Department Phone: (562) 570-6611 Email: April.Apodaca@longbeach.gov Planned Actions: Since granting the developer a six-we...

Program: HOME Investment Partnerships Program (HOME) Finding: 2023-002 Contact Person: April Apodaca Administrative & Financial Services Bureau Manager Community Development Department Phone: (562) 570-6611 Email: April.Apodaca@longbeach.gov Planned Actions: Since granting the developer a six-week extension on January 26, 2024, the Community Development Department has continued to communicate with the developer to obtain the missing documentation. During a Teams call with a representative from KPMG on July 18, 2024, the City provided the auditor with evidence of continued correspondence with the developer, in the form of emails dated March 18, 2024, March 20, 2024, and, most recently, July 1, 2024. Expected Completion Date: 12/31/2024

View Audit 327788

Finding 505057 (2023-003)

Material Weakness 2023

Housing Authority of Brevard County

FL

HUD Housing Programs Material Weakness Special Tests & Provisions

2023-003 Special Tests and Provisions – Selection from the Waiting List Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2022-004 from March 31, 2022 ...

2023-003 Special Tests and Provisions – Selection from the Waiting List Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Material Weakness in Internal Control and Material Noncompliance This is a repeat finding of 2022-004 from March 31, 2022 Condition: 14 out of 137 new admissions were selected for testing, but testing was suspended after testing 8 files due to the number of errors. Exceptions were noted as follows: • 1 tenant file had the following errors: o The tenant signed the request for tenancy approval form after the voucher expiration date. o The Authority did not follow their administrative plan when selecting applicants for admission. As a result, the tenant was not admitted properly into the Section 8 program. • 1 tenant file error where the tenant and landlord signed the request for tenancy approval form after the voucher expiration date. • 5 tenant file errors where the Authority did not follow their administrative plan when selecting applicants for admission. As a result, the tenants were not admitted properly into the Section 8 program. • 1 tenant file error where the tenant was selected from the tenant-based mainstream waiting list. A separate waiting list was maintained for tenant based mainstream vouchers in the same county or municipality covered by the regular Section 8 waiting list (the mainstream waiting list has currently been exhausted). The Authority's administrative plan does not allow a separate waiting list for the mainstream vouchers. In addition, the separate tenant based mainstream voucher waiting list was ranked randomly by the Authority's system through a lottery ranking technique. This is not in compliance with the Authority's administrative plan, which states that the waiting list should be organized by preference point and then by date and time of application (first come first serve basis). Recommendation: The Authority should correct the deficiencies and ensure staff is aware of acceptable procedures as outlined in the Authority’s Administrative plan. In addition, the Authority should review staffing levels, skill sets and case load. Furthermore, the Authority should utilize an ongoing quality control review process to ensure proper procedures are being followed. Action Taken: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review process and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.

View Audit 327740

Finding 505056 (2023-002)

Significant Deficiency 2023

Housing Authority of Brevard County

FL

HUD Housing Programs Eligibility Material Weakness

2023-002 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance This is a repeat finding of 2022-003, reported as a Materi...

2023-002 Eligibility – Tenant Files Section 8 Housing Choice Vouchers Program – CFDA Number 14.871 Mainstream Vouchers – CFDA Number 14.879 Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance This is a repeat finding of 2022-003, reported as a Material Weakness from March 31, 2022 (initially occurred as Finding 2021-003, Significant Deficiency) Condition: Out of a total tenant population of approximately 1,775 tenants, 25 files were selected for testing. Exceptions were noted as follows: • 1 tenant file error for one missing 214 affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o General assistance income was included in income when it should have been excluded. Correcting this error would increase the HAP rent from $958 to $1,027. o One missing 214 affidavit form for a member of the household. However, based on the birth certificate, the member of the household is a U.S. citizen. • 1 tenant file had the following errors: o Two members of the household did not check the checkbox on the 214-affidavit form indicating their immigration status. However, based on the birth certificates, the two household members are U.S. citizens. o The tenant’s medical expense was misreported on the 50058. However, the error had no effect on the HAP rent. • 1 tenant file had the following errors and correcting the errors would decrease the HAP rent from $846 to $724: o Miscalculation of social security income reported on the 50058. o Miscalculation of medical expense reported on the 50058. o Miscalculation of the tenant’s annual unreimbursed childcare costs reported on the 50058. • 1 tenant file error where a member of the household over the age of 18 did not sign the 9886. • 1 tenant file had the following errors and correcting the errors would have no effect on the HAP rent: o Food assistance was included as income when it should have been excluded. o The tenant’s utility allowance was misreported on the 50058. • 1 tenant file error where the tenant’s utility allowance was misreported and correcting the error would decrease the HAP rent from $1,198 to $1,183. • 1 tenant fille error where the tenant did not sign the lease agreement. 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: We concur with the recommendation. Due to the COVID-19 pandemic and related staff absences and turnover, we were unable to provide an ongoing quality control review processes and provide ongoing staff training and timely management reviews. We are focused on implementing such procedures and will review staffing levels, skill sets, and case load for each employee.

View Audit 327740

Finding 504955 (2023-001)

Significant Deficiency 2023

Huntsville City Board of Education

AL

Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking § 200.303

Finding: Certain timecards within Title I Part A, Assistance Listing #84.010, were not properly approved prior to payment of the payroll expenditure. Response: Application used to accumulate time and attendance records does not contain embedded administrative programming and controls to ensure all...

Finding: Certain timecards within Title I Part A, Assistance Listing #84.010, were not properly approved prior to payment of the payroll expenditure. Response: Application used to accumulate time and attendance records does not contain embedded administrative programming and controls to ensure all time and attendance information is approved by the employee and supervisor prior to payroll preparation. Management is working with the software provider to develop and embed the appropriate administrative controls and procedures to provide automated processing. In the immediate term, management will, with the assistance of the software provider, develop and utilize a hard copy report of all time and attendance records for each pay period by employee, school and/or department. Prior to payroll preparation, all entries on the report will be reconciled and manual employee and supervisor approvals will be documented. Principals and Department Heads will receive training in proper procedures for timecard approval. Anticipated Completion Date: August 2023

View Audit 327710

Finding 504918 (2023-001)

Significant Deficiency 2023

Talmud Torah D Nitra

NY

Matching / Level of Effort / Earmarking Allowable Costs / Cost Principles Reporting

Finding 2023-01: The audit report was received by the FAC after the due date of May 31, 2024. Recommendation: A system should be implemented that designates multiple points of contact for the auditor, ensuring continuity in the event of key employee transitions and facilitating timely completion o...

Finding 2023-01: The audit report was received by the FAC after the due date of May 31, 2024. Recommendation: A system should be implemented that designates multiple points of contact for the auditor, ensuring continuity in the event of key employee transitions and facilitating timely completion of future audits. Action Taken: Since being made aware of the issue, the administrator and his staff appointed additional board members to gain familiarity with the annual audit process. This will ensure that the auditor will receive all necessary information and documentation in a timely manner, even in the event of employee transitions. In addition, staff has been trained and made aware of the general audit process to ensure future compliance. Implementation Date: Corrective Action plan has been implemented as of September 6, 2024

View Audit 327670

Finding 504880 (2023-005)

Significant Deficiency 2023

Rangeley Lakes Heritage Trust

ME

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency § 200.302

RLHT will add procedures to the current financial policies document that contain oversight over the receipt and use of federal award funds.

View Audit 327661

Finding 504836 (2023-001)

Significant Deficiency 2023

Life Asset, Inc.

DC

Reporting Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties § 200.303 § 200.512

Views of Responsible Officials: Life Asset thought it had done what was required by submitting the annual audit on time directly to Federal Grantors (U.S. Department of the Treasury and the U.S. Small Business Administration). Once Life Asset became aware of the requirement to also file data collect...

Views of Responsible Officials: Life Asset thought it had done what was required by submitting the annual audit on time directly to Federal Grantors (U.S. Department of the Treasury and the U.S. Small Business Administration). Once Life Asset became aware of the requirement to also file data collection forms for single audit to the Federal Audit Clearinghouse, Life Asset did so right away. Life Asset has established an internal control procedure to ensure that the data collection forms and reporting package will be filed timely moving forward.

View Audit 327570

Finding 504763 (2023-001)

Significant Deficiency 2023

Bright Nutrition

TX

Questioned Costs Allowable Costs / Cost Principles Matching / Level of Effort / Earmarking

Significant Deficiency Federal Program: Child and Adult Care Food Program Federal Agency: U.S. Department of Agriculture Federal Award Year: 2023 Individual responsible for corrective action: Date corrective action will be implemented: Carmen Morales / Executive Director November 5, 2024 Response: I...

Significant Deficiency Federal Program: Child and Adult Care Food Program Federal Agency: U.S. Department of Agriculture Federal Award Year: 2023 Individual responsible for corrective action: Date corrective action will be implemented: Carmen Morales / Executive Director November 5, 2024 Response: In FY 2023, our organization experienced a major weakness in internal controls over expenditures for the Child and Adult Care Food Program, as highlighted in Finding 2023-001 of the recent financial audit. The audit found that our systems of internal control contained neither detection nor prevention elements. This raised doubts about whether we have adequate controls to prevent or detect instances of noncompliance with grant requirements. Our internal review has shown that the deficiency derives from weaknesses in our processes and systems, which failed to appropriately authorize or approve expenditures based on compliance with the Uniform Guidance. We realize the urgency in resolving this situation for proper management of federal awards under federal statutes, regulations and award terms. Corrective Action: To rectify the identified deficiency and align with the auditor's recommendation, our organization is implementing a comprehensive Corrective Action Plan. We have engaged a reputable CPA consulting firm specializing in internal controls and federal compliance. This firm will enter into a rigorous inspection of existing procedures to identify weaknesses and suggest improvements in prevention and help us greatly strengthen detection procedures. We recognize that skill upgrading and greater understanding of the task at hand among our staff, especially those with financial management or grant administration responsibilities are extremely important. Therefore, we will have special training sessions. These meetings will focus on the special demands of the Uniform Guidance and underline the importance of adhering to internal control measures. This applies to a full-scale review and improvement of the internal control over expenditures. This entails redefining the granting of authorization and approval procedures, as well as separating duties which must be met within the federal guidelines. It also involves installing checks and balances to ensure strict compliance with these guidelines. In view of the importance of adhering to standards for internal control, we promise to follow best practices as defined in the "Standards for Internal Control in the Federal Government" by the Comptroller General of the United States and the "Internal Control Integrated Framework" by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Determined as we are to constantly improve, our organization will use a systematic approach in order to monitor compliance with internal controls. Under this scheme, regular reporting and analysis is used to quickly find potential problems. It will be a transparent and all-inclusive monitoring process. Our organization knows just how important documentation is, and we will build a robust system in line with federally required documents. This system provides transparency and accountability in our financial management activities, taking another step toward compliance with requirements for responsible stewardship of federal funds. We will continue to co-operate closely with our CPA consulting firm and the auditing body until we can prove that there is significant progress in eliminating the large-scale deficiency. Thank you for your guidance. We will continue to improve our internal controls at the highest level possible so as to meet and exceed federal standards. This comprehensive Corrective Action Plan will be effective immediately.

View Audit 327384 Questioned Costs: $1

Finding 504722 (2023-001)

Significant Deficiency 2023

Barrio Logan College Institute

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking

To the Department of Education Barrio Logan College Institute respectfully submits the following corrective action plan for the year ended August 31, 2023. Name and address of independent public accounting firm: Moss Adams LLP 4747 Executive Drive, Suite 1300 San Diego, California 92121Audit period:...

To the Department of Education Barrio Logan College Institute respectfully submits the following corrective action plan for the year ended August 31, 2023. Name and address of independent public accounting firm: Moss Adams LLP 4747 Executive Drive, Suite 1300 San Diego, California 92121Audit period: August 31, 2023 The findings from the August 31, 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section II of the schedule, Financial Statement Findings, does not include findings and is not addressed. Finding 2023-001 – Reporting – Significant Deficiency in Internal Controls Over Compliance Recommendation We recommend that the Organization set a timeline for closing the books, preparing audit schedules and conducting the audit so the audit can be completed timely. Management should ensure that all involved in the audit process have adequate capacity, are aware of the deadlines and commit to them. Action to be Taken Barrio Logan College Institute agrees with the finding. We are committed to getting the single audit completed on time. A plan for August 31, 2024 audit has been developed and will begin in November 2024 and is expected to be completed before the deadline in 45 CFR 75.501.

View Audit 327339

Finding 504581 (2023-001)

Material Weakness 2023

Minneola District Hospital No. 2

KS

Special Tests & Provisions Material Weakness Significant Deficiency

2023-001 – Special Tests and Provisions Corrective action planned: Minneola Healthcare will open a new bank account that will hold the debt reserve amount. A deposit into the debt reserve account will be made monthly via auto transfer on the 10th of each month till December 2027. There will be one w...

2023-001 – Special Tests and Provisions Corrective action planned: Minneola Healthcare will open a new bank account that will hold the debt reserve amount. A deposit into the debt reserve account will be made monthly via auto transfer on the 10th of each month till December 2027. There will be one withdrawal from this account done yearly to transfer funds to a CD. The yearly payment amount will have its own account with the amount of the next years payment needed. Anticipated completion date: November 30th, 2024 Contact person responsible for corrective action: Controller

View Audit 327169

Finding 504518 (2023-004)

Significant Deficiency 2023

Economic Development Bank for Puerto Rico

PR

Procurement, Suspension & Debarment Subrecipient Monitoring Cash Management

Management agrees with the finding. The amendment in the Subrecipient Agreement to increase the grant awards from $50,000 to $150,000 resulted in new information provided by customers replacing in the Award Management Application’s, (Canopy), old information used in the original grant award. The ban...

Management agrees with the finding. The amendment in the Subrecipient Agreement to increase the grant awards from $50,000 to $150,000 resulted in new information provided by customers replacing in the Award Management Application’s, (Canopy), old information used in the original grant award. The bank established new procedures/requirements to avoid duplicate disbursements and/or confirm customers' bank accounts before processing transactions. All resources working on the CDBG-DR Small Business Financing (SBF) project have been trained to perform their role in accordance with the Program Guidelines, SOPs, and regulations. Cases identified with deficiencies, as part of the 2023 Single Audit at the Grant Awarding and Closing Stages, will be used as examples to prevent this situation from repeating in the future and to establish additional quality control (QC) by Team Leaders. Additionally, recapture (repayment by the Grantee of any Grant amount received) of awarded and disbursed funds will apply when there's failure to comply with the SBF Program Guidelines.

View Audit 327082

Finding 504327 (2023-001)

Material Weakness 2023

Wyoming Coalition Against Domestic Violence and Sexual Assault

WY

Matching / Level of Effort / Earmarking Reporting § 200.303

Finding: 2023-001 - Earmarking, Reporting (Performance Progress Reporting) – Material Weakness in Internal Controls Over Compliance and Instance of Noncompliance (Scope Limitation) Recommendation: We recommend that the Coalition develop policies and procedures for tracking actual expenditures rela...

Finding: 2023-001 - Earmarking, Reporting (Performance Progress Reporting) – Material Weakness in Internal Controls Over Compliance and Instance of Noncompliance (Scope Limitation) Recommendation: We recommend that the Coalition develop policies and procedures for tracking actual expenditures related to earmarking requirements and maintain all supporting documentation for the calculation of the earmarking percentages that are reported in the semi-annual performance progress reports. Corrective Action Plan: The Coalition’s staff has developed policies and procedures for tracking actual expenditures related to these requirements, and maintaining all supporting documentation for the calculation of the earmarking percentages that are reported in the semi-annual progress reports. The Coalition has developed an internal control process for reviewing and approving calculations required by Section 50 of the grant agreement and has strengthened its reporting management review controls to ensure that the review is effective to ensure the completeness and accuracy of reports, and that all elements are appropriately supported, prior to submission the federal agency. Anticipated Completion: Late Summer and Fall of 2023 Responsible Party: WCADVSA Co-Directors, Tiffany Eskelson-Maestas and Susie Markus

View Audit 326879

Finding 504284 (2023-002)

None 2023

The Community College Foundation

CA

Reporting Matching / Level of Effort / Earmarking

Finding 2 2023-2 – Improper Identification of Federal Awards, Agree: Management agrees to enhance its tracking of federal expenditures within the general ledger. Management agrees with the auditors’ recommendations to ensure that personnel receive frequent Uniform Guidance training. We also agree th...

Finding 2 2023-2 – Improper Identification of Federal Awards, Agree: Management agrees to enhance its tracking of federal expenditures within the general ledger. Management agrees with the auditors’ recommendations to ensure that personnel receive frequent Uniform Guidance training. We also agree this will help to ensure the proper tracking and reporting of all federal awards. Management acknowledges that the lack of understanding may have resulted in the misstatement of awards included in the SEFA. We expect to have training arranged as soon as November 30, 2024.

View Audit 326816

Finding 504273 (2023-007)

Material Weakness 2023

St. Philips Child Development Center

DC

Eligibility Matching / Level of Effort / Earmarking

Recommendation: The Center should maintain copies of the eligibility information provided by the families each year during initial determination and subsequent redetermination and retain the information in each child’s file View of Responsible Officials and Planned Corrective Actions: The Center ag...

Recommendation: The Center should maintain copies of the eligibility information provided by the families each year during initial determination and subsequent redetermination and retain the information in each child’s file View of Responsible Officials and Planned Corrective Actions: The Center agrees with the finding. The Center is in the process of implementing the recommendation.

View Audit 326809

Finding 504216 (2023-002)

Significant Deficiency 2023

Koinonia, Inc. 053-11202

NC

HUD Housing Programs Procurement, Suspension & Debarment Reporting § 200.302 § 200.303

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN August 27, 2024 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 ...

Koinonia, Inc. Lenoir, North Carolina CORRECTIVE ACTION PLAN August 27, 2024 U.S. Department of Housing and Urban Development Charles Bennett Federal Building 400 West Bay Street, Suite 1015 Jacksonville, Florida 32202 Koinonia, Inc. respectfully submits the following Corrective Action Plan for the year ended December 31, 2023. Bernard Robinson & Company, L.L.P. 1501 Highwoods Blvd., Suite 300 Post Office Box 19608 Greensboro, North Carolina 27419-9608 The findings from the year ended December 31, 2023 Schedule of Findings and Questioned Costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDING - Financial Statement Audit and Federal Award Program Audit Finding 2023-001: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Projects (Section 223(f)/207) Recommendation: We recommend that the Project funds are only used for expenses of the Project. Additionally, we recommend the related entity reimburse the operating cash of the Project $15,985 for the payroll fees paid. Action Taken: Management acknowledges the Project funds were used for expenses of another entity. Management will ensure the related entity reimburses the operating cash of the Project $15,985 for the payroll fees paid and ensure that the Project funds are only used for expenses of the Project. Finding 2023-002: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 223(f)/207) Recommendation: We recommend management review/enhance its accounting and internal control procedures to ensure that all key accounts are reconciled and reviewed with supporting evidence of such review. Action Taken: We agree with Finding 2023-002 and the recommendation described in the accompanying schedule of findings and questioned costs. Management will review the accounting ial procedures, system of internal controls and policies. FINDING - Federal Award Program Audit Finding 2023-003: U.S. Department of Housing and Urban Development, Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 223(f)/207) Recommendation: We recommend that management review its policies and procedures in place to ensure that the residual receipts deposit is made per regulatory guidelines. Action Taken: We agree with Finding 2023-003 described in the accompanying schedule of findings and questioned costs. Management will deposit $4,285 into the Project's residual receipts account. Management will review its policies and procedures in place to ensure that the residual receipts deposit is made per regulatory guidelines. If HUD has questions regarding this corrective action plan, please call 828-758-2617. Sincerely yours, Chassidy Triplett Project Administrator Koinonia, Inc.

View Audit 326713

Corrective Action Plans

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