Corrective Action Plans

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Condition: The Organization allocates personnel costs to federal programs based on wage forms that reflect estimated time expected to be worked across programs. Supervisors perform biweekly reviews of employee time charged within the Paylocity system and compare allocations to supporting information...
Condition: The Organization allocates personnel costs to federal programs based on wage forms that reflect estimated time expected to be worked across programs. Supervisors perform biweekly reviews of employee time charged within the Paylocity system and compare allocations to supporting information such as program schedules and caseloads. However, we noted that: - There is no formal documentation retained evidencing the supervisor's review of supporting records (e.g., caseloads, schedules) to substantiate that recorded time aligns with actual work performed; and - The only evidence of review is system approval within Paylocity, which indicates the timecard was approved but does not demonstrate the nature, extent, or basis of the review performed. Planned Corrective Action: Family Guidance Centers will require direct supervisors to document their review of supporting records (e.g., caseloads, schedules) of direct reports to substantiate that recorded time aligns with actual work performed as a part of their bi-weekly timesheet reviews. Family Guidance Centers will retain this documentation in accordance with its document retention policy. Contact person responsible for corrective action: Jim Hagestad, CFO Anticipated Completion Date: July 1, 2026
El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, t...
El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, the following corrective actions are being implemented: 1. Revised Application and Documentation Requirements: o The Sliding Fee Program application forms are being updated to include structured sections for staff to record income from supporting documentation (e.g., pay stubs, tax returns), rather than relying on the patient to write their income on the application, which will greatly reduce incorrect income stated on support. Staff will be responsible for calculating annual gross income based on supporting documentation and have a checklist to ensure documentation is complete and retained/uploaded in the system. 2. Two-Step Review Process: o A staff member (the “Preparer) will calculate the annual gross income, determine the household size, and determine the eligible sliding fee discount, and a second staff member (the “Reviewer”) will independently review and verify the Preparer’s calculations and determinations based on the supporting documentation. Both parties will document their review of the application to establish accountability. 3. Staff Training and Ongoing Competency Checks: o Comprehensive refresher training will be provided to all staff involved in the sliding fee program process, including the use of the poverty guidelines, income calculation methods, the new forms, entering income and household size into the system, and uploading support to the system. 4. Formal Ongoing Monitoring and Review: o The Billing Department will conduct regular audits of completed sliding fee applications and eligibility determination forms to ensure compliance with policies. Errors will be tracked and addressed through corrective action and coaching. Person Responsible: Ricardo Ornelas Position of Responsible Party: Chief Financial Officer Completion Date: August 31, 2026
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate ...
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate documentation to verify primary residence status as part of the CDBG/HOME loan reconciliation workbook process.  Implementing periodic monitoring procedures for loan recipients.  Maintaining documentation in loan files to support compliance throughout the affordability period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and has implemented loan file monitoring procedures to verify occupancy compliance. Name of the contact person responsible for corrective action: Melanie Marquez Planned completion date for corrective action plan: 6/30/2026
Finding 1221501 (2025-002)
Material Weakness 2025
Hips
DC
Views of Responsible Officials: As noted in your findings, those instances occurred only prior to December 2024 and no misallocations were noted after that. HIPS implemented a second level of review and approval by the program managers during FY25. HIPS's current payroll and time tracking systems do...
Views of Responsible Officials: As noted in your findings, those instances occurred only prior to December 2024 and no misallocations were noted after that. HIPS implemented a second level of review and approval by the program managers during FY25. HIPS's current payroll and time tracking systems do not have the capacity to implement time tracking at this level of complexity. In FY 26, Supervisors will review and document review of proposed time allocations on the payroll allocations spreadsheets prior to month start to ensure that the allocation correctly matches the proposed schedule, and at month end to assess any changes needed based on actual time worked on various grant activities. We will also search for new software options to improve approval and entry process.
The County has implemented additional internal controls, including a workflow for sharing invoices during 2025 when it was discovered that the grant reporting was not done properly. The County also adopted a new grant policy in March 2026 to provide additional levels of review from the grant applica...
The County has implemented additional internal controls, including a workflow for sharing invoices during 2025 when it was discovered that the grant reporting was not done properly. The County also adopted a new grant policy in March 2026 to provide additional levels of review from the grant application process through closeout of a grant. This further ensures accurate and timely reporting going forward.
In order to keep cash as accurate as possible, we will work to clear interfund as often as possible. With upcoming development revenue that we will see come in over the next 1-2 years on the non profit side, we will work to prioritize returning funds to the Public Housing Operating Funds. To prevent...
In order to keep cash as accurate as possible, we will work to clear interfund as often as possible. With upcoming development revenue that we will see come in over the next 1-2 years on the non profit side, we will work to prioritize returning funds to the Public Housing Operating Funds. To prevent co-mingling of cash, we will begin a plan to break apart the funds for each program - Spencer, COCC, 3rd and 11th. Each quarter, we access payroll allocations to better reflect employees’ use of time and actual costs incurred by program and by LITC property. Public Housing and COCC training is planned that all finance staff will attend to make sure proper HUD procedures, rules, and guidelines are followed. The plan is to reduce the receivable down to $-0- as soon as possible and within 5 years.
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount...
MCR has established a procedure to require a completed application with signature and supporting documentation in order to qualify for a sliding fee scale. Any incomplete applications or those with incomes greater than 200% of the poverty level will only result in consideration for courtesy discount. Financial counselors have 7 business days from the return of a patient application to determine completeness and eligibity for sliding fee scale. The Chief Financial Officer, Kara Onorato, will be responsible for ensuring that this process is followed. The new policy was approved by the board of Directors in December 2025. The new process is being implemented in 2026. Internal audit began monthly audits and corrective training in February 2026 with target goal by Q3 2026.
Due to inadequate monitoring of grant deadlines and project implementation timelines, the Organization did not obligate certain federal funds before the expiration of the award period. As a result, a portion of the awarded funds remained unused and was no longer available for program activities. The...
Due to inadequate monitoring of grant deadlines and project implementation timelines, the Organization did not obligate certain federal funds before the expiration of the award period. As a result, a portion of the awarded funds remained unused and was no longer available for program activities. The Organization will implement enhanced grant management procedures to ensure that federal funds are obligated and utilized within the approved period of availability. Corrective actions include: 1. Maintaining a centralized grant tracking system that identifies award periods, obligation deadlines, expenditure deadlines, and closeout requirements. 2. Requiring quarterly reviews of grant balances and project progress by program and finance personnel. 3. Establishing written procedures for monitoring unobligated balances and addressing delays in project implementation. Providing training to program managers and fiscal staff regarding federal grant requirements, including obligation and period-of-performance requirements. Requiring management review of all federal awards at least 90 days prior to expiration to identify and address any risk of unexpended or unobligated funds. Anticipated Completion Date: Immediately
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced proc...
Views of Responsible Officials and Planned Corrective Action: Management is aware of this matter and acknowledges the need to strengthen controls over the timely reconciliation and review of aged accounts payable related to federal awards. Management has implemented, or will implement, enhanced procedures designed to prevent similar issues in future reporting periods, including: (1) formalizing written policies requiring monthly accounts payable reconciliations; (2) adding a review control focused specifically on items outstanding more than 90 days, including documented investigation and resolution; and (3) training accounting personnel on these procedures and related documentation requirements. Management believes these corrective actions will improve the timely identification, review, and resolution of aged accounts payable balances in future reporting periods.
All grants are to be labeled as federal and non-federal when entered into the Chamber’s general ledger (Emily), and when grant documents are saved internally (Chamber Staff). Expenses associated with federal grants are to be coded and classed to those grants for accurate entry on the SEFA (Emily). T...
All grants are to be labeled as federal and non-federal when entered into the Chamber’s general ledger (Emily), and when grant documents are saved internally (Chamber Staff). Expenses associated with federal grants are to be coded and classed to those grants for accurate entry on the SEFA (Emily). The Executive Director (Tom) will be involved in the preparation of the SEFA to ensure only federal grant expenses are included, and that no expenses are omitted.
The City will establish a process of documenting the approval of submitted reports along with the source of information input into said reports.
The City will establish a process of documenting the approval of submitted reports along with the source of information input into said reports.
The Band has added additional staff within its OMB to increase their ability to perform more thorough seperation of duties and more accurately process these submissions. A complete internal review of the Band's OMB policies and procedures is scheduled and expected completion is December 31, 2026.
The Band has added additional staff within its OMB to increase their ability to perform more thorough seperation of duties and more accurately process these submissions. A complete internal review of the Band's OMB policies and procedures is scheduled and expected completion is December 31, 2026.
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Corrective Action Plan: The return of tenant security deposits were not completed on time due to staff turnover. Stanan’s occupancy specialist and supervisor will closely monitor the timing of the return of security deposits. Anticipated Completion Date: The implementation of training and procedures...
Corrective Action Plan: The return of tenant security deposits were not completed on time due to staff turnover. Stanan’s occupancy specialist and supervisor will closely monitor the timing of the return of security deposits. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the tim...
Corrective Action Plan: The annual recertifications were not completed on time due to difficulty obtaining the required tenant information. Stanan will start the process earlier in the year to collect the documentation needed. Stanan’s occupancy specialist and supervisor will closely monitor the timing and progress of all tenant annual recertifications to avoid untimely filings in the future. Anticipated Completion Date: The implementation of training and procedures is expected to be completed by September 30, 2026.
2025-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2026
2025-003: Reporting Compliance Requirement The City will review the current procedures for maintaining documentation for when quarterly project and expenditures reports are completed, reviewed and submitted. Contact Person: Rosie Cavazos, CFO Proposed implementation date: September 30, 2026
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split betwee...
The Department of Behavioral Health (DBH) agrees with the findings and will put controls in place to resolve the issue. On May 20, 2026, DBH trained all grants staff on how to use combo codes in the timekeeping system (Peoplesoft) so that individuals whose time is split across grants or split between grant and local projects can record their time to each funding source. This new process will be rolled out starting June 12, 2026.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Economic Security Administration (ESA) concurs with this finding. ESA will review its current case review procedures to ensure that prioritization of assignments aligns with regulatory timeliness requirements. Based on the results of this review, ESA will update its procedures as needed.
The Child and Family Services Agency (CFSA) concurs with the finding. CFSA has instituted a point-of-payment invoice validation and cost determination process that will allow the Agency to retire the quarterly expenditure reporting process in its entirety. Providers submit invoices that align with t...
The Child and Family Services Agency (CFSA) concurs with the finding. CFSA has instituted a point-of-payment invoice validation and cost determination process that will allow the Agency to retire the quarterly expenditure reporting process in its entirety. Providers submit invoices that align with their contract schedules and they self-report on a schedule-oriented tool. The CFSA team reviews, validates, and approves each and every invoice. The tool tracks invoiced cost for the entire fiscal year such that by year’s end there is a verified, validated catalogue of reported costs that are used to derive the family-based rate that drive the adjustment claims for these special tests and provisions.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Child and Family Services Agency (CFSA) concurs with the finding. The June 2025 implementation of STAAND, CFSA’s new system, included safeguards to mitigate the generation of claims for federal reimbursement for payments made to any provider for which there is a critical licensure issue.
The Department of Human Services (DHS) agrees with the findings and will work within the Division of Customer Workforce Employment and Training (DCWET) team to mitigate the causes of the findings. These findings are mostly caused by inconsistency of caseload management practices. Another mitigating ...
The Department of Human Services (DHS) agrees with the findings and will work within the Division of Customer Workforce Employment and Training (DCWET) team to mitigate the causes of the findings. These findings are mostly caused by inconsistency of caseload management practices. Another mitigating factor is attributable to glitches in information technology around the sanction process. DCWET has been working with OIS to eliminate inaccuracies in customer assignments. DCWET conducted a systematic review of each caseload to ensure that customers are properly assigned to PITs, which allows effective tracking of their participation (non-participation) leading to sanctioning and reduction in benefits. The PIT Clean-Up exercise was implemented on May 6, 2026. The PIT Clean up exercise has significantly enhanced the operational efficiency of each assigned PIT. Customers who were not participating in the TEP program were identified and placed in special PIT from which they will go through the sanctioning process and ultimately see their benefits reduced. The second issue is glitches in information technology, which have caused inconsistencies in the non-compliance period for non-participating customers. DCWET is working with the OIS to automate the sanction process to ensure that the required non-compliance outreach efforts are timely completed and customers sanctioned. The automation process would eliminate inconsistencies in executing the required outreach efforts. The automation process development started on May 20, 2026, and will be implemented on October 1, 2026.
The Department of Human Services (DHS)/Economic Security Administration (ESA) agree with the auditor’s findings regarding the lack of completion of requests from the Child Support Enforcement (CSE) to the TANF program to impose a child support on parents who have not cooperated with Child Support co...
The Department of Human Services (DHS)/Economic Security Administration (ESA) agree with the auditor’s findings regarding the lack of completion of requests from the Child Support Enforcement (CSE) to the TANF program to impose a child support on parents who have not cooperated with Child Support compliance requirements. The incomplete work was due to staff transitions occurring during the review period which impacted the oversight and productivity of DHS – ESA staff working on the child support sanction process. The following corrective action plan has been developed by DHS/ESA to address the findings. These controls would provide DHS/ESA with the ability to identify discrepancies, promote accountability, and ensure that actions are carried out timely and accurately. The work will be performed by staff working in the Division of Customer, Workforce Employment and Training (DCWET). The DCWET leadership will: • Conduct training sessions for the newly assigned staff to ensure they understand the procedures and expectations to complete the required tasks. The training will also provide clarity about the procedures for imposing a child support sanction and lifting a child support sanction. The lack of clarity was caused by the sanction team’s staff turnover and inability to timely backfill vacancies due to budget constraints. A new staff has been assigned to the team, and OPM has updated the manual that contains the procedures for imposing and lifting child support sanctions. • Implement an internal digital tracking system to ensure completion of all required tasks in a timely and accurate manner. This will include a process to re-assign work when staff are on leave for two or more days. OPM is working with OIS to automate some of the manual processes while retaining the integrity of the process. OPM will collaborate with OIS to automate both the non -cooperation sanction imposition and lifting. OIS will create a digital tracking system that would lead to improvement in the supervision, tracking, and monitoring of staff daily activities and completion of assignments. • Increase supervision and monitoring of employees responsible for completing the requests from the Office of the Attorney General OAG by conducting scheduled follow-up reviews to monitor progress of work and provide guidance to staff, as needed. • Review the procedures document to ensure that the process of calculating sanctions and benefit amounts as well as the content of sanction letters are accurate and timely.
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income su...
The Department of Human Services (DHS) agrees with the findings, and we’ll work with the DCAS and DICM teams to mitigate the causes of the findings. These findings are mostly residual issues with the tables in DHS/ESA DCAS system. ESA needs to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. This would be automating the process by connecting the 2-step process into one task. This automation process would be a permanent solution to curbing stale and unsubstantiated hours from migrating to Q5i. DCWET will work with DICM to request that a JIRA ticket be created to enhance DCAS to tie the income evidence in the income support case to the employment evidence in the person record to allow the employment hours to end date once the income evidence is end dated. The ESA DPO needs to conduct staff training (re-training) of all SSR on the DCAS screens which require action to confirm employment. This means that the DPO should dedicate resources to providing adequate training to SSRs involved in updating customers’ employment information in DCAS. The DCWET Deputy Administrator will take the lead with the DPO counterpart to implement the necessary training starting before September 30, 2027.
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