Corrective Action Plans

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-011 1. Finding Summary The auditor determined that the institution did not consistently obtain and document required verification information prior to disbursing Title IV federal student aid for students selected for verification. As a result, the institution could not demonstrate compliance with federal verification requirements, increasing the risk that Title IV funds were disbursed before verification was completed. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that required verification documentation was not consistently obtained and documented prior to the disbursement of Title IV federal student aid for students selected for verification. 3. Root Cause Analysis The root cause of this finding resulted from weaknesses in verification monitoring procedures and inadequate review controls, which allowed Title IV aid to be packaged and disbursed prior to the completion and documentation of required verification. 4. Corrective Action(s) Management has implemented standardized checklists and workflows, added secondary review, provided additional training to staff, and implemented periodic internal monitoring. Description of Corrective Actions Management has implemented enhanced verification workflows and system controls to prevent packaging or disbursement of Title IV aid until verification is fully completed. A mandatory supervisory review has been established, and targeted staff training has been conducted to reinforce verification requirements. Periodic internal monitoring and quality assurance reviews will be performed to ensure on going compliance. 5. Risk Mitigation (Required - Even if Disagreeing) The corrective actions mitigate the risk of disbursing Title IV funds prior to verification completion by strengthening verification workflows, system controls, and supervisory review. Targeted staff training and ongoing internal monitoring further reduce the likelihood of premature disbursements and support sustained compliance with federal verification requirements. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Director of Financial Aid 7. Implementation Timeline • Corrective action implemented: Yes (No) • If not fully implemented, expected completion date: June 30, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) Fully implemented Partially implemented (Not yet implemented) Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability Management will conduct regular supervisory and periodic internal reviews of verification files to confirm that required documentation is completed prior to Title IV packaging and disbursement. Continued staff training, maintained system controls, and standardized verification procedures will be sustained to ensure long-term compliance and timely identification of any deficiencies.

Federal Program / Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-010 1. Finding Summary The auditor determined that the institution did not consistently obtain or maintain official transfer transcripts required to document prior academic completion and establish Title IV eligibility in accordance with the Higher Education Act and federal regulations. As a result, the institution could not fully demonstrate compliance with Title IV student eligibility documentation requirements, increasing the risk of awarding federal aid to potentially ineligible students. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that official transfer transcripts were not consistently obtained or maintained to adequately document prior academic completion and establish Title IV eligibility in accordance with federal requirements. 3. Root Cause Analysis The root cause of this finding was gaps in staff training related to transfer transcript requirements and insufficient supervisory review to ensure required documentation was obtained and retained prior to the awarding or disbursement of Title IV federal student aid. 4. Corrective Action(s) Management has implemented standardized checklists and workflows, added secondary review, provided additional training to staff, and implemented periodic internal monitoring. Description of Corrective Actions Management has enhanced oversight by implementing additional supervisory review to confirm required transfer transcripts are received and documented before Title IV processing, provided targeted training to address staff knowledge gaps regarding eligibility requirements, and improved documentation practices by centralizing the collection and retention of official transfer transcripts. 5. Risk Mitigation (Required - Even if Disagreeing) The corrective actions reduce the risk of awarding or disbursing Title IV funds to ineligible students by ensuring that high school completion documentation is consistently collected, verified, and retained prior to aid processing. Enhanced supervisory review, centralized documentation practices, strengthened system controls, and ongoing staff training provide multiple layers of oversight to prevent documentation gaps and support sustained compliance with federal eligibility requirements. 6. Responsible Party • Office/Department: Office of Admissions • Title of Responsible Official: Director of Admissions • Name (optional): ________ 7. Implementation Timeline • Corrective action implemented: Yes (No) • If not fully implemented, expected completion date: Action is fully implemented, but will transition to a new automated process at a later date. 8.Status of Corrective Action (For Prior-Year or Repeat Findings) Fully implemented Partially implemented (Not yet implemented) Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability Management will conduct ongoing supervisory and periodic internal reviews of student files to verify that official transfer transcripts are consistently obtained, documented, and retained prior to Title IV awarding or disbursement. Continued staff training, standardized documentation procedures, and strengthened system controls will be maintained to ensure long-term compliance and to promptly identify and correct any deficiencies.

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-009 1. Finding Summary The auditor identified that some students lacked required documentation ofhigh school completion or an allowable alternative in their files yet were awarded Title IV federal student aid. As a result, the institution could not demonstrate compliance with Title IV student eligibility requirements, creating a risk of disbursement to ineligible students. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that required documentation of high school completion or an allowable alternative was not consistently maintained in student files prior to the disbursement of Title IV federal student aid. 3. Root Cause Analysis The root cause of this finding was insufficient supervisory review of student eligibility documentation and decentralized documentation practices that resulted in inconsistent collection and retention of required records. 4. Corrective Action(s) Management has implemented standardized checklists and workflows, added secondary review, enhanced system controls, and implemented periodic internal monitoring. Description of Corrective Actions The institution has taken corrective action to strengthen compliance with Title IV student eligibility requirements related to documentation of high school completion. Management has implemented standardized eligibility checklists and documented workflows to ensure required documentation is collected and verified prior to awarding or disbursing federal student aid. A mandatory supervisory or secondary review has been added to confirm eligibility and documentation completeness before processing or disbursement occurs. In addition, system controls within the Student Information System (SIS), financial aid software, and document management systems have been enhanced to require receipt and retention of acceptable high school completion documentation before Title IV funds can be awarded. Targeted staff training has been conducted to reinforce federal eligibility requirements, institutional procedures, and documentation standards. To ensure ongoing compliance, the institution has established periodic internal monitoring and quality assurance reviews of student files to verify documentation accuracy and consistency. These measures are designed to prevent recurrence of the finding and support sustained compliance with federal regulations. 5. Risk Mitigation (Required - Even if Disagreeing) The implemented corrective actions mitigate the risk of awarding or disbursing Title IV funds to ineligible students by ensuring that high school completion documentation is collected, verified, and retained prior to aid processing. Standardized workflows, enhanced system controls, supervisory review, targeted staff training, and ongoing internal monitoring collectively strengthen compliance oversight, reduce documentation errors, and promote consistent adherence to federal student eligibility requirements. 6. Responsible Party • Office/Department: Office of Admissions • Title of Responsible Official: Director of Admissions • Name (optional): _ 7. Implementation Timeline a. Corrective action implemented: Yes (No) b. If not fully implemented, expected completion date: June 30, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) Fully implemented Partially implemented (Not yet implemented) Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability Management will conduct periodic internal reviews and quality assurance checks of student eligibility files to confirm that required high school completion documentation is consistently obtained and maintained prior to Title IV disbursement. Supervisory reviews, ongoing staff training, and continued use of standardized workflows and system controls will be sustained to reinforce compliance, identify issues timely, and ensure long-term adherence to federal Title IV eligibility requirements.

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-008 1. Finding Summary The auditor identified that seven (7) out of sixty (60) sampled students had Title IV-created credit balances that remained on their accounts for more than 14 days without being released to the student or parent. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that the identified condition resulted from the system not pulling credit balances per semester. 3. Root Cause Analysis The root cause was the absence of the system not pulling credit balances per semester. Therefore, it is a manual process to verify if the current semester aid creates a refund for current semester charges when a balance from a prior semester is rolling forward. 4. Corrective Action(s) Management has enhanced system controls and implemented periodic internal monitoring. Description of Corrective Actions To address this finding and prevent recurrence, the University is performing weekly reviews of all student accounts that had aid processed during that week. This review is important because all statements are reviewed even if a credit balance is not showing to identify if the aid for the period creates a credit for the semester despite a beginning balance. Further, the University is transitioning to a new accounting system which will identify credit by term. The new system, Colleague, which will automate the process, will be implemented in approximately 18 months. 5. Risk Mitigation (Required - Even if Disagreeing) The institution recognizes the importance of mitigating compliance risk in this area. According!y, the corrective actions described above are designed to timely identify student accounts with a refundable credit balance and future audit findings. 6. Responsible Party a. Office/Department: Business Office b. Title of Responsible Official: Senior Accountant c. Name (optional): 7. Implementation Timeline Manual corrective actions have been implemented and are ongoing as part of standard operating procedures. The automated process is anticipated to be fully in place within 18 months once the University transitions to the Colleague system. • Corrective action implemented: Yes (No) • If not fully implemented, expected completion date: Action is fully implemented, but will transition to a new automated process at a later date. 8.Status of Corrective Action (For Prior-Year or Repeat Findings) (Fully implemented) Partially implemented Not yet implemented Evidence of Implementation An example can be provided for a student with a balance who received a refund for the current semester despite not showing a credit balance. 9. Monitoring and Sustainability The University will continue its manual review process until it can be automated.

Federal Program/ Assistance Listing Number (ALN) 84.268, 84.063, 84.007, 84.033 Finding Reference Number 2024-007 1. Finding Summary The auditor identified inconsistencies in the application of Cost of Attendance (COA) budgets, indicating that COA components were not applied uniformly to students within similar categories and were not consistently supported by documentation. 2. Management's Position Management agrees with the finding. Management Explanation Management agrees with the finding and acknowledges that Cost of Attendance budgets were not applied consistently across similarly situated students. The University recognizes the importance of uniform COA application and adequate documentation to ensure accurate financial aid determinations and compliance with federal regulations and is committed to implementing corrective measures to address this issue. 3. Root Cause Analysis Office of Fiscal Affairs The root cause was the absence of standardized Cost of Attendance budget templates and documented procedures, combined with training gaps and limited supervisory review. These conditions led to inconsistent application of COA components across student categories and insufficient documentation to support the amounts used in financial aid packaging. 4. Corrective Action(s) Management is working to implement standardized workflows and periodic internal monitoring. The University has also enhanced system controls. Description of Corrective Actions To address this finding and prevent recurrence, the University has implemented standardized COA checklists and workflows to ensure consistent application of Cost of Attendance components across similarly situated students. Supervisory review has been added prior to finalizing COA determinations to verify accuracy, consistency, and compliance with federal requirements. In addition, system controls within the student information system and financial aid management software have been enhanced to support standardized COA budgets and reduce the risk of inconsistent manual adjustments. Periodic internal monitoring and quality assurance reviews have been established to assess ongoing compliance, identify variances, and support the long-term sustainability of corrective actions. 5. Risk Mitigation (Required - Even if Disagreeing) The University recognizes the importance of reducing regulatory risk associated with the consistent application of Cost of Attendance budgets. The corrective measures implemented are intended to strengthen consistency, oversight, and system-based controls in COA determinations, thereby minimizing the risk of inaccurate financial aid awards, inconsistent student treatment, and future audit findings. 6. Responsible Party • Office/Department: Office of Financial Aid • Title of Responsible Official: Financial Aid Director • Name ( optional): -------------- 7. Implementation Timeline • Corrective action implemented: Yes (No) • If not fully implemented, expected completion date: June 30, 2026 8. Status of Corrective Action (For Prior-Year or Repeat Findings) Fully implemented Partially implemented (Not yet implemented) Evidence of Implementation In progress, evidence is not yet available. 9. Monitoring and Sustainability The University will maintain ongoing oversight of Cost of Attendance determinations through periodic internal reviews and supervisory verification of COA budgets. System controls, standardized workflows, and quality assurance checks will be routinely evaluated to ensure consistent application across student categories and sustained compliance with federal requirements.

Assistance listing numbers and program names: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) 93.767 Children’s Health Insurance Program (CHIP) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Completion date: June 30, 2025 Agency’s Response: Concur AHCCCS would like to note this matter was discovered through internal review of Office of the Inspector General (OIG) recoupment documentation and filings with Centers for Medicare & Medicaid Services (CMS). This matter was reviewed in detail by our financial management team and AHCCCS determined this was caused by a few factors: (1) staffing issues and employee turnover in all units involved in the process to return OIG recoupments to CMS. (2) A breakdown of inter and intra-departmental communication and collaboration. Actions Taken: ● Filling the related following positions that experienced turnover: Accounting Supervisor, Reporting Administrator, and 2 Accounting Specialists. ● Increased collaboration across the respective departments and divisions to ensure the federal share of all case recoupments is timely returned to CMS. ● Revised our standard work processes to include quarterly reconciliations of case recoupments among the various departments and divisions. Actions Remaining: ● AHCCCS anticipates having reported and returned the federal share to CMS for all case recoupments identified by June 30, 2025.

Assistance listing numbers and program names: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) 93.767 Children’s Health Insurance Program (CHIP) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact persons and titles: Vanessa Templeman, Inspector General, AHCCCS Office of Inspector General Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Completion date: December 31, 2025 Agency’s Response: Concur In fiscal year 2023, the process of holding quarterly reviews of deferred cases did not occur due to resources being diverted to focus on Strike Force activities involved in addressing the behavioral health crisis. Additionally, Office of the Inspector General (OIG) announced a re-organization in December 2023 that resulted in permanent transitions to other teams for several staff. Teams were given time to finalize cases and move items to other investigators in order to limit disruption to cases. By April 2024, after the Strike Force initiative had been unwound and the member team structure changes for personnel were finalized, the member team restarted its process of quarterly deferred case reviews. At the first review in April 2024, cases in the deferred backlog that were not completed in the timeframe set for the reviews were postponed to the next quarterly review in July. AHCCCS OIG commits to a review of the current Deferred Process and will determine areas of improvement to include timeliness for deferred case review completion, quarterly completed deferred case review reports, and required documentation for all deferred case processes.

Assistance listing number and program name: 93.778 Medicaid Assistance Program (Medicaid; Title XIX) 93.778 COVID-19 Medicaid Assistance Program (Medicaid; Title XIX) Agency: Arizona Health Care Cost Containment System (AHCCCS) Name of contact person and title: Jeff Tegen, Assistant Director, AHCCCS Division of Business and Finance Anticipated completion date: December 31, 2027 Agency’s Response: Concur In May 2023, AHCCCS announced its initial findings of credible and willful fraud by sober-living providers across the state. Since then, AHCCCS has suspended more than 300 providers, assisted over 10,000 individuals with the humanitarian response, and implemented more than 20 new initiatives to combat fraud, waste, and abuse in the Medicaid program. As the extent of the fraud was revealed, AHCCCS recognized the need for comprehensive, system-wide strategies. AHCCCS partnered with the Attorney General and Governor’s Office to develop a comprehensive plan to address the loopholes fraudulent providers were exploiting. Actions Taken: ● Increased scrutiny of claims based on claims volume. ● Issued a moratorium on new provider registrations for impacted provider types. ● Prevented Reimbursement of Claims for Impossibly Rendered Services. ● Claims for Substance Abuse Services for Children under the age of 12 to Require Clinical Review Prior to Payment. ● Set thresholds for services to initiate a prepayment review. ● Required claims to be billed for specific dates of service rather than ranges. ● Flagged claims for services of the same style/overlapping codes. ● Created a prepayment review process for providers utilizing suspicious billing practices. ● Eliminated retroactive billing. ● Credible Allegation of Fraud suspensions include both provider entities and owners/ behavioral health (BH) practitioners. ● Implemented ID.Me identity verification for AHCCCS Online. ● Required providers to disclose any third-party billing relationships. ● BH Providers are now considered high-risk provider types for provider enrollment. ● Per Diem codes have been set to only be able to be billed once per day. ● Practitioners, including BH Technicians, can no longer be patients at the same provider. ● Worked with the Arizona Corporation Commission to flag suspicious registrations. ● Ensured AHCCCS coding adhered to National Correct Coding Initiative standards and confirmed no edits had been turned off. ● Streamlined AHCCCS reporting of bad actors to the appropriate professional oversight boards. ● Creation and publication of the Covered Behavioral Health Services Guide to connect all relevant AHCCCS policies and explain how they interact in the Behavioral Health System of Care. ● Robust changes to our AHCCCS Provider Enrollment System to address fraud, waste and abuse (FWA) issues. ● Update to the Behavioral Health Residential Facilities policy (to be published shortly) to provide greater detail and clarity for providers and members about what should and should not be included in services rendered by this provider type. ● Creation of the prepayment review process for fee for service claims and inclusion of data measurement to allow for agile modification going forward to respond to over utilization or abuse of codes. ● Creation of the Community Partner Assistor Organization Reviews to prevent abuse of access to the Health-e-Arizona Plus system. ● Designated pathways of partnering on large scale quality of care investigations between the Division of Fee for Service and managed care organizations to prevent unnecessary member impact. ● Social media campaign to encourage the public to report FWA/abuse & neglect. ● Requirement of all providers to transition to Electronic Funds Transfer. ● Removed the phone attestation option for American Indian Health Program (AIHP) enrollment, and are in the process of implementing the AIHP verification process with tribal partners and Indian Health Services based on utilization. ● Memorandums of Understanding with AZ Board of BH Examiners and Board of Nursing to promote interagency information sharing and referrals, as well as the close referral relationship with the Arizona Department of Health Services. ● Regular Public BH System Cross-Agency Collaboration meetings including all agencies, boards, commissions and the GO in the public health space ● Updates to the provider enrollment policy in AMPM 610, explicitly requiring many more disclosures of providers, and making it clear without full and transparent registration information, providers will be terminated or denied enrollment with AHCCCS. ● Implemented policies which required BH Professionals, required to oversee the clinical services provided at Behavioral Health Residential Facilities and Outpatient Behavioral Health Clinics, to be reported upon registration and be listed on claims submissions ● Mandatory transition to Electronic Fund Transfer (direct deposit) for all AHCCCS provider reimbursements ● Linking BHP to BH companies and facilities they work for Actions Remaining (but not limited to): Implementing eligibility integrity requirements for AIHP enrollment. ● Implementation of Alivia – a new AI powered data analytics platform for pre-pay and post-pay claims analysis, currently in the development and planning stage ● Conduct onsite quality of care reviews for patients in treatment longer than 90 days. ● Require medical records to define specialized services. ● Implement a new pre/post pay claims system. AHCCCS continuously monitors our systems and investigates instances of fraud, waste or abuse. Any areas of concern which are identified are then addressed and system improvements are made. Furthermore, AHCCCS utilizes data analysis to confirm that these system improvements are having the intended impacts and that provider networks remain robust.

Finding 2024-010 Material Weakness in Internal Control and Noncompliance, Late Issuance of the 2024 Single Audit Reporting Package to the Federal Audit Clearinghouse: Condition: The Single Audit packages for the City’s fiscal years ended June 30, 2024, June 30, 2023 and June 30, 2022 should have been submitted to the Federal Audit Clearinghouse by March 31, 2025, March 31, 2024 and March 31, 2023, respectively. The City missed the filing deadlines, making the filings for 2024, 2023 and 2022, late. Contact Person: Daniel Garrick, Director of Finance Corrective Actions Planned: We agree with the finding. The City and Danbury Public Schools have made the audits a top priority by filling vacant positions and hiring an audit consulting firm. The 2025 audit is in process and we anticipate that the 2026 audit will be completed in a timely manner. Anticipated Completion Date: March 31, 2027

Finding 2024-015 Material Weakness in Internal Control and Material Noncompliance – Reporting Condition: For the Education Stabilization Fund- Elementary and Secondary School Emergency Relief (84.425D), American Rescue Plan Elementary and Secondary School Emergency Relief (84.425U), the City provided supporting documentation that was unable to be agreed to the amounts that were submitted to the State in the annual performance report ESF - ESSER Recipient Data Collection Form OMB PRA Number: OMB No. 1810-0749 for the key line items: Line 3.b1 LEA expenditures by ESSER Subgrant fund, expenditure category, and object code, Line 3.b10 Number of specific positions supported with ESSER Funds, 3. Line 3.c Allocation of ESSER funds to schools and criteria used to allocate funds to schools, and Line 5.a Full Time Equivalent positions. Contact Person: Michael Weaver, CFO, Danbury Public Schools Corrective Actions Planned: We agree with the finding. The District acknowledges that a formal reconciliation process did not exist at the time of submission to verify that data entered into the annual ESF-ESSER Recipient Data Collection Form (OMB No. 1810-0749) was agreed to underlying financial records and supporting documentation prior to submission to the State. The District will proactively strengthen internal controls over federal reporting by implementing a formal reconciliation policy and establishing designated review prior to submission. Completion Date: 6/30/2025

Finding 2024-011 Material Weakness and Material Noncompliance Finding, Reporting – Special Reporting Condition: For Coronavirus State and Local Fiscal Recovery Funds (ALN# 21.027), none of the quarterly Project and Expenditure Reports were submitted as required, and instead the City elected to submit an annual Project and Expenditure Report that was submitted past the deadline for the fourth quarterly report. Contact Person: Kara Prunty, Assistant Director of Finance – Grants, City of Danbury Corrective Actions Completed: We agree with the finding. The City has implemented a centralized SLFRF quarterly reporting process under a designated grants/finance lead, including a recurring quarterly close schedule and a two-level review (preparer and approver) prior to submission. All submitted reports, supporting documentation, and submission confirmations are retained in a central repository.

Finding 2024-014: Material Weakness in Internal Control and Material Noncompliance – Reporting Condition: For the Community Development Block Grants (CDBG) Entitlement/Special Purpose Grants Cluster (14.218), For the entitlement funding allocated to the City, they were required to submit four quarterly reports during the year and two annual reports. Of the three entitlement reports selected for testing, each one was submitted after the deadline. For the COVID-19 funding allocated to the City, they were required to submit quarterly reports duringthe year for two separate awards, for a total of eight quarterly reports, and one annual report. None of the required COVID-19 funding reports were submitted during the current year. Contact Person: Kara Prunty, Assistant Director of Finance – Grants, City of Danbury Corrective Actions Completed: We agree with the finding. The City has implemented a centralized reporting process under a designated grants/finance lead, including a recurring quarterly close schedule and a two-level review (preparer and approver) prior to submission. All submitted reports, supporting documentation, and submission confirmations are retained in a central repository.

Action taken: CRMHS management concurs with the finding. During the fiscal year ended June 30, 2024, CRMHS did not consistently operate internal controls over federal cash management as designed. Specifically, a federal draw was processed in excess of immediate cash needs and was not fully reconciled to supporting allowable expenditures prior to submission. This resulted in federal funds being drawn in advance of program disbursement requirements. Management acknowledges that this practice does not comply with 2 CFR §200.305, which requires non-federal entities to minimize the time between drawdown of federal funds and their disbursement for program purposes. While the funds were ultimately expended on allowable program costs, the timing of the draw created a compliance exception and reflects a material weakness in internal control over compliance. Management takes this matter seriously and has implemented corrective measures to strengthen cash management oversight and reconciliation procedures. Such actions include: • CRMHS has completed a full reconciliation of all drawdowns under Assistance Listing 93.696 to supporting allowable expenditures through June 30, 2024. • Any excess cash balances identified were evaluated and adjusted to ensure compliance with federal cash management requirements. • Pre-Draw Reconciliation Requirement—No draw request may be submitted without documented reconciliation to recorded allowable expenditures. • Segregation of Duties and Review—the draw request and documented reconciliation will be reviewed and signed off on by a second qualified member of the accounting team. • Monthly Grant Cash Monitoring—CRMHS will compare cumulative drawdowns to cumulative allowable expenditures to identify and resolve any excess cash position.

Finding: 2024-001: Material Weakness - Untimely Audit Submission in Accordance with 0MB Uniform Guidance Description of Finding: The Chamber did not electronically submit their December 31, 2024 Single Audit reporting package (Single Audit Report, Data Collection Form, Status of Prior Year Findings, and a Corrective Action Plan) within the required time period. Cause: The submission was delayed because the Single Audit could not be completed on time due to change in audit firm and staffing shortages. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian understands the seriousness of this deficiency and the need for strict adherence to timely audit submissions per the OMB Uniform Guidance. Additional staff have been hired to assist in accounting processes, including a Controller to review all accounting processes and procedures with the Director of Finance and implement best practice recommendations and stronger month-end closing procedures and schedule. The delay in performing the 2024 audit was caused by a change in auditors. Our previous auditor did not have the capacity to continue our audit engagement due to staff shortages related to COVID. A new audit firm identified and engaged. However, there were delays in beginning the audit, and staffing challenges internally with completing the audit such that deadlines were not met. Additionally, an external finance and accounting firm was hired in September 2025 to provide additional capacity and high-level support to bring our audits current by March 2026. The additional staffing, external expertise, and improved procedures will prevent untimely submissions in future years. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Karen Wood, Not-for-Profit CFO (Creating Answers LLC), 916-930-0777, kwood@creatinganswers.com Projected Completion Date: March 2026 If the Office of Policy and Management and/or Oversight Agency has questions regarding this Plan, please call Ryan Fong at (916) 446-7883.

Federal Program - U.S. Department of Housing and Urban Development Assistance Listing Number 14.157 - Supportive Housing for the Elderly (Section 202) Material Weakness & Noncompliance Category of Finding - Cash Management Name of contact person – Nation Wright, AICDC Chief Operating Officer Corrective action – The Corporation has changed management agent to Tapestry which has the procedures and controls in place to detect and prevent a similar finding to occur in the future. Completion date – Management and the Board of Directors implemented the above as of December 2024.

Federal Program - U.S. Department of Housing and Urban Development Assistance Listing Number 14.157 - Supportive Housing for the Elderly (Section 202) Material Weakness & Noncompliance Category of Finding - Special Tests and Provisions Name of contact person – Nation Wright, AICDC Chief Operating Officer Corrective action – The Corporation changed the management agent to Tapestry and a deposit of $11,680 was made on January 9, 2025 to properly fund the replacement reserve. Completion date – Management and the Board of Directors implemented the above as of January 2025.

Federal Program - U.S. Department of Housing and Urban Development Assistance Listing Number 14.157 - Supportive Housing for the Elderly (Section 202) Material Weakness & Noncompliance Category of Finding - Eligibility Name of contact person – Nation Wright, AICDC Chief Operating Officer Corrective action – The Corporation has changed management agent to Tapestry which has a compliance department to assist site staff in completing tenant recertifications. Completion date – Management and the Board of Directors implemented the above as of December 2024.

Management acknowledges that this finding was also reported in the prior fiscal year. Due to staffing changes within the finance department and competing operational priorities, the corrective actions previously planned were not fully implemented in time to ensure timely filing of the required reports. Management recognized the importance of timely regulatory filings and has taken additional steps to strengthen internal processes and oversight. Significant staff turnover within the finance department during and after the audit period resulted in delays in preparing audit schedules and supporting documentation required for the completion of the related regulatory filings. In addition, formalized procedures and a compliance calendar for regulatory reporting deadlines were not fully implemented during the prior year. Finance Management will implement a financial compliance calendar to track all required regulatory reporting deadlines, including IRS Form 990, single audit and other financial reports. The calendar will include preparation, review, and submission deadlines to ensure reports are completed and filed in time. Finance management will coordinate with external auditors and tax preparers to support timely completion of filings. Responsible party: Finance Management Target Completion Date: June 30, 2026 Monitoring: The Finance Director will maintain and review the compliance calendar monthly to monitor upcoming deadlines and filing status. The CFDO will periodically review compliance with reporting requirements to ensure filings are completed within required timeframes.

Management acknowledges this finding and recognizes the importance of maintaining adequate internal control over the preparation and review of accounting records. This finding was also reported in the prior fiscal year, however due to turnover within key finance leadership roles and limited staff capacity and expertise during the audit period, the previously planned corrective actions were not fully implemented. While improvement began toward the end of Fiscal Year 2025 (FY25), management acknowledges that the implementation of strengthened internal control procedures will continue into Fiscal Year 2026 (FY26), as the newly established finance team further develops and formalizes these processes. The Finance Department experienced turnover within key finance leadership roles, which limited the department's capacity and expertise necessary to implement the corrective actions and process improvements identified in the prior year audit. The organization has since strengthened the finance department by hiring additional staff to support the implementation of improved internal controls, formalized procedures, and regulatory reporting processes. Finance leadership has implemented additional review procedures over the preparation of the accounting records including supervisory review of journal entries, documented monthly account reconciliations and a standardized month-end checklist. These procedures will help ensure accounting records are accurate, complete and reviewed timely. While improvements begin during the end of FY25, full implementation of these process improvements will continue into FY26 to ensure sustainable internal control practices and timely regulator reporting. Responsible party: Finance Management Target Completion Date: June 30, 2026 Monitoring: Management reviews the month end close calendar monthly to ensure all reconciliation, journal entries, and reporting are completed and documented. Finance management also reviews monthly financials with the program leaders during soft close.

2024-005 – Reporting Contact Person Terry Hanson Corrective Action Plan Management recognizes the delayed submission of the 2024 audit to the Federal Audit Clearinghouse. To prevent recurrence, management is developing a compliance calendar and assigning responsibility for federal filing deadlines to the Director of Finance. Regular progress reviews will ensure all audit deliverables are completed and submitted within the required ninemonth period. This corrective measure will improve accountability and ensure timely compliance with federal reporting standards. Planned Completion Date for CAP Immediately

2024-004 – Reserve for Replacement Contact Person Terry Hanson Corrective Action Plan Management will request a waiver from HUD to cease deposits to the RFR Account until such time that the account falls below the HUD recommended minimum required deposit, per 4350.1. If waiver is not forthcoming, management will request that owner provide funding to RFR, until such time that the operating account balance reflects a positive balance and the property is able to deposit to RFR. Planned Completion Date for CAP Immediately

Finding Number: 2024-004 Finding Title: Eligibility Program: 93.778 Medical Assistance Program Name of Contact Person Responsible for Corrective Action: Janelle White – Controller Health and Wellness Service Team Melody Santana-Marty – Controller Community Services and Supports Corrective Action Planned: Internal quality controls specific to the Medicaid program, will be reviewed and updated. Department-wide communication to staff regarding the importance of complete and adequate supporting documentation in the case file prior to case approval has been implemented and will continue on an ongoing basis. This communication will include guidance on how to determine whether documentation is sufficient, along with examples of acceptable support. At a minimum, required documentation will include: • Documentation verifying citizenship. • Examples of properly completed applications. • Reconciliation of the income verification in MAXIS and the documentation in the case file. • Reconciliation of the asset verification in MAXIS and the documentation in the case file. The Quality Assurance review process and Corrective Action Plan have been documented and communicated to provide guidance for new staff, serve as refresher training for existing staff, and ensure that appropriate actions are consistently followed. This documentation will be reviewed and revised as necessary to maintain compliance and consistency across the department. Supervisory review has been implemented for new hires. When issues are identified with current staff, enhanced review strategies and procedures will be applied to ensure required documentation is properly reviewed prior to case approval. Supervisors will conduct periodic reviews of case files to ensure that all required documentation is on file. If errors are identified and overpayments occur, the Department will follow established protocols of the Minnesota Department of Human Services regarding the identification, reporting, and recovery of overpayments. Anticipated Completion Date: 06/10/2026

Finding 2024-003 Federal Agency Name: U.S. Department of Agriculture Assistance Listing Number: #10.766 Program Name: Community Facilities Loans and Grants, Community Facilities Loans and Grants Compliance Requirement: Special Tests and Provisions Finding Summary: The Hospital did not sufficiently fund their reserve account. As of December 31, 2024, the Hospital should have USDA debt reserves at least equal to $459,326. Responsible Individuals: Doug B. Lewis, Chief Financial Officer Corrective Action Plan: Management will review the reserve account requirements and ensure appropriate contributions are made during the fiscal year.

Corrective Action Plan • Policies and Procedures Reinforcement – Review and reinforce procurement policies to ensure all purchases are supported by approved requisitions and required quotations. • Documentation Retention Controls - Implement controls to ensure all procurement documentation is properly filed and retrievable. • Staff Training and Development – Provide training on procurement requirements under uniform guidance. This training will focus on compliance with policies and procedures and emphasize the importance of require documentation for each process and best practices. • Monitoring and Compliance Review - Establish periodic internal review procedures to ensure adherence to procurement policies. Name of the contact person responsible for corrective action plan Jesús A. Rodríguez Avilés – Financial Planning and Analysis Director Anticipated Completion date June 30, 2025

The Town has implemented a process whereas the Town Manager and Board of Trustees review all federal or state grant agreements to verify whether the grant agreement outlines a CFDA number in determining whether the funds are related to federal awards.