Corrective Action Plans

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Finding 2023-002: This finding is for Education Department Condition 1. Impact: For 3 or (5%) of 60 non-payroll transactions tested, (a) no financial records were available to substantiate allowability; or (b) the available procurement file documentation was insufficient to substantiate allowability...
Finding 2023-002: This finding is for Education Department Condition 1. Impact: For 3 or (5%) of 60 non-payroll transactions tested, (a) no financial records were available to substantiate allowability; or (b) the available procurement file documentation was insufficient to substantiate allowability, as follows: The noncompliance resulted in a total questioned cost of $604. Condition 2. For 13 or (20%) of 65 payroll transactions tested, no departmental timecards or timesheet documentation was provided to support compensation, taxes, and fringe benefits. Condition 3. Of the 49 payroll transactions tested where departmental timecards or timesheet support was provided, we identified the following: 1) For 1 employee, the uniform timesheet reported 16 hours of sick leave, while the departmental timesheet reported 80 hours of regular work. 2) For 1 employee, the uniform timesheet was not signed by all required authorized signatories. 3) For 1 employee, the uniform timesheet reported 56 regular hours, while the departmental timesheet reflected 43 regular hours; however, the employee was paid for 80 regular hours, resulting in an overpayment of approximately $76 (processed on May 2, 2023). Root Cause Analysis • For Condition 1, ineffective documentation filing and retention controls were exacerbated by the relocation of the State Treasury office during the audit period. • For Condition 2, ineffective documentation filing and retention controls existed at the departmental agency level, where timesheets or other timekeeping records were retained. • For Condition 3(a), insufficient internal controls at the departmental level failed to ensure reconciliation of departmental timesheets with uniform timesheets submitted to the State Treasury. The Treasury does not consistently receive departmental support and therefore relies on agency review and certification. • For Condition 3(b), required signatory authorization controls failed at both the departmental and treasury levels. • For Condition 3(c), existing controls failed to detect and prevent the overpayment. Corrective Actions 1) For Condition 1. Strengthen documentation filing and retention controls. 2) For Condition 2 & 3 a) Enhance monitoring controls at the departmental level or implementing a uniform timekeeping system to reduce reconciliation burdens b) Establish policies requiring submission of department timekeeping report to the State treasury to allow for secondary reconciliation c) Reinforcing the requirement that when changes are made affecting uniform timesheets but not departmental records, appropriate explanatory documentation be retained. Responsible Parties For Condition 1. • Director of DOTA/Payable Section - Strengthen documentation filing and retention controls. For Condition 2 & 3 • Director of Education/Timekeepers - Enhance monitoring controls at the departmental level or implementing a uniform timekeeping system to reduce reconciliation burdens • Director of DOTA and Payroll Section - Establish policies requiring submission of departmental timekeeping reports to the State treasury to allow for secondary reconciliation. • Director of DOTA and Payroll Section - Reinforce the requirement that when changes are made affecting uniform timesheets but not departmental records, appropriate explanatory documentation be retained. Timeline Verification of Effectiveness For condition 1, the State Treasury will perform routine inspections of the filing systems to verify compliance and address individuals who resist necessary changes. For Conditions 2 and 3, payroll will not be disbursed to any department that fails to adhere to the new action plan
View Audit 372843 Questioned Costs: $1
U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit...
U.S. Department of Health and Human Services Period of Performance Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: We recommend that the Organization design, implement, monitor and maintain evidence over internal controls. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.
U.S. Department of Health and Human Services Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to suppo...
U.S. Department of Health and Human Services Allowability Child Care and Development Block Grant – Assistance Listing No. 93.575 Recommendation: The auditors recommend the Organization design, implement, and monitor internal controls over allocations as well as maintain source documentation to support amounts charged to the grant. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review the current internal controls over allocations and source documentation to identify any gaps or weaknesses and develop a plan to address any identified gaps or weaknesses, including updating policies and procedures as necessary. Management will also communicate the updated policies and procedures to all relevant employees and provide training as needed. Monitoring and testing procedures will be implemented to ensure that the updated policies and procedures are being followed. There will also be regular reviews and updates to the policies and procedures as needed to ensure ongoing effectiveness. Management will assign responsibility for maintaining source documentation to a specific individual or team and develop a system for organizing and storing source documentation, such as a centralized electronic database. Monitoring and testing procedures will be implemented to ensure that source documentation is being maintained and is readily accessible. Lastly, there will be regular reviews and updates to the system for organizing and storing source documentation as needed to ensure ongoing effectiveness.
View Audit 372833 Questioned Costs: $1
Finding: 2023-003: Material Weakness and Questioned Cost - Grant Claim Support Description of Finding: SacAsian’s accounting system design did not align grant billings with the general ledger’s underlying expenses, as only direct costs were coded to the grant and other allowable costs flowed to unre...
Finding: 2023-003: Material Weakness and Questioned Cost - Grant Claim Support Description of Finding: SacAsian’s accounting system design did not align grant billings with the general ledger’s underlying expenses, as only direct costs were coded to the grant and other allowable costs flowed to unrestricted. As a result, the ledger detail did not clearly demonstrate the grant claim support without additional reconciliation. Cause: A comprehensive system for allocating and documenting grant-related costs had not yet been implemented. Statement of Concurrence or Nonconcurrence: SacAsian agrees with the finding. Corrective Action: SacAsian understands and acknowledges the significance of this finding and the potential that it creates for documentation gaps. The Controller and Director of Finance have implemented an ERP system which allows for better cost reporting and reviews of the grant-related expenses for accuracy, reliability, and reconciliation. While the general ledger details do not align, SacAsian did provide full documentation to substantiate the expenses claimed in each billing. Moving forward, all expenditures that have been billed will be reconciled to the general ledger monthly by the Director of Finance, Controller, and external CFO firm to ensure that billings match to expenditure detail and have been correctly allocated. Responsible Party: Ryan Fong, Director of Finance, 916-446-7883, rfong@sacasiancc.org Karen Wood, Not-for-Profit CFO (Creating Answers LLC), 916-930-0777, kwood@creatinganswers.com Pat Fong Kushida, President & CEO, 916-446-7883, patfk@sacasiancc.org Projected Completion Date: October 2025
View Audit 372580 Questioned Costs: $1
Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps...
Management concurs with this finding. The delayed submission resulted from insufficient internal controls and oversight under prior leadership. The individuals previously responsible for this function are no longer with the Organization. Under current leadership, management has taken immediate steps to strengthen oversight and ensure future compliance. Knowledgeable personnel are now in place and have been made fully aware of all federal reporting requirements and deadlines. Management is actively developing formalized policies and procedures governing federal reporting, including a centralized compliance calendar, documented workflows, defined roles and responsibilities, and an internal review process prior to submission. These measures will be implemented by the first quarter of 2026.
Notre Dame Health System ceased operation prior to the date of this report. Accordingly, mnagement is unable to take corrective action or implement further internal control improvements related to this finding.
Notre Dame Health System ceased operation prior to the date of this report. Accordingly, mnagement is unable to take corrective action or implement further internal control improvements related to this finding.
View Audit 372473 Questioned Costs: $1
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting an audit for fiscal ...
Statement of Concurrence or Nonconcurrence: CUAHSI agrees with the finding and recommendation. CUAHSI Corrective Action: Action by CUAHS! impacting audit year 2023: NA Corrective actions to processes and responsibilities impacting subsequent years: CUAHSI is behind on submitting an audit for fiscal year (FY) 2023. Management has made clearing this backlog its highest priority. The schedule is to complete and file the FY 2023 package by fall 2025 and the FY 2024 package shortly thereafter, at which point CUAHSI expects to return to on-time Federal Audit Clearinghouse filings. Recent upgrades to the accounting system, the hiring of in-house finance staff, and revised closing procedures are designed to streamline and accelerate future audit preparation so that all subsequent audits are filed by the required deadlines. Name of Contact Person: • Maureen S. Ako, Director of Finance • Telephone: (339) 221-5400 • Email: msabino@cuahsi.org Projected Completion Date: 2026-09-30
Implement a tracking system (spreadsheet or database) to monitor completion of home visits and conferences for all enrolled children. Train teachers and family service staff on the requirements and proper documentation procedures for home visits and parent-teacher conferences. Conduct monthly review...
Implement a tracking system (spreadsheet or database) to monitor completion of home visits and conferences for all enrolled children. Train teachers and family service staff on the requirements and proper documentation procedures for home visits and parent-teacher conferences. Conduct monthly reviews to ensure compliance
Confirm the specific reporting periods and deadlines for all DHHS grants, including ARP and CRRSA grants. Ensure semiannual SF-425 reports are submitted within the deadlines outlined in the grant agreements, and annual SF-425 reports for ARP and CRRSA grants Maintain documentation of submission date...
Confirm the specific reporting periods and deadlines for all DHHS grants, including ARP and CRRSA grants. Ensure semiannual SF-425 reports are submitted within the deadlines outlined in the grant agreements, and annual SF-425 reports for ARP and CRRSA grants Maintain documentation of submission dates and retain copies of all reports for audit and compliance purposes. Establish an internal calendar and reminder system to track future SF-425 reporting deadlines to prevent delays.
Finding 2023-004 Assistance Listings: 93.567 & 93.576 Issue: Eligibility documentation needed strengthening. Corrective Actions 1. Apricot Hard Stops – Mandatory ORR eligibility fields prevent enrollment without complete data. 2. Enhanced Case Notes – Case managers must document eligibility review a...
Finding 2023-004 Assistance Listings: 93.567 & 93.576 Issue: Eligibility documentation needed strengthening. Corrective Actions 1. Apricot Hard Stops – Mandatory ORR eligibility fields prevent enrollment without complete data. 2. Enhanced Case Notes – Case managers must document eligibility review and note interpreter use. 3. File Accountability – Physical files labeled with responsible case manager; cross-checked during audits. 4. Compliance Reviews – Compliance Coordinator conducts quarterly file audits. Responsible Official: Javid Siddiqi, Director of Immigration Services Implementation Date: Completed January 2025; quarterly monitoring ongoing.
Finding 2023-003 Assistance Listings: 93.567 & 93.576 Issue: Two reports were resubmitted after the deadline due to formatting problems. Corrective Actions 1. Clarification Provided – Original submissions were on time; errors arose from incompatible file formats. 2. Two-Step Review – Reports prepare...
Finding 2023-003 Assistance Listings: 93.567 & 93.576 Issue: Two reports were resubmitted after the deadline due to formatting problems. Corrective Actions 1. Clarification Provided – Original submissions were on time; errors arose from incompatible file formats. 2. Two-Step Review – Reports prepared by Compliance Coordinator, then sequentially reviewed by Director of Immigration Services and CEO. 3. Submission Log – Central log with due dates, submission confirmations, and file-format checks. 4. Quarterly Spot-Checks – Compliance Coordinator tests report files on recipient software. Responsible Officials: Javid Siddiqi (Director), Rachel Kornfeld (CEO) Implementation Date: Process in place since August 2023.
Finding 2023-002 Assistance Listings: 93.567 & 93.576 Issue: Inadequate timekeeping allocation procedures. We respectfully acknowledge the finding inadequate allocation procedures, and we offer the following clarifications. Corrective Actions 1. Payroll System Upgrade – Implementing UKG with grant a...
Finding 2023-002 Assistance Listings: 93.567 & 93.576 Issue: Inadequate timekeeping allocation procedures. We respectfully acknowledge the finding inadequate allocation procedures, and we offer the following clarifications. Corrective Actions 1. Payroll System Upgrade – Implementing UKG with grant allocation fields (configuration underway). 2. Manager Review Cycle – Monthly allocation reports auto-sent to managers; signed approvals returned to Accounting. 3. CFO Review & Sign-off – CFO verifies and finalizes allocations before posting to FundEZ. 4. Written Policies – Comprehensive timekeeping and allocation manual (draft completed; final issue by July 15 2025). Responsible Official: Renee Carroll, CFO Target Completion: System live and policies finalized by July 30, 2025.
Finding 2023-001 Assistance Listings: 93.567 & 93.576 Issue: Expense allocations lacked sufficient grant-level detail. We respectfully agree with your finding of deficiency in internal controls and are working through the process to correct this. Root Cause Rapid program expansion outpaced existing ...
Finding 2023-001 Assistance Listings: 93.567 & 93.576 Issue: Expense allocations lacked sufficient grant-level detail. We respectfully agree with your finding of deficiency in internal controls and are working through the process to correct this. Root Cause Rapid program expansion outpaced existing finance capacity and procedures. Corrective Actions 1. Finance Team Expansion – Hired full-time CFO, staff accountant, and external consultant (Jan 2025). 2. Policy & Procedure Overhaul – New written procedures (completed Mar 2025) referencing 2 CFR 200 Subpart E. 3. Tri-System Documentation – All expenses now recorded and cross-referenced in FundEZ (accounting), Apricot (program), and a reconciliation workbook. 4. Monthly Reconciliations – Accounting staff prepare grant-by-grant reconciliations; Program Director and CFO jointly sign off during month-end close. Responsible Official: Renee Carroll, CFO Implementation Date: Fully operational as of January 2025; monthly review ongoing.
Corrective Action Taken: A qualified CFO has been hired and controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Corrective Action Taken: A qualified CFO has been hired and controls have been put in place to ensure proper determination of audit requirements and timely completion of future single audits.
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice a...
Planned Corrective Action: The Organization will implement and reinforce a comprehensive system for retaining all invoices, payment records, and supporting documentation associated with federal awards. Additionally, the Organization will create and maintain a clear record retention policy. Invoice and Payment Documentation: • All invoices related to the federal program will be promptly reviewed and approved by the appropriate personnel to ensure they reflect allowable costs under the specific terms and conditions of the award. • Management will establish clear procedures for the proper recording and classification of payments, ensuring that they are linked directly to the corresponding federal program expenses. • All supporting documentation (e.g., purchase orders, contracts, receipts) will be retained in electronic formats within the accounting system, in accordance with the Organization’s record retention policy, ensuring availability for future audits or reviews. Retention and Accessibility: • The Organization will maintain a secure, organized filing system for all invoices and payments, ensuring that each record is easily accessible for audit purposes. This system will include electronic records that are stored in a centralized database, with restricted access to authorized personnel. • Retained invoices and payment documentation will be kept for the full duration required by federal regulations, typically for a period of at least seven years after the final expenditure report for the federal award has been submitted, or as otherwise required by the specific federal agency. Periodic Reviews and Monitoring: • To ensure ongoing compliance, Management will perform periodic reviews of federal program expenditures and documentation. This will include random sampling of invoices and payment records to confirm that they are complete, accurate, and in compliance with federal regulations. • In the event of any discrepancies or issues identified during these reviews, Management will take immediate corrective action to address the issue and prevent recurrence. By maintaining thorough records of all invoices and payments, the Organization aims to not only comply with federal audit requirements but also to ensure transparency, accountability, and sound financial management of federal funds.
View Audit 372196 Questioned Costs: $1
2023-001 RESERVE ACCOUNT FUNDING Grantor: U.S. Department of Agriculture Award Name: Rural Rental Housing Loans Award Year: 2023 Award Numbers: Various CFDA Number: 10.415 Criteria: The Project’s reserve account must be fully funded and maintained in a separate bank account. Condition: During our au...
2023-001 RESERVE ACCOUNT FUNDING Grantor: U.S. Department of Agriculture Award Name: Rural Rental Housing Loans Award Year: 2023 Award Numbers: Various CFDA Number: 10.415 Criteria: The Project’s reserve account must be fully funded and maintained in a separate bank account. Condition: During our audit testing, we noted that while the Project maintained a separate bank account for reserves, it was not fully funded. Cause: Yearly budgeted transfers were not made to ensure the account is fully funded. Effect: Reserve bank account is underfunded. Questioned Costs: None noted. Recommendation: The Project should implement controls to ensure that the reserve bank account is fully funded. Management’s Views and Corrective Action Plan: Management will correct this when sufficient funds are able to be transferred into the reserve account
Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of d...
Finding Number: 2023-002 Condition: The System failed to make the monthly debt service reserve fund deposits required by the USDA loan agreement. Planned Corrective Action: Once it was determined that it was necessary to keep the balance of the fund at a prorated amount to the required one year of debt service by ten years, we began funding it in order to meet that requirement by the end of fiscal year 2023, which we did, and we have maintained the required funding since then. Contact person responsible for corrective action: Eric Draime, CFO Anticipated Completion Date: 6/30/2023
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2024.
View Audit 372174 Questioned Costs: $1
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2024.
View Audit 372174 Questioned Costs: $1
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies...
Authority's Response and Planned Corrective Action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Section 8 Housing Choice Vouchers, Mainstream Vouchers and Emergency Housing Voucher Programs to ensure that established internal control policies are being followed on a timely basis. Leonard Spicer, Executive Director, is responsible for implementing this corrective action by December 31, 2024.
View Audit 372174 Questioned Costs: $1
Views of Responsible Officials and Planned Corrective Action: The Director of Academic Support will report monthly to the Grants Team during the regularly scheduled meeting the required information pertaining to this finding to make sure RPS is in compliance. This will begin in November at our regul...
Views of Responsible Officials and Planned Corrective Action: The Director of Academic Support will report monthly to the Grants Team during the regularly scheduled meeting the required information pertaining to this finding to make sure RPS is in compliance. This will begin in November at our regularly scheduled meeting.
Views of Responsible Officials and Planned Corrective Action: Weekly staffing reports are sent to the locations for administrators to identify employees assigned to their location. Title 1 Grant Manager is sent a monthly personnel report that identifies all employees coded to Title 1 by location. Th...
Views of Responsible Officials and Planned Corrective Action: Weekly staffing reports are sent to the locations for administrators to identify employees assigned to their location. Title 1 Grant Manager is sent a monthly personnel report that identifies all employees coded to Title 1 by location. There is a semi-annual in-person staff validation process. The team includes the enrollment and planning, Talent, and Budget Departments. The grants team will schedule standing meetings (biweekly) with the grant manager, accountant, and the Director of Budget to ensure all payroll is correct as it relates to Title I Part A. This will begin immediately following the next pay period. When discrepancies are identified, the Title 1 Grant Accountant will prepare an journal entry to move the payroll charges out of the Title 1 fund to the correct fund by journal entry
View Audit 372148 Questioned Costs: $1
Corrective Action Plan Finding 2023-002: Late Submission of the Audit Contact Person: Annah Ceballos Anticipated Completion Date: September 30, 2026: Will be reflected in the December 31, 2025 audit. Planned Corrective Action: The Tribe agrees with the late submission finding. The Tribe has hired a ...
Corrective Action Plan Finding 2023-002: Late Submission of the Audit Contact Person: Annah Ceballos Anticipated Completion Date: September 30, 2026: Will be reflected in the December 31, 2025 audit. Planned Corrective Action: The Tribe agrees with the late submission finding. The Tribe has hired a consultant to assist in the closeout process. This will ensure timely submission of the annual audit in future periods.
Full text of the Corrective Action Plan includes a chart, table or footnotes.
Full text of the Corrective Action Plan includes a chart, table or footnotes.
FINDING 2023-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audi...
FINDING 2023-004 Information on the federal program: Subject: Water and Waste Disposal Systems for Rural Communities – Reporting Federal Agency: U.S. Department of Agriculture Assistance Listing Number: 10.760 Federal Award Number: N/A Pass-Through Entity: N/A Compliance Requirements: Reporting Audit Findings: Material Weakness, Noncompliance Condition: The District did not have proper controls in place to ensure that the RD442-2 and RD 442-3 forms were filled out and submitted. Context: Form RD442-2 and Form RD442-3 were not submitted to the granting agency. The District may submit the financial data in other forms, however, the required reporting information was not submitted at all for the year under audit. The forms are required to be submitted on GAAP accrual basis. Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The third-party accounting firm will prepare the required forms which will be reviewed by the Board of Directors prior to submission. Responsible Party and Timeline for Completion: The third-party accounting firm and the Board of Directors will implement the corrective action plan, which will go into effect with the next required submission for 2025.
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