Corrective Action Plans

Finding 502675 (2023-001)

Significant Deficiency 2023

OK

HUD Housing Programs Reporting

CORRECTIVE ACTION PLAN ISSUED BY THE BOARD OF DIRECTORS Big 5 Ada Housing, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of public accounting firm: John Flusche, CPA 5735 East 102nd Street Tulsa, Oklahoma 74137 Audit Period: Yea...

CORRECTIVE ACTION PLAN ISSUED BY THE BOARD OF DIRECTORS Big 5 Ada Housing, Inc. respectfully submits the following corrective action plan for the year ended December 31, 2023. Name and address of public accounting firm: John Flusche, CPA 5735 East 102nd Street Tulsa, Oklahoma 74137 Audit Period: Year ended December 31, 2023 The findings from the December 2023, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDING No. 2023-001: Recommendation: The Project’s management should redeposit the funds into the Replacement Reserve bank account as soon as possible, to bring the account to the correct balance. Action Taken: The Project’s management will redeposit the funds into the replacement reserve account in 2024.

View Audit 324698

Finding 502674 (2023-003)

Material Weakness 2023

City of Homer, Alaska

AK

Questioned Costs Subrecipient Monitoring Material Weakness § 200.512

Finding 2023-003 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Planned Corrective Actions: The Finance Department is continuing its efforts in establishing and enforcing internal deadlines to ensure the financial statements ar...

Finding 2023-003 Deadline for Federal Single Audit – Reporting – Noncompliance and Material Weakness in Internal Control over Compliance Planned Corrective Actions: The Finance Department is continuing its efforts in establishing and enforcing internal deadlines to ensure the financial statements are audited within the appropriate reporting deadlines. The department has shifted staff duties to ensure the FY24 financial statements will be completed within the appropriate reporting deadlines. Individual(s) Responsible for Corrective Action Plan Elizabeth Fischer (Finance Director) Jenna deLumeau (Controller) Anticipated Completion Date: The department has developed internal deadlines to ensure the FY24 financial statements will be completed within the appropriate reporting deadlines. This has been completed.

View Audit 324691

Finding 502672 (2023-002)

Significant Deficiency 2023

County of Kings, California

CA

Subrecipient Monitoring Reporting § 200.332

Corrective Action Plan: ...

Corrective Action Plan: To ensure compliance with 2 CFR Part 200, Uniform Administrative Requirements, Post Federal Award Requirements, the county (Human Services Agency) will follow Kings County’s subrecipient monitoring policy and procedure. In addition, it will establish a procedure and checklist that is specific to FFA, GH, and STRTP subrecipients, due to the unique structure and involvement of CDSS. The County (Human Services Agency) will draft written policies and procedures for monitoring identified subrecipients receiving Foster Care Title IV-E funds that will include the following steps: •Annually, the County (Human Services Agency) will request from each placement agency utilized a copy of their audited financial statements and complete an annual risk assessment of each FFA, GH, and STRTP agency receiving Foster Care Title IV-E funds to determine the agency’s risk of non-compliance withFederal statutes and regulations. The risk level determined for each agency will determine the appropriate level of subrecipient monitoring. •To ensure compliance with the management decision letters and audit findings of CDSS, the County (Human Services Agency) will follow up with each agency with a request for their corrective action plan. This will be done promptly after receipt of the subrecipient’s audit report, ensuring that subrecipients are aware of any issues and can take appropriate and timely corrective action. Contact Information of Responsible Official: Atonya Moore Deputy Director – Fiscal Kings County Human Services Agency 559-852-2214

View Audit 324690

Finding 502658 (2023-001)

Significant Deficiency 2023

Fundacion De Desarollo Comunal De Puerto Rico

PR

Reporting § 200.512

FUNDACION DE DESARROLLO COMUNAL DE PUERTO RICO, INC. (FUNDESCO) acknowledges the findings identified during the single audit regarding reporting requirements stemming from a lack of personnel. However, FUNDACION DE DESARROLLO COMUNAL DE PUERTO RICO, INC. (FUNDESCO) has already contracted capable per...

FUNDACION DE DESARROLLO COMUNAL DE PUERTO RICO, INC. (FUNDESCO) acknowledges the findings identified during the single audit regarding reporting requirements stemming from a lack of personnel. However, FUNDACION DE DESARROLLO COMUNAL DE PUERTO RICO, INC. (FUNDESCO) has already contracted capable personnel to assist in the finance department to comply with financial reports.

View Audit 324674

Finding 502646 (2023-002)

Significant Deficiency 2023

J.h. Floyd Sunshine Village, Inc.

FL

Allowable Costs / Cost Principles HUD Housing Programs Questioned Costs

B. Finding 2023-002 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 207/223(f)) (CFDA# 14.155) Allowable costs/cost principles The Project disbursed $47,837 of legal costs that were not operating expenses for the pro...

B. Finding 2023-002 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 207/223(f)) (CFDA# 14.155) Allowable costs/cost principles The Project disbursed $47,837 of legal costs that were not operating expenses for the project. (1) Comments on the Finding and Each Recommendation Management concurs with this finding and the current management agent has ensured that $47,837 was reimbursed from entity non-project funds. (2) Actions Taken on the Finding The funds were reimbursed from entity non-project funds.

View Audit 324633 Questioned Costs: $1

Finding 502645 (2023-001)

None 2023

J.h. Floyd Sunshine Village, Inc.

FL

Questioned Costs HUD Housing Programs Procurement, Suspension & Debarment

A. Finding 2023-001 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 207/223(f)) (CFDA# 14.155) Residual Receipts The Project did not deposit their residual receipts deposit of $31,573 from prior year surplus cash wit...

A. Finding 2023-001 Mortgage Insurance for the Purchase or Refinancing of Existing Multifamily Housing Projects (Section 207/223(f)) (CFDA# 14.155) Residual Receipts The Project did not deposit their residual receipts deposit of $31,573 from prior year surplus cash within the required deadline of 90 days after year end. (1) Comments on the Finding and Each Recommendation Management concurs with this finding, agrees with the auditor recommendation, and has made the required residual receipts deposit. (2) Actions Taken on the Finding The funds have been deposited to residual receipts.

View Audit 324633 Questioned Costs: $1

Finding 502631 (2023-007)

Significant Deficiency 2023

Promise Healthcare Nfp

IL

Reporting Internal Control / Segregation of Duties Significant Deficiency § 200.329

Action taken in response to finding: 1. Develop documentation procedures: In Progress a. Establish a standardized procedure for documenting the preparation and review of Federal Financial Reports. 2. Select appropriate party for independent review: Complete ...

Action taken in response to finding: 1. Develop documentation procedures: In Progress a. Establish a standardized procedure for documenting the preparation and review of Federal Financial Reports. 2. Select appropriate party for independent review: Complete 3. Store and maintain documentation in a shared location for future audit and review: Complete Name of the contact person responsible for corrective action: Keith Flores, CFO Planned completion date for corrective action plan: End of 2024

View Audit 324609

Finding 502587 (2023-001)

Significant Deficiency 2023

Family Service and Guidance Center of Topeka, Inc.

KS

Reporting Internal Control / Segregation of Duties

Comments on the Finding Recommendation The Center experienced unusual and extensive staff shortages in the finance department in the reporting period. The Center does not expect these circumstances to be repeated, but will implement a policy that designates 2 staff/positions to monitor grant report ...

Comments on the Finding Recommendation The Center experienced unusual and extensive staff shortages in the finance department in the reporting period. The Center does not expect these circumstances to be repeated, but will implement a policy that designates 2 staff/positions to monitor grant report deadlines. Action Taken The Center has a Policy for Grant Reporting that designates the staff responsible for tracking grant deadlines. The policy will be updated so that multiple staff/positions are listed as being responsible for grant report deadlines.

View Audit 324583

Finding 502566 (2023-001)

Material Weakness 2023

New York College of Traditional Chinese Medicine

NY

Reporting Special Tests & Provisions Student Financial Aid

Finding 2023-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of inaccurate and untimely reporting of enrollment status. The issue was due to human error from a previous employee who has been term...

Finding 2023-001: Inaccurate and Untimely Enrollment Status Reporting Comments on Finding and Recommendation(s): Statement of Concurrence: We concur with the finding of inaccurate and untimely reporting of enrollment status. The issue was due to human error from a previous employee who has been terminated as well as a misunderstanding of the policy. The transition period following the termination further compounded these issues. Actions Taken or Planned: 1. New Hire: We have already hired a new member for Financial Aid position since April 2023. This individual is responsible for ensuring the accuracy and timeliness of enrollment status reporting moving forward. 2. Staff Training: • All relevant personnel, including the newly hired staff, have been scheduled for ongoing training on financial aid compliance and the reporting process. • We will ensure that each employee is proficient in using the reporting systems (e.g., NSLDS, COD) and understands the required timelines for submission. 3. Process Review and Improvement: We are reviewing our existing processes to identify gaps and inefficiencies in the current reporting system. Once identified, these processes will be updated to ensure better data accuracy and timeliness. 4. Ongoing Monitoring and Compliance Audits: We will establish regular internal audits and monitoring protocols to ensure continuous compliance with reporting standards. Completion Date: Ongoing Dong-Hua Yang MD, PhD Title: Administrative Dean

View Audit 324573

Finding 502558 (2023-002)

Significant Deficiency 2023

Puerto Rico Health Insurance Administration

PR

Questioned Costs Allowable Costs / Cost Principles Reporting

The PRHIA was proactive to ensure compliance in submitting the 2023 Single Audit Report by due date, maximizing the human resources available, in collaboration with auditors. The PRHIA expects to ensure compliance by submitting the 2023 Single Audit Report by its due date.

View Audit 324551

Finding 502544 (2023-003)

Significant Deficiency 2023

Brooklyn Bureau of Community Service Dba Brooklyn Community Services

NY

Questioned Costs Reporting Significant Deficiency § 200.512

Finding 2023-03 Reporting – Data Collection Form and Reporting Package (Significant Deficiency) U.S. Department of Health and Human Services Community Services Block Grant (Federal Assistance Listing #93.569) Federal Award Numbers: 60204, 60215, 60225, and 60235 Federal Award Year: 2020-2023 R...

Finding 2023-03 Reporting – Data Collection Form and Reporting Package (Significant Deficiency) U.S. Department of Health and Human Services Community Services Block Grant (Federal Assistance Listing #93.569) Federal Award Numbers: 60204, 60215, 60225, and 60235 Federal Award Year: 2020-2023 Responsible Officials Contact Information: 1) Monae Priolenau-Jones Telephone 718-310-5610, mpriolenau@wearebcs.org 2) Jodi Querbach Telephone 718-310-5600, X 1015 jquerbach@wearebcs.org View of Responsible Officials and Corrective Action Plan: Management agrees that the single audit reporting package was not submitted within the required timeframe due to key employee turnover coupled with staffing challenges subsequent to year end. In addition, BCS began a transition from one third-party external firm to another third-party firm in September of 2022. The former firm held the general ledger data for BCS and has been slow to turn it over in a manageable manner causing the delay in filing of the single audit report package. Dmitriy Goyzman (current Chief Financial Officer) was hired in December of 2022 and is actively in the process of hiring a new internal finance team. Back office finance department operations are currently filled by the second third-party external firm. In addition to the CFO, BCS has payroll, purchasing and 2 staff accountants and will have a Controller on staff by mid-June of 2023. Hiring of five additional positions for grants management will be completed in the Fall of 2023 replacing BDO personnel with in-house staff. In our new configuration, BCS will: 1) own its financial software and data, 2) be sufficiently staffed to run its day-to-day financial operations, 3) be able to support program operations in an efficient manner and 4) be able to respond and complete audits on time. The management will ensure that the single audit report package is submitted before the March 31, 2025 deadline. Pursuant to the action plan outlined in the response to Finding 2023 001, the audited financial statements will be issued by November 30th, 2024. Immediately following, the finance team will turn their attention to the reports required by the Uniform Guidance and the Federal Form 990 with a goal of completing fiscal 2024 reporting requirement by January 2025. Recommendation: We recommend that BCS enhance its closing and reporting process to ensure the reports required by the Uniform Guidance is submitted by the aforementioned deadline.

View Audit 324549

Finding 502532 (2023-002)

None 2023

Cuyuna Regional Medical Center

MN

Reporting Subrecipient Monitoring § 200.512

Identifying Number: 2023-002 Finding: Late Issuance of 2023 Single Audit Reporting Package Corrective Actions Taken or Planned: The Center will issue the single audit reporting package after the external audit is completed. Our single audit was performed timely, however, the purposeful delay of the ...

Identifying Number: 2023-002 Finding: Late Issuance of 2023 Single Audit Reporting Package Corrective Actions Taken or Planned: The Center will issue the single audit reporting package after the external audit is completed. Our single audit was performed timely, however, the purposeful delay of the external audit impacted our ability to finalize. Contact Persons(s) Responsible for Correction Action: Katie Berg, CFO Completion Date: October 30, 2024

View Audit 324527

Finding 502505 (2023-004)

Significant Deficiency 2023

Catholic Charities West Michigan

MI

Reporting Significant Deficiency

Action Taken: Timely reporting as well as documented approvals are very important to Catholic Charities West Michigan and we agree that we must demonstrate that proper reviews or reports have occurred. We have implemented a process including monthly meetings with the Program Manager and the Finance...

Action Taken: Timely reporting as well as documented approvals are very important to Catholic Charities West Michigan and we agree that we must demonstrate that proper reviews or reports have occurred. We have implemented a process including monthly meetings with the Program Manager and the Finance Accountant to review activity and close the month. All reporting is now filed timely with proper documented review.

View Audit 324497

Finding 502499 (2023-002)

Significant Deficiency 2023

Catholic Charities West Michigan

MI

Reporting Cash Management Significant Deficiency

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will rec...

Action Taken: Modifications of the Administrative Financial Management and Cash Management policies will be made to further address concerns identified in the Single Audit. In addition, the reconciliation process will be reviewed and improved to assure timely preparation of the SEFA. CCWM will reconcile federal programs to the passthrough agencies 9 months into the fiscal year at a minimum as part of the preparation of the SEFA report.

View Audit 324497

Finding 502370 (2023-003)

Significant Deficiency 2023

Eger Health Care and Rehabilitation Center Fha 012-10056

NY

Questioned Costs Reporting

Finding Reference Number 2023-003 1. Name of contact person responsible for corrective action Annmarie Covone, Executive Vice President/Chief Financial Officer 2. Corrective action planned 3. Our organization will reach out to HRSA to request permission to resubmit our PRF period 5 submission’s los...

Finding Reference Number 2023-003 1. Name of contact person responsible for corrective action Annmarie Covone, Executive Vice President/Chief Financial Officer 2. Corrective action planned 3. Our organization will reach out to HRSA to request permission to resubmit our PRF period 5 submission’s lost revenue so that lost revenue will agree to our underlying records and audited financial statements. 4. Anticipated Completion Date This will be completed in October 2024. 5. If the client does not agree with the findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding Reference No. 2023-003 Contact Information Annmarie Covone Executive Vice President/Chief Financial Officer 205 Lexington Avenue, 2nd Floor, New York, NY 10016 P (646) 633-4702 acovone@archcare.org

View Audit 324409

Finding 502369 (2023-002)

Significant Deficiency 2023

Eger Health Care and Rehabilitation Center Fha 012-10056

NY

HUD Housing Programs Questioned Costs Reporting

Finding Reference Number 2023-002 1. Name of contact person responsible for corrective action Annmarie Covone, Executive Vice President/Chief Financial Officer 2. Corrective action planned Management changes caused delays in locating support for the single audit testing. Accordingly, the new mana...

Finding Reference Number 2023-002 1. Name of contact person responsible for corrective action Annmarie Covone, Executive Vice President/Chief Financial Officer 2. Corrective action planned Management changes caused delays in locating support for the single audit testing. Accordingly, the new management anticipates that these matters will not repeat themselves in the future periods and the audited financial statements will be submitted timely. 3. Anticipated Completion Date This will be completed in October 2024. 4. If the client does not agree with the findings or believes corrective action is not required, include an explanation and specific reasons We agree with Finding Reference No. 2023-002 Contact Information Annmarie Covone Executive Vice President/Chief Financial Officer 205 Lexington Avenue, 2nd Floor, New York, NY 10016 P (646) 633-4702 acovone@archcare.org

View Audit 324409

Finding 502366 (2023-001)

Material Weakness 2023

City of Hughson

CA

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

Future funding for the City of Hughson will be thoroughly vetted to determine if there are any federal funds included in the monies to be received. Each new source of funding will be documented as to the source of the funding and the restrictions on its use. A thorough review of these funds will be ...

Future funding for the City of Hughson will be thoroughly vetted to determine if there are any federal funds included in the monies to be received. Each new source of funding will be documented as to the source of the funding and the restrictions on its use. A thorough review of these funds will be made at year end to determine if the City has met the $750,000 threshold to request a single audit in a timely manner.

View Audit 324399

Finding 502354 (2023-002)

None 2023

Universal Technology College of Puerto Rico, INC

PR

Student Financial Aid Reporting Matching / Level of Effort / Earmarking

The Institution reinforced its internal control procedures to ensure that the student disbursement date agrees with COD disbursement date back in 2023 when last year’s finding was disclosed. This single discrepancy was caused by an identified human error that has been addressed.

View Audit 324396

Finding 502353 (2023-001)

Significant Deficiency 2023

Universal Technology College of Puerto Rico, INC

PR

Student Financial Aid Subrecipient Monitoring Allowable Costs / Cost Principles

This years Single Audit will be planned with enough time alongside the auditor in order to ensure submission before the due date. No later than October 15, 2024 we will already have engaged an auditor to perform and begin the Single Audit for the year ending September 30, 2024.

View Audit 324396

Finding 502347 (2023-001)

Material Weakness 2023

Catron County

NM

Cash Management Reporting

The County has assigned a specific individual for grant and contract maintenance.

View Audit 324391

Finding 502118 (2023-003)

Material Weakness 2023

Organic Crop Improvement Association International, Inc.

NE

Internal Control / Segregation of Duties Material Weakness Reporting

Financial Statement Preparation Corrective Action Planned: The Association will continue to rely on its system of oversight provided by the board of directors in reviewing the financial statements of the Association. The Association will also be mindful of identifying a qualified volunteer or pot...

Financial Statement Preparation Corrective Action Planned: The Association will continue to rely on its system of oversight provided by the board of directors in reviewing the financial statements of the Association. The Association will also be mindful of identifying a qualified volunteer or potential board member who could review the financial statements. Anticipated Completion Date: December 31, 2024 Responsible Parties: Management and Board of Directors

View Audit 324340

Finding 502110 (2023-001)

Material Weakness 2023

The Homeless Families Foundation

OH

Cash Management Reporting Questioned Costs § 200.516

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2023 through December 31, 2023 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Fin...

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2023 through December 31, 2023 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2023-001 a. Comments on the Finding and Recommendation. Uniform Guidance stipulates that reimbursements are paid to subrecipients in a timely manner. The Organization did not pay subrecipients in a timely manner for the months of January through June 2023, resulting in $261,999 of untimely reimbursements. b. Action Taken or Planned on the Finding The Organization met with subrecipients prior to December 31, 2023 to establish increased control processes, including outlining documentation requirements, timeframes for reimbursement submission, identifying correct staff contacts for timely communications, and formalizing a timeframe for approving/distributing subrecipient disbursements. The Organization has paid all reimbursements through December 2023 as of February 2024.

View Audit 324321 Questioned Costs: $1

Finding 502092 (2023-001)

Significant Deficiency 2023

Ripley County, Missouri

MO

Subrecipient Monitoring Reporting § 200.510

This audit has taught me a lot concerning what is required with the SEFA report in the County Budget process. I will print out a copy of all Community Development Block Grant Funds that were expensed in the year in a report from QuickBooks. I will include those with the SEFA (Schedule of Expenditure...

This audit has taught me a lot concerning what is required with the SEFA report in the County Budget process. I will print out a copy of all Community Development Block Grant Funds that were expensed in the year in a report from QuickBooks. I will include those with the SEFA (Schedule of Expenditures of Federal Awards) report. I will also follow up with Alan Lutes, Executive Director with Ozark Foothills Regional Planning Commission, when I complete the SEFA report and have their office review the report to make sure all Community Development Block Grant Funds are included that were expenses that year from their office. In addition, I will include all supporting documents in the budget process to review with the County Commissioners at the time of the budget approval.

View Audit 324279

Finding 501998 (2023-002)

Material Weakness 2023

Athens Land Trust INC

GA

Cash Management Reporting

Corrective Action Plan – The current Finance Director and Housing Director have implemented an updated system that tracks, collects, and assembles the proper documentation for the monthly grant expenditure reports during the last week of the month to ensure timely submissions to the grantor. Even th...

Corrective Action Plan – The current Finance Director and Housing Director have implemented an updated system that tracks, collects, and assembles the proper documentation for the monthly grant expenditure reports during the last week of the month to ensure timely submissions to the grantor. Even though Athens Land Trust is a small organization with less than 25 employees, several staff members are being cross trained on the reporting process to ensure reporting is not disrupted by any potential future staffing changes. The updated system is reviewed periodically at biweekly director meetings to ensure oversight by the Executive Director.

View Audit 324199

Finding 501997 (2023-006)

Material Weakness 2023

Cleveland Urban Minority Alcoholism Outreach Project, Inc.

OH

Questioned Costs Allowable Costs / Cost Principles Period of Performance § 200.300 § 200.305 § 200.308 § 200.309 § 200.403

1. Cleveland UMADAOP will obtain written prior approval for any expenditure deviations from the originally approved budget. This topic will be covered when training occurs during the quarterly review of grant guidelines. 2. As part of its updated financial policies and procedures, Cleveland UMADAOP...

1. Cleveland UMADAOP will obtain written prior approval for any expenditure deviations from the originally approved budget. This topic will be covered when training occurs during the quarterly review of grant guidelines. 2. As part of its updated financial policies and procedures, Cleveland UMADAOP will seek to document all financial activity to ensure compliance with grant and federal guidelines. 3. As part of the updated financial policies and procedures, Cleveland UMADAOP will seek written confirmation from funders whenever there is a deviation from the terms outlined in the original award documentation. 4. As part of the updated financial policies Cleveland UMADAOP will be using the services of a virtual accounting firm that specializes in: a) standardized monthly financial reporting packages that will be reconciled to the approved budgets; b) standardized monthly close processes that lock transactions at the end of each month; and c) electronic document retention for A/P and A/R among other services.

View Audit 324194 Questioned Costs: $1

Corrective Action Plans

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