Corrective Action Plans

Action Steps: The district has hired a new food service director who has taken measures to implement a more accurate record-keeping system, which includes Accu-Claim, as recommended by ISBE. The new system provides a more detailed daily report. Also, the cashiers at the point of sale have been retrained so that the recording and reporting is accurate. Contact Person(s): Kala Dudley, Food Service Director Ruby Howard, Unit Office Secretary Darren Root, Superintendent Anticipated Completion Date: December 31, 2023

Recommendation: The District should put into place internal controls to ensure all steps of verification are completed by program management, including secondary review of the free and reduced rosters after the verification process has been completed. Action to be taken: The District concurs with the finding and will implement a review process to ensure students selected for the verification process are changed to the proper status. Additionally, the District will retain the proper documentation to support the verification process.

Recommendation: The District should put into place internal controls that ensure there is a process to verify the free and reduced students submit applications or be switched to full pay status in their software. Action to be taken: The District concurs with the finding and will put procedures in place to verify that free and reduced students all have applications on file and properly qualify for that status.

Method of Implementation - The School District shall obtain and provide necessary training to personnel regarding A.S.S.A. reporting guidelines and low income eligibility guidelines; the School District shall ensure student lunch statuses are documented appropriately throughout the District's online databases {PowerSchool, PaySchools, IEP Direct, etc.). Responsible for Implementation - Food Service Director, School Accountant & School Business Administrator. Implementation Date - Immediate

Method of Implementation - The School District shall allow an internal control procedure that completes a verification of a report prior to submission. This will allow the Business Office (Accountant & SBA) to verify the data prior to submittal. Person Responsible for Implementation - Food Service Director, School Accountant & School Business Administrator. Implementation Date - Immediate

Method of Implementation - The Food Service Director shall maintain a listing of necessary food service operational enhancements and capital expenditures. By April of each year, the Food Service Director will review cash and expenditures for prior months. If cash is expected to accumulate in excess of 3 months average expenditures, the Food Service Director will begin to purchase items for the Food Service operation contained on the list referenced above. A plan is in place for expending the funds but it is in the review process. The SBA has also began budgeting percentages of different salaries in the cafeteria budget (custodial, accountant, etc). Person Responsible for Implementation - Food Service Director & School Business Administrator. Implementation Date - 6/30/2024

Planned Corrective Action Plan: Upon initial notification of the verification findings, the District Food Services department immediately began corrective action to ensure the success of the SY 23-24 Verification. Specifically, three Food Services Office staff members were actively involved in the Verification training offered by the governing State agency, as well as, the software provider. All questions throughout the verification process were immediately asked of the State agency and/or software provider as appropriate. All supporting documents were reviewed by two staff members at the time of submission. Once verification was completed on November 15, 2023, a report was pulled to show change in status. The change in status for families that did and did not respond was reviewed by two staff members to ensure accuracy. Anticipated Completion: 11/16/2023 Responsible Contact Person: Jaleena Davis, Director - School Food Services

The Shenandoah Valley School District respectfully submits the following corrective action plan for the year ended June 30, 2023. The findings from the Single Audit Report Year Ended June 30, 2023 included in the schedule of findings and questioned costs are discussed below. Finding 2023-001: Reporting: Child Nutrition Cluster Contact Person: Anthony Demalis, Business Manager Recommendation: The District should establish internal control procedures over reporting requirements. Action: Cafeteria Manager will meet with Business Manager or Assistant Business Manager to review child nutrition reports prior to submission for reimbursements. Date for Completion: December 1, 2023

Condition: The District’s school lunch office maintained production records and manual count sheets instead of using the point-of-sale system for tracking student meal counts. Corrective Action Planned: The District has implemented a point-of-sale system for sales of meals and will use system reports as support for the monthly claims for reimbursement. Anticipated Completion Date: September 2023 Contact: Ann-Marie Geyster, School Business Manager

Child Lane management staff re-assessed program staff access to determine the changes that needed to be made in order to protect program integrity. To ensure valid DCH claims are submitted the following steps were taken:1. Employment was terminated for the staff person involved in the invalid DCH nutrition claims.2. Child Lane changed Field Representatives from working from home and provided work stations at the Administrative Office instead effective July 1, 2023. 3. A police report was filed with the Signal Hill Police Department.4. A claim was submitted with Great American under Child Lane’s employee fraud insurance policy.5. User names and passwords were reset for all staff and staff were re-trained.6. Child Lane added a Quality Assurance Specialist whose responsibility is to assist in enforcing all CACFP program policies, procedures, and guidelines. 7. Child Lane management re-assigned providers to a different Field Representative.8. Child Lane staff conducted household contact verification to approximately 150 provider enrollments out of the approximate 450 providers that were claiming at the time.9. Child Lane limited access for CACFP Field Representatives so that they are not able to make changes to provider profiles. Only the nutrition program manager is able to make changes.10. All prospective DCH providers speak to the program manager and only the program manager and one other staff person are responsible for signing new providers.11. The direct deposit procedure was updated so that DCH providers complete the electronic forms themselves directly to their individual Paycom account, complete an electronic signature and complete a two-step verification process through Paycom when changes are made. Nutrition program staff is not able to make changes to direct deposit for DCH providers.12. Downward adjustment claims were submitted through Child Lane’s CNIPS account for the invalid claims that were identified. The downward adjustments were reduced from current claim reimbursements. An email was received on November 17, 2023 by the California Department of Social Services, (CDSS) Fiscal Policy and Analysis Bureau verifying that all the associated downward adjustment claims were processed and deducted from current claim reimbursements. 13. Entries were made on Child Lane’s GL to recognize the reduction in income due to the downward adjustment claims submitted to agree with CDSS claim reimbursements for 2022-2023 Fiscal Year. The amount for previous Fiscal Years was posted to Contracts Settlements under the Management and General cost center. An entry was made as of June 30, 2023 to reduce the Family Day Care Contracts CACFP expense for the invalid claims for Fiscal Year 2022-2023 and offset to the Family Day Care Contracts expense under the Management and General cost center. Name of Contact Person Responsible for Planned Corrective Actions: Maria Almeida, Contracts & Compliance Manager Anticipated Completion Date: November 30, 2023

Recommendation: We recommend that the District implement added controls to prevent the lapse in self-monitoring reviews from occurring in the future. Action to be taken: The District concurs with the facts of this finding and will strive to improve controls to ensure that self-monitoring reviews are completed on a timely basis.

Recommendation: The District should verify that all required components of meal applications are completed fully and accurately and that income eligibility is recalculated accurately prior to approval. Action to be taken: The District concurs with the facts of this finding and will verify that all income eligibility is recalculated accurately prior to approval.

Corrective Action Plan: The District will put procedures back in place to make sure we are using current eligibility procedures (applications) to determine student eligibility. Anticipated Corrective Action Plan Completion Date: August 15, 2023 Contact Information: For additional information regarding this finding please contact Bill Trewyn, Business Manager, at 262-741-9143.

Child Nutrition Reporting - Contact: Jeremy Mack, Business Agent. Completion date: June 30, 2024. The District administrator has reviewed the reporting requirements with the Child Nutrition staff and will review monthly claims for submission.

CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2023 Finding 2023-001 – Verification Population Criteria: Section III, P. of the grant agreement from the California Department of Education Nutrition Services Division Permanent Single Agreement, states that verification must be completed on Household meals Benefit Applications as specified by Child Nutrition Program (CNP) regulations and guidance. Local Education Agency (LEA) must select the sample by the lesser of 3% or 3000 of the approved applications on file as of October 1, selected from error prone applications. Condition: While gaining our understanding of controls over verification, management noted that they rely on their internal software, Paradox, to tally the number of applications on file as of October 1, as well as any reports considered error prone. The system does not print out a report to list out all applications and management was unable to reproduce any report to show the total number of applications to agree to the tallied applications from the Paradox system as of October 1. The paradox system is based on the applications entered into the system by the School Nutrition Program Personnel. Questioned Costs: None Corrective Actions Taken or Planned: The Paradox database system generates a report that provides a listing of students with approved applications and also provides student totals. We are working with the Applied Technology Department to develop an additional report that will populate a listing of approved applications that includes application totals. The application totals from the approved application report will be used to determine the application tally and will be used to compute the required sample size. Error prone applications have been and will continue to be used to meet the required number of application selections that are required to be verified. Responsible Official Lilia S. Chavez, Director of Externally Funded Programs lschavez@la-archdiocese.org (213) 637-7915 Anticipated Completion Date January 31, 2024

Procurement Federal agency: U.S. Department of Agriculture Federal program title: Child Nutrition Cluster CFDA Number: 10.553, 10.555, and 10.559 Pass-Through Agency: Minnesota Department of Education Pass-Through Number(s): 1-0882-000 Award Period: July 1, 2022 – June 30, 2023 Type of Finding: • Significant Deficiency in Internal Control over Compliance and Other Matters CORRECTIVE ACTION PLAN (CAP): Recommendation: It is recommended that the District implement procedures and controls to ensure proper procurement procedures are being followed. Explanation of Disagreement with Audit Findings: There is no disagreement with the audit finding. Actions Planned in Response to the Finding: The District will continue to work on establishing procedures and controls to ensure proper procurement procedures are being followed. Official Responsible for Ensuring CAP: Tina Burkholder, Director of Business Services. Planned Completion Date for CAP: June 30, 2024.

Finding Number 2023-003 — Excess in Food Service Fund — Repeat Finding - Material Weakness in Internal Control/Noncompliance — Special Tests and Provisions Condition: As of year-end, June 30, 2023, the district had a fund balance in the food service fund in excess of three months operating expenses by approximately $ 268,411. Responsible Person: Carl Seiter, Director of Business Services Implementation Date: June 30, 2024 Corrective Action: The district has filed a spend down plan with the State of Michigan. This plan includes increasing labor costs for the operation of a kitchen at Winn Elementary School. Additionally, the district will purchase much needed new equipment. Sincerely Carl Seiter Director of Business Services Shepherd Public Schools

The district has implemented procedures for the future to ensure all transacttions are recorded in the period of benefit and account reconciliations are performed in a timely manner. Anticipated Completion Date: June 30, 2023 Responsible Party: Kathy VanSchaick

2023-003 - Income Eligibility Guidelines - Contact: Sam Lehman, Director of Business Services. Completion date: June 30, 2024. The District will improve its evaluation of income eligibility for Child Nutrition Cluster program by following the income eligibility guidelines.

The District will implement controls in its meal claim process to ensure that student meals claimed for reimbursement equal student meals served. The Food Service Supervisor and/or Food Service Administrative Assistant will create a summary meal count sheet each month totaling the number of student meals seved based on the electronic and manual meal count sheets prior to submitting the meal claim in the Michigan Nutrition Data System (MiND). The monthly meal claim submitted will be filed with the supporting documentation an dsigned by the individual submitting the claim attesting that the meals claimed match the meals counted.

#2023-004 Material Weakness related internal controls and compliance with Special Tests and Provisions – Verifications: The District did not perform verification of free/reduced meal applications until March 2023. Recommendation: Auditor recommends the District maintain close communication with the Department of Education, particularly during any period when there is a change in manner in which the food service program operates. Action Taken: The Bandon School District will maintain close communication with the Department of Education, particularly during any period when there is a change in the manner in which the food service program operates. The Director of Food Services will also reach out to the verification team to make sure verifications are done promptly. They will also check regularly for incoming applications that also must be verified promptly. Effective May 2023.

#2023-002 Material Weakness related to eligibility for free and reduced price meals: During a transitional year where all meals were being provided free to all students under various funding sources, the District did not actively solicit applications from households and did not process those applications that were received until nearly six months later. Recommendation: Auditor recommends the District maintain close communication with the Department of Education, particularly during any period when there is a change in manner in which the food service program operates. Action Taken: The Bandon School District will maintain in close communication with the Department of Education, particularly during any period when there is a change in the manner in which the food service program operates. Director of Food Services will also regularly reach out to ODE’s assigned Nutrition Specialist to verify the certification of students’ classification on free, reduced and paid students is correct. Effective May of 2023.

The District agrees with the finding and will ensure that staff follows the District’s food service program procurement procedures to ensure that TDA approval is obtained prior to all future Food Service Fund capital expenditure purchases. Relative the $221,648, the District remitted a Capital Expenditure Request with TDA on September 25, 2023 for the 2023-24 fiscal year, which TDA approved. However, this request relates to the capital expenditures incurred in January and February 2023 in the 2022-23 fiscal year.

USDA Foods Receipts: Criteria: Evidence of distribution in the form of signed invoices for USDA Foods is required to be maintained for CSFP and TEFAP. Evidence of receipt of USDA foods should be maintained to ensure compliance with the award. Condition: Signed invoices evidencing USDA food distributed were not retained. Context: Our sample of 25 distributions of USDA Foods included two instances where invoices were not properly signed and one instance where the invoice was not retained. Known and likely questioned costs are unknown. Effect: GSFB runs the risk that improper distribution will not be prevented without appropriate document retention. Cause: In all three instances, administrative issues resulted in the untimely lack of retention of signed invoices. Recommendation: We recommend that GSFB reinforce the importance of retaining signed invoices in accordance with award requirements. GSFB should further assign an individual within their organization to assume a higher level of direct responsibility for the administration of federal awards by GSFB. Contact: Bryan O'Connor, VP, Finance & Administration Corrective Actions Taken or Planned: GSFB staff audit sales order paperwork in connection with product received from Maine Department of Agriculture, Conversation, and Forestry. The audit consists of running a list of any outbound order that had DACF allocated inventory on it, comparing that list to returned paperwork, and confirming that said paperwork was signed. For any agency paperwork that can not be located and/or is not signed, a follow-up email is sent to the specific partner requesting a signature. In June 2023, GSFB staff increased the frequency of auditing from monthly to weekly, allowing a more timely follow-up on any paperwork concerns. The Customer Service and Inventory Management teams share responsibility for auditing and follow-up.

Finding 2023-002 - School Breakfast Program No. 10.553; Grant Period: Year Ended June 30, 2023 and National School Lunch Program - Assistance Listing No. 10.555; Grant Period: Year Ended June 30, 2023 Recommendation: The School should ensure that processes are in place to review and approve of invoices for purchases related to the breakfast and lunch program. Also, the meal counts and monthly claim reimbursements should be reviewed and confirmed by someone other than the person compiling the counts. These processes should be documented. Action Taken: Purchase orders for food and supply purchases will be filled out by the Cafeteria Manager and approved by the Chief Operating Officer (COO). Once the food is delivered, the Cafeteria Manager will submit the invoice to the COO and he will match it to the invoice and review and sign the invoice. On a monthly basis, the COO will review and approve the monthly meal counts, compiled by the Cafeteria Manager and submit the meal claim reimbursement. The COO, Craig Eichmann, will be responsible for implementing this updated process and it will be fully implemented by October 31, 2023.