Corrective Action Plans

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Re: 2025-001 Filing and Accuracy of the SF-425 & 2025-002 Transaction Approvals The senior management team including the Executive Director Michele Craig, CFO Jill Hansen, and the Finance Committee of the Governing Board have reviewed and agree with the audit findings. Regarding the 2025-001 Filing ...
Re: 2025-001 Filing and Accuracy of the SF-425 & 2025-002 Transaction Approvals The senior management team including the Executive Director Michele Craig, CFO Jill Hansen, and the Finance Committee of the Governing Board have reviewed and agree with the audit findings. Regarding the 2025-001 Filing and Accuracy of the SF 425, in order to file the semi-annual SF 425 that was due on 1/30/25 for the period of 7/1/24-12/31/24 we needed to have closed accounting periods with accurate financial statements. When our CFO Jill Hansen began in early December 2024, the last month that had been closed was September 2024 due to the resignation of both the accounting tech and the CFO. It took several months to accurately close and update financial records. We now have a checklist of month-end tasks that ensures the generation of accurate and on time financial statements. These tasks and deadlines are incorporated in the fiscal calendar that will be reviewed with the Finance Committee each month. We successfully submitted the most recent semiannual SF 425 on time and will meet the next SF 425 deadline, October, 2026. The above corrective actions have been incorporated and this issue has been corrected.
Responsible Person(s): Chaye Neal-Jones, Director of Office of Enterprise Management Services; Eric Billings, Director of Grants Management Corrective Action Planned: Staff is working with DBHDS IT to ensure that ticketing workflow includes managerial approval. Additionally, system administrators ar...
Responsible Person(s): Chaye Neal-Jones, Director of Office of Enterprise Management Services; Eric Billings, Director of Grants Management Corrective Action Planned: Staff is working with DBHDS IT to ensure that ticketing workflow includes managerial approval. Additionally, system administrators are removing individuals from the system when they receive HR notification of their separation from the agency via email and the system automatically disables inactive accounts after 60 days. DBHDS is still working to develop a process for periodically reviewing the appropriateness of system users access and the activity of system administrators within the system. Estimated Completion Date: 7/1/2026
Responsible Person(s): Eric Billings, Director of Grants Management; Chaye Neal-Jones, Director of Office of Enterprise Management Services Corrective Action Planned: DBHDS identified that CSB subaward information was not being captured within the system's reports. Responsible staff are now entering...
Responsible Person(s): Eric Billings, Director of Grants Management; Chaye Neal-Jones, Director of Office of Enterprise Management Services Corrective Action Planned: DBHDS identified that CSB subaward information was not being captured within the system's reports. Responsible staff are now entering the executed date for CSB subawards which is being picked up by the report. Documents with an inception date of July 1, 2025, within the system have been updated to reflect the correct executed date. DBHDS staff are still working with the vendor to ensure that the report is working correctly. Estimated Completion Date: 4/1/2026
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE ...
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 6/15/2026
Responsible Person(s): Kavansa Gardner, Business Program Manager Senior, Benefit Programs; David Carico, Business Operations Manager Corrective Action Planned: Below is the narrative for CR901 and CR902 Records Retention, including current production deployment timelines. CR901 establishes the datab...
Responsible Person(s): Kavansa Gardner, Business Program Manager Senior, Benefit Programs; David Carico, Business Operations Manager Corrective Action Planned: Below is the narrative for CR901 and CR902 Records Retention, including current production deployment timelines. CR901 establishes the database infrastructure required to support compliant records retention within case management system. This includes partition creation across 75 plus high volume tables to enable structured aging and controlled purge activity aligned to retention thresholds. Production Deployment Timeline; scheduled as part of the February 2026 technical release. This phase is foundational and will be completed before purge logic can safely execute. CR902 Retention Logic and controlled execution; CR902 operationalizes the records retention policy by implementing controlled purge jobs leveraging the partitioning framework established in CR901. This Change Request moves the solution from infrastructure readiness to active lifecycle management. Phase 1 Database partition creation (February 2026 production release schedule) Phase 2 Controlled purge implementation (March 2026 release schedule) Phase 3 Validation, audit confirmation, and reporting controls (April 2026 release schedule) Phase 4 Reoccurring operational retention cycles with documented runbooks (ongoing/living) Estimated Completion Date: 4/30/2026
Responsible Person(s): Kavansa Gardner, Business Program Manager Senior, Benefit Programs; Lunita Browder-Harris, Business Operation Specialist, Business Operations Corrective Action Planned: DSS has identified critical or conflicting roles in the management system. The roles in scope have the capab...
Responsible Person(s): Kavansa Gardner, Business Program Manager Senior, Benefit Programs; Lunita Browder-Harris, Business Operation Specialist, Business Operations Corrective Action Planned: DSS has identified critical or conflicting roles in the management system. The roles in scope have the capability to perform all actions within the system, including inputting applications, determining eligibility, and authorizing benefits. DSS is in the process of implementing a procedure for reviewing and revoking conflicting roles ands privileges for all localities. DSS will work with APA to ensure adequate separation of duties is implemented within the eligibility system. Estimated Completion Date: 6/30/2026
Responsible Person(s): Barry Davis, Information Security Officer; John Vosper, Assistant Director Information Security and Risk Management Corrective Action Planned: DSS has contracted with two vendors to perform external IT Audits over sensitive systems. DSS is able to completed between 25-35 IT au...
Responsible Person(s): Barry Davis, Information Security Officer; John Vosper, Assistant Director Information Security and Risk Management Corrective Action Planned: DSS has contracted with two vendors to perform external IT Audits over sensitive systems. DSS is able to completed between 25-35 IT audits out of their 89 sensitive systems per year. DSS expects all IT systems will be audited by the end of 2027. A set of 31 IT Audits will be completed March 30, 2026. Estimated Completion Date: 12/31/2027
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE ...
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 5/29/2026
Responsible Person(s): Mike Jones, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awardin...
Responsible Person(s): Mike Jones, Chief Information Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 6/30/2026
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: DSS is establishing the processes and supporting system resources to ensure that DSS has an effective and compliant change management process. These ...
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: DSS is establishing the processes and supporting system resources to ensure that DSS has an effective and compliant change management process. These include: completion of migrating all application to a single repository which enables change tracking and version control in development projects; use of workflows in the system to enforce delivery of required artifacts prior to change submission; changes to the Change Advisory Board process, and post-change processes to validate meeting the acceptance criteria. Estimated Completion Date: 4/30/2026
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE ...
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 3/9/2026
Responsible Person(s): Barry Davis, Information Security Officer; John Vosper, Assistant Director Information Security and Risk management Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective act...
Responsible Person(s): Barry Davis, Information Security Officer; John Vosper, Assistant Director Information Security and Risk management Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 12/30/2028
Responsible Person(s): Barry Davis, Information Security Officer; John Vosper, Assistant Director Information Security and Risk Management; Steve McCauley, Assistant Director Information Security and Risk Management Corrective Action Planned: DSS Information Security and Risk Management is reconcili...
Responsible Person(s): Barry Davis, Information Security Officer; John Vosper, Assistant Director Information Security and Risk Management; Steve McCauley, Assistant Director Information Security and Risk Management Corrective Action Planned: DSS Information Security and Risk Management is reconciling the system to identify security roles for each sensitive system. Estimated Completion Date: 6/30/2026
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: DSS will follow the direction of the IAG Team to improve compliance with the security standard. IAG has created a new roadmap for remediation of rela...
Responsible Person(s): Dan Lewis, Chief Technology Officer; Timothy Kelly, Innovation, Architecture and Governance Director Corrective Action Planned: DSS will follow the direction of the IAG Team to improve compliance with the security standard. IAG has created a new roadmap for remediation of related IT security and governance findings, and the IAG director is working with the CTO, CISO and TSD leadership on defining concrete plans for remediation of all related findings. The IAG director, the CTO and the TSD leadership continue to implement and refine the division-wide process to ensure sufficient resources are available and dedicated to prioritizing and implementing the planned IT governance structure changes. Roadmap review sessions are scheduled. Remediation working sessions are in process of being scheduled. Estimated Completion Date: 3/27/2026
Responsible Person(s): Steve Hanoka, Information Security Officer Corrective Action Planned: DMAS has started confirming the geographic location for sensitive data monthly and the vulnerability scans every 90 days for the one provider Medicaid management services IT Service provider. DMAS is taking ...
Responsible Person(s): Steve Hanoka, Information Security Officer Corrective Action Planned: DMAS has started confirming the geographic location for sensitive data monthly and the vulnerability scans every 90 days for the one provider Medicaid management services IT Service provider. DMAS is taking steps to ensure that this is completed for all of the service providers that are not under cloud oversight. Estimated Completion Date: 6/30/2026
Responsible Person(s): Ida Witherspoon, Chief Financial Officer; William Carter, Federal Reporting Manager Corrective Action Planned: Grants now uses a financial system created report to perform a perfunctory audit, matching submission data received from the various Program and Budget staff against ...
Responsible Person(s): Ida Witherspoon, Chief Financial Officer; William Carter, Federal Reporting Manager Corrective Action Planned: Grants now uses a financial system created report to perform a perfunctory audit, matching submission data received from the various Program and Budget staff against each individual upload into the federal system. Vendors are filtered by ALN by each analyst responsible for monitoring the various ALN's that make up the DSS portfolio. Once the lists are cross checked, DSS reaches out again to the sub awarding authority responsible within the agency to ask for additional FFATA information. Estimated Completion Date: 6/30/2026
Responsible Person(s): Ida Witherspoon, Chief Financial Officer; Ousman Kah, Subrecipient Monitoring Coordinator; James Pell, ARMICS Program Manager Corrective Action Planned: As part of the compliance review, an analysis will be conducted to identify divisions and associated service provider agenci...
Responsible Person(s): Ida Witherspoon, Chief Financial Officer; Ousman Kah, Subrecipient Monitoring Coordinator; James Pell, ARMICS Program Manager Corrective Action Planned: As part of the compliance review, an analysis will be conducted to identify divisions and associated service provider agencies that manage substantial fiscal responsibilities under federal or state funding streams. This includes mapping subrecipient institutions and other state agencies such as the Office of Community Services (OCS) that receive federal grant allocations. The objective is to ensure visibility into entities handling large-scale financial transactions, assess their internal controls, and confirm adherence to applicable federal and state requirements. This analysis will serve as the foundation for targeted monitoring and risk mitigation strategies. DSS receives federal funding, which is disbursed to state agencies as a pass-through transaction. These transactions are initiated by various divisions within DSS, based on agreements with subrecipients, and then sent to Finance for review/processing. The subrecipients receiving federal funding must carry out the mission of that specific federal program. Pass-through transactions are required to be summarized and submitted to DOA for year-end financial reporting by agency and ALN (Assistance Listing Number, i.e., 10.561 = SNAP). DSS needs to obtain confirmation that each agency receiving federal funding is using the federal funds appropriately and within the guidelines of the grant award. ARMICS team will work to obtain financial control assurances from identified significant fiscal recipients. Estimated Completion Date: 11/30/2026
Responsible Person(s): Rebecca Ullrich, Associate Director of Early Childhood Policy and Innovation Corrective Action Planned: Mitigating Information: -DOE identified incorrectly coded transactions at the end of SFY2025 and had begun correcting some entries prior to the APA audit. -DOE Finance and E...
Responsible Person(s): Rebecca Ullrich, Associate Director of Early Childhood Policy and Innovation Corrective Action Planned: Mitigating Information: -DOE identified incorrectly coded transactions at the end of SFY2025 and had begun correcting some entries prior to the APA audit. -DOE Finance and Early Childhood Divisions are developing strategies to ensure alignment of project codes with appropriate grant awards each federal fiscal year. These strategies will be in place no later than September 1, 2026. -General ledgers adjustments have been posted for the identified ARP grant transactions. DOE is in the process of returning those ineligible funds to the federal government. All funds were returned on February 5, 2026. Estimated Completion Date: 9/1/2026
Responsible Person(s): Fernanda Crandol, Chief Financial Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awa...
Responsible Person(s): Fernanda Crandol, Chief Financial Officer Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 5/31/2026
Responsible Person(s): Office of Information Management and Othello Dixon, Office of Information Security Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 ...
Responsible Person(s): Office of Information Management and Othello Dixon, Office of Information Security Corrective Action Planned: This finding was marked as FOIA Exempt (FOIAE) and as a result, the State Comptroller has determined that the resulting corrective actions are FOIAE under §2.2-3705.2 (9.) of the Code of Virginia. Federal awarding agencies and pass-through entities, please see the Appendix titled “Applicable Management Contacts for Findings and Questioned Costs” to request the corrective action planned from the applicable entity. Estimated Completion Date: 3/2/2026
U.S. DEPARTMENT OF EDUCATION 2025-002 Special Education Cluster Grants – ALN’s 84.027 & 84.173 Recommendation: We recommend procedures be implemented to ensure that charges to the grant program are incurred within the period of performance included in the grant award. Explanation of disagreement wit...
U.S. DEPARTMENT OF EDUCATION 2025-002 Special Education Cluster Grants – ALN’s 84.027 & 84.173 Recommendation: We recommend procedures be implemented to ensure that charges to the grant program are incurred within the period of performance included in the grant award. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: We have reviewed the finding and have since implemented controls to ensure that expenditures are charged to a grant only after final approval has been issued in the grant portal. Name(s) of the contact person(s) responsible for corrective action: Aisha Oppong, Executive Director of Business and Support Services Planned completion date for corrective action plan: January 12, 2026.
Name of auditee: Seniors First, Inc. Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: July 1, 2024 through June 30, 2025 CAP prepared by: Name: Stephanie Vierstra Position: Executive Director Telephone: (530) 878-5705 Finding 2025-001 Comments: Management agrees with t...
Name of auditee: Seniors First, Inc. Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: July 1, 2024 through June 30, 2025 CAP prepared by: Name: Stephanie Vierstra Position: Executive Director Telephone: (530) 878-5705 Finding 2025-001 Comments: Management agrees with the finding. Actions: Management will implement a process of developing and implementing written procedures to ensure that Single Audit reporting packages and DCFs are submitted to the FAC timely and is working with the FAC and applicable agencies to address prior-year submissions. Anticipated completion date: March 31, 2026
Date: 1/21/2026 Division: Office of the County Manager Corrective Action Plan Audit Report Number: Finding Number: 2025-004 Finding: The Office of the County Manager did not have adequate internal controls to ensure proper documentation was maintained for reporting requirements. Corrective Action Ta...
Date: 1/21/2026 Division: Office of the County Manager Corrective Action Plan Audit Report Number: Finding Number: 2025-004 Finding: The Office of the County Manager did not have adequate internal controls to ensure proper documentation was maintained for reporting requirements. Corrective Action Taken or To Be Taken: Proper documentation for the current fiscal year will be reviewed by management prior to fiscal year end. If already taken, date of completion: If to be taken, estimated date of completion: January 2026 Agency Response Does the Agency Agree with finding?: Yes ☒No ☐Partially ☐ If No or Partial, Please explain reason(s) why: Additional Comments: Division Responsible for Corrective Action Plan Name, Title: Abbe Yacoben, Chief Financial Officer Address or Mailstop: 1001 E. Ninth St., Bldg A City, State, Zip Code: Reno, NV 89512 Phone Number: (775) 325-8243 Email: ayacoben@washoecounty.gov
Finding 2025-002 - Significant Deficiency in Internal Control over Compliance - Student Financial Condition Found: One undergraduate student had aggregate subsidized loans over the aggregate limit. Corrective Action Plan: Previously, Antioch College utilized loan history data from Free Application f...
Finding 2025-002 - Significant Deficiency in Internal Control over Compliance - Student Financial Condition Found: One undergraduate student had aggregate subsidized loans over the aggregate limit. Corrective Action Plan: Previously, Antioch College utilized loan history data from Free Application for Federal Student Aid (FAFSA). FAFSA data was utilized because National Student Loan Data System (NSLDS) loan history data was not always available when Antioch College prepared financial aid award letters. Due to the potential loan history discrepancies between data reported via FAFSA versus NSLDS, at the start of each academic year, Antioch College now uses NSLDS data to update loan history of each student to ensure Antioch College has the correct loan balances for each student. This procedural change was put into effect with the start of the 2025-2026 academic year. Person Responsible for Corrective Action Plan Implementation: Director of Financial Aid
Finding Reference Number: 2025-003 Corrective Action: APC is enhancing its compliance approach for loan-related obligations, including reserve reviews and tenant documentation. Oversight of required monitoring activities will be reinforced under the direction of Renee Wright, Director of Property Ma...
Finding Reference Number: 2025-003 Corrective Action: APC is enhancing its compliance approach for loan-related obligations, including reserve reviews and tenant documentation. Oversight of required monitoring activities will be reinforced under the direction of Renee Wright, Director of Property Management. Responsible Person(s): Brett A. Mlinarich, Director of Finance; Renee Wright, Director of Property Management Anticipated Completion Date: March 31, 2026
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