Corrective Action Plans

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Finding 2024-03 Filing of Single Audit Reports. Management concurs with the finding. Beginning July 1, 2025, IHS will be transitioning some of its financial reporting and audit support functions to an outside CPA firm specializing in nonprofit services. It is anticipated that this transition will he...
Finding 2024-03 Filing of Single Audit Reports. Management concurs with the finding. Beginning July 1, 2025, IHS will be transitioning some of its financial reporting and audit support functions to an outside CPA firm specializing in nonprofit services. It is anticipated that this transition will help assist in meeting the single audit filing deadline.
Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements
Finding 2024-02 Internal Control Over Compliance: Written Compliance Policies and Procedures. Management concurs with the finding. In June 2025, IHS completed revising its Fiscal Policy Manual to incorporate key Uniform Grant Guidance compliance requirements
Management has registered with Sam.gov and obtained a Unique Entity ID (UEI) for the submission of the single audit report for the fiscal year ended June 30, 2024. The UEI does not expire and is therefore addressed for future single audits.
Management has registered with Sam.gov and obtained a Unique Entity ID (UEI) for the submission of the single audit report for the fiscal year ended June 30, 2024. The UEI does not expire and is therefore addressed for future single audits.
Finding 2024-003 | Untimely Submission of Financial Status Reports — State Services HIV/SRVS Program Significant Deficiency in Internal Control over Compliance | Contract HHS001317000004 | First-Time Finding Finding Number: 2024-003 Planned Completion Date: June 30, 2025 Responsible Official(s): Jos...
Finding 2024-003 | Untimely Submission of Financial Status Reports — State Services HIV/SRVS Program Significant Deficiency in Internal Control over Compliance | Contract HHS001317000004 | First-Time Finding Finding Number: 2024-003 Planned Completion Date: June 30, 2025 Responsible Official(s): Josafat Saldivar, Fiscal Officer (primary); Juan E. Rodriguez, Executive Director (oversight and approval) Agency Response: STDC acknowledges the finding. FSR #1 under Contract HHS001317000004 (State Services — HIV/SRVS) for the period September 1, 2023 through February 29, 2024 was submitted on April 22, 2024, 22 days after the March 31, 2024 contractual due date required under Contract Attachment B §C. STDC concurs that the late submission constitutes noncompliance with the contract's reporting requirements. Finding 2024-003 shares the same root cause as Finding 2024-001: the absence of a formal, cross-program FSR submission calendar with assigned responsibility and advance reminder controls, compounded by the Fiscal Officer being new to the role during FY2024, and recovery efforts following the ransomware attack. Because both findings share a common root cause, STDC has designed a single integrated corrective action that will address both findings simultaneously through implementation of a cross-program FSR Submission Calendar covering all active federal and state contracts. Corrective Actions to Be Implemented: The corrective actions for Finding 2024-003 are the same as those described for Finding 2024-001. A single cross-program FSR Submission Calendar will be implemented to address both findings. The steps are provided below for reference. Action 1 (Target: April 30, 2025): Develop a formal, written FSR Submission Calendar covering all active federal and state programs, including State Services Contract HHS001317000004. The calendar will identify each FSR period, the contractual due date, the assigned responsible staff member, and advance reminder dates at 30 days and 7 days prior to each deadline. Action 2 (Target: April 30, 2025): Configure automated calendar reminders (Outlook or equivalent) for each FSR due date and each advance reminder date for all programs, including State Services. Reminders will be sent to the Fiscal Officer and the Executive Director. Action 3 (Target: May 15, 2025): Present the completed FSR Submission Calendar to the Executive Director for review and written approval. Retain the signed calendar in the grants compliance files and update it at the start of each new contract year. Action 4 (Target: May 31, 2025): Beginning in May 2025, include FSR submission status for all programs, including State Services, as a standing agenda item in the monthly Fiscal Officer report to the Executive Director. Action 5 (Target: June 30, 2025): Conduct a cross-training session with at least one backup staff member to ensure continuity of FSR submission across all programs in the event of staff absence or turnover. Monitoring and Evaluation: Monthly FSR status reports to the Executive Director will verify that all financial reports across all programs, including State Services, are submitted on or before contractual due dates. The FSR Submission Calendar will be reviewed and updated annually at the start of each contract year.
Finding 2024-001 | Untimely Submission of Financial Status Reports — Ryan White HIV/AIDS Program Significant Deficiency in Internal Control over Compliance | ALN 93.917 | First-Time Finding Finding Number: 2024-001 Planned Completion Date: June 30, 2025 Responsible Official(s): Josafat Saldivar, Fin...
Finding 2024-001 | Untimely Submission of Financial Status Reports — Ryan White HIV/AIDS Program Significant Deficiency in Internal Control over Compliance | ALN 93.917 | First-Time Finding Finding Number: 2024-001 Planned Completion Date: June 30, 2025 Responsible Official(s): Josafat Saldivar, Finance Director (primary); Juan E. Rodriguez, Executive Director (oversight and approval) Agency Response: STDC acknowledges the finding. FSR #1 under Contract HHS001122200004 (Ryan White HIV/AIDS Program, ALN 93.917) for the period April 1 through September 30, 2023 was submitted on February 14, 2024, 106 days after the October 31, 2023 contractual due date. STDC concurs that the late submission constitutes noncompliance with the reporting requirements of Contract HHS001122200004 and 2 CFR Part 200. STDC recognizes the need for a more formalized and proactive process to ensure timely submission of all required financial reports. No formal, cross-program FSR submission calendar with assigned responsibility and automated advance reminders was in place during FY2024. Related reports had been prepared and submitted by the former Finance Director, Ms. Julia C. Gonzalez, but this one had not been completed prior to her departure. Mr. Josafat Saldivar was appointed as Interim Fiscal Officer after Ms. Gonzalez's departure (last work date was October 13, 2023). Shortly after his interim appointment, STDC suffered a ransomware attack on November 3, 2023, which also impacted the accounting system. Recovery efforts were completed and the database restored in January 2024, after which Mr. Saldivar and his staff began data entry and catching up on required reports for all funding agencies. STDC is fully committed to implementing the controls necessary to prevent recurrence across all programs. Corrective Actions to Be Implemented: Action 1 (Target: April 30, 2025): Develop a formal, written FSR Submission Calendar covering all active federal and state programs (Ryan White, State Services, HOPWA, Aging Cluster, LIHEAP). The calendar will identify each FSR period, the contractual due date, the assigned responsible staff member, and advance reminder dates at 30 days and 7 days prior to each deadline. Action 2 (Target: April 30, 2025): Configure automated calendar reminders (Outlook or equivalent) for each FSR due date and each advance reminder date. Reminders will be sent to the Fiscal Officer and the Executive Director for all programs. Action 3 (Target: May 15, 2025): Present the completed FSR Submission Calendar to the Executive Director for review and written approval. Retain the signed calendar in the grants compliance files and update it at the start of each new contract year. Action 4 (Target: May 31, 2025): Beginning in May 2025, include FSR submission status (upcoming due dates, submission dates, and any variances from the schedule) as a standing agenda item in the monthly Fiscal Officer report to the Executive Director. Action 5 (Target: June 30, 2025): Conduct a cross-training session with at least one backup staff member to ensure continuity of FSR submission across all programs in the event of staff absence or turnover. Monitoring and Evaluation: Monthly FSR status reports to the Executive Director will verify that all financial reports are submitted on or before contractual due dates. The FSR Submission Calendar will be reviewed and updated annually at the start of each contract year. Any late submission will be immediately reported to the Executive Director and documented in the Finance Department's internal review records.
TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immedi...
TOFMHS concurs with the finding. The Agency filed both semi annual and annual financial reports for three grants during the fiscal year on a timely basis. The one semi-annual report was inadvertently filed late. However, upon notice by the Payment Management System of it being overdue, it was immediately filed. The Agency will prepare a checklist of required federal reports by the finance department, which will be monitored by the Program Director. Responsible Person: Fiscal Officer/Program Director Completion Date: January 1, 2025
Corrective Action Plan: Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them informed of the status of required financial reporting. The audit for the year end June 30, 2025 has been expedited and will be issued prior t...
Corrective Action Plan: Management has been in contact with HRSA and the Office of Federal Assistance Management Division of Financial Integrity to keep them informed of the status of required financial reporting. The audit for the year end June 30, 2025 has been expedited and will be issued prior to the reporting deadline. To prevent recurrence, management will implement enhanced controls over grant reporting compliance including: •Establishment of a reporting calendar with key deadlines, •Implementation of a standardized checklist to ensure all reporting is completed timely and accurately, and •Periodic management review of reporting status to ensure deadlines are met. Responsible Party - Judy Stein, CFO Estimated Completion - 3/31/2026
Finding # 2024-003 Corrective Action Plan: Subsequent to year-end, management has deposited the required funds into the reserve account to bring the organization into compliance with the USDA loan agreement. To prevent recurrence, management will strengthen its monitoring of debt covenant and reserv...
Finding # 2024-003 Corrective Action Plan: Subsequent to year-end, management has deposited the required funds into the reserve account to bring the organization into compliance with the USDA loan agreement. To prevent recurrence, management will strengthen its monitoring of debt covenant and reserve requirements by implementing the following controls: •Establish a tracking schedule for all loan-related requirements, •Incorporation of reserve funding requirements into the organization’s cash flow planning process, and •Review by appropriate management personnel to ensure timely compliance with all loan agreement provisions. Responsible Party - Judy Stein, CFO Estimated Completion - 3/31/2026
Moving forward, the District will ensure that all supporting documents are retained for reporting elements related to grants. Additionally, the District will add additional review procedures for any reporting items related to grants.
Moving forward, the District will ensure that all supporting documents are retained for reporting elements related to grants. Additionally, the District will add additional review procedures for any reporting items related to grants.
Finding Number: 2024-003 Finding Title: Reporting Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: The account activity will be reviewed and reconciled monthly to check for chart of accounts errors. When quarterly repo...
Finding Number: 2024-003 Finding Title: Reporting Program: 93.778 Medicaid Cluster Name of Contact Person Responsible for Corrective Action: Tracy Bowman Corrective Action Planned: The account activity will be reviewed and reconciled monthly to check for chart of accounts errors. When quarterly reports are completed two fiscal staff will have reviewed the chart of accounts codes. Anticipated Completion Date: 1/31/2025
Condition: Of the 40 students selected for Return of Title IV (R2T4) testing, 1 student did not have the appropriate amount returned to the federal agency. Planned Corrective Action: To prevent human error from occurring in the future, the Office of Financial Aid has immediately implemented the foll...
Condition: Of the 40 students selected for Return of Title IV (R2T4) testing, 1 student did not have the appropriate amount returned to the federal agency. Planned Corrective Action: To prevent human error from occurring in the future, the Office of Financial Aid has immediately implemented the following process: When a recipient of Title IV grant or loan assistance withdraws from Eastern Michigan University and a Return of Title IV calculation is performed, a Senior Financial Aid Advisor or member of the Financial Aid Management staff will review all required returns completed to ensure accuracy. This review will occur on a weekly basis. Contact person responsible for corrective action: Jennifer Tremewan, Asst. Director Office of Financial Aid Anticipated Completion Date: December 31, 2024
Condition: Of the 40 students selected for enrollment reporting testing, 5 students did not have their status updated appropriately. Planned Corrective Action: The Office of Financial Aid has implemented a process to communicate and confirm with the office responsible for enrollment reporting to ver...
Condition: Of the 40 students selected for enrollment reporting testing, 5 students did not have their status updated appropriately. Planned Corrective Action: The Office of Financial Aid has implemented a process to communicate and confirm with the office responsible for enrollment reporting to verify that enrollment rosters will not be/have not been sent after a semester has officially ended. Contact person responsible for corrective action: Jennifer Tremewan, Asst. Director Office of Financial Aid Anticipated Completion Date: December 31, 2024
U.S. Department of Health and Human Services U.S. Department of Treasury • Significant Deficiency in Internal Control over Compliance Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During ...
U.S. Department of Health and Human Services U.S. Department of Treasury • Significant Deficiency in Internal Control over Compliance Low-Income Home Energy Assistance - Assistance Listing No. 93.568 Coronavirus State and Local Fiscal Recovery Funds – Assistance Listing No. 21.027 Condition: During our testing of performance and special reporting, we noted that the Organization did not maintain documentation evidencing review or approval of submitted reports. The reports tested did not include evidence demonstrating that an authorized individual reviewed and approved the performance and special reports prior to submission. Recommendation: The Organization should implement formal internal controls over performance and special reporting by establishing documented procedures that require review and approval of all reports prior to submission. Management should define clear roles and responsibilities for report preparation and independent review, ensure that reviews are performed by an authorized individual, and maintain documentation evidencing review and approval, such as signatures, dates, or electronic approvals, to support compliance with performance reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The Organization will implement formal internal controls over performance and special reporting by developing and documenting standardized procedures for the preparation, review, and approval of all required federal performance and special reports. These procedures will clearly define roles and responsibilities for report preparation and independent review, including identification of authorized individuals responsible for final approval. Evidence of review and approval—including signatures, dates, or electronic approval records—will be retained in the grant file to support compliance with reporting requirements. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 30, 2026.
Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Seco...
Significant Deficiency in Internal Control over Compliance The Emergency Food Assistance Program (Administrative); Commodity Supplemental Food Program (Administrative)– Assistance Listing No. 10.568 and 10.565 Condition: The Organization does not have formal procedures in place to determine the Second Harvest Food Bank expenses incurred during the fiscal year that should be allocated to the TEFAP/CSFP administrative revenue received. The Organization has historically recognized revenue based on when cash is received which is not appropriate. Recommendation: We recommend the allocation of allowable costs and activities be completed at a minimum on a quarterly basis. Also, any direct expenses related to program activities should be recorded to the respectiveidentifying program fund number within the accounting software. The amount of revenue recognized for the programs should be reflected of the expenses incurred up to the administrative funds received from the respective funders. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization will implement a standard allocation to be completed on a quarterly basis at the minimum. This process will be reviewed by management to ensure implementation. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is June 2026.
U.S. Department of Agriculture 2024-005 • Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 1 out of the 21 agencies tested which distributed TEFAP commodit...
U.S. Department of Agriculture 2024-005 • Material Weakness in Internal Control over Compliance Food Distribution Cluster– Assistance Listing No. 10.569 Condition: During our testing, we identified there was no monitoring performed for 1 out of the 21 agencies tested which distributed TEFAP commodities during fiscal year 2024. Recommendation: The Organization should prioritize the timely monitoring of participating agencies to allow for changes in food distributions if any ineligible participants are discovered. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: The organization developed a schedule to complete monitoring and created a checklist to ensure that all documentation is in the appropriate folder. In addition, the organization began conducting internal audits to ensure the developed processes are being followed. Name(s) of the contact person(s) responsible for corrective action: Dawn Godshall, Executive Director Planned completion date for corrective action plan: Planned completion date is May 2026.
2024-005 - Reporting Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 2026.
2024-005 - Reporting Corrective Action Plan: Management agrees with the finding and has committed the resources giving rise to the finding. Person(s) Responsible: M. Michael Garza Timing for Implementation: June 30, 2026.
Management agrees with the finding and has taken corrective action to ensure the timely completion and submission of the audit reporting package. With the implementation of Sage Intacct and the strengthening of internal accounting processes, Porchlight is now able to begin audit preparation earlier ...
Management agrees with the finding and has taken corrective action to ensure the timely completion and submission of the audit reporting package. With the implementation of Sage Intacct and the strengthening of internal accounting processes, Porchlight is now able to begin audit preparation earlier in the year. Regular monthly reconciliations and improved staff training have significantly reduced the number of adjustments required at year‐end. Financial statements will be prepared internally prior to the audit process, allowing management to review financial information earlier and provide complete information to the auditors in a timely manner. While certain reporting configurations within Sage Intacct continue to be refined, Porchlight is working with outside consultants experienced with the system to ensure reporting functionality operates effectively. Porchlight is also developing a formal year‐end close checklist and reporting calendar to ensure that all financial reporting tasks are completed on schedule and that audit preparation begins sufficiently in advance of reporting deadlines. The Finance Director, with oversight from the Executive Director, is responsible for monitoring audit timelines and, along with our auditors, ensure all deadlines for submission to the Federal Audit Clearinghouse are met. Staffing improvements and the engagement of external consultants have strengthened the organization’s capacity to complete the audit process in a timely manner. Management will continue to monitor internal timelines and reporting procedures to ensure future audit submissions are completed within required deadlines. Person(s) Responsible: Halle Pollay Timing for Implementation: In process
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule...
To ensure consistent completion of the Sliding Fee Discount Form for all patients, new procedures have been implemented to improve the collection and documentation of required information. Patient registration forms have been revised to reflect these updates. Clerical staff will now conduct schedule preparation and identify patients who are non-compliant with the Sliding Fee Discount Form requirements. Post visit audits will be conducted to confrim that all necessary data is being accurately captured. The Revenue Cycle Manager will continue to provide on-site training across all locations and will work in close collaboration with clerical support staff, Clinic Managers, the Director of Operations, and the Director of Quality to ensure successful implementation and ongoing compliance.
Audit Finding Reference: SD-2024-003 Improve Internal Controls & Compliance with Procurement Planned Corrective Action: All contracts involving any federal grants will include the appropriate CRF 200 & 200.327 language. The language will be a required element of all federal contract, and will be cle...
Audit Finding Reference: SD-2024-003 Improve Internal Controls & Compliance with Procurement Planned Corrective Action: All contracts involving any federal grants will include the appropriate CRF 200 & 200.327 language. The language will be a required element of all federal contract, and will be clearly identified. No contracts will be approved by the City Manager without this language. Planned Implementation Date of Correction Action: Immediately as of date of deficiency notice 3-2-26. Person Responsbile for Corrective Action: Director of Finance
Finding 2024-006 - Late Submission of Data Collection Form Corrective Action Plan: Management will implement a formal compliance calendar to track Uniform Guidance reporting deadlines. Responsibility for submission will be assigned to a specific individual. Audit progress will be monitored regularly...
Finding 2024-006 - Late Submission of Data Collection Form Corrective Action Plan: Management will implement a formal compliance calendar to track Uniform Guidance reporting deadlines. Responsibility for submission will be assigned to a specific individual. Audit progress will be monitored regularly to ensure timely completion and submission of the reporting package and Data Collection Form. Additionally, management will address underlying financial reporting control weaknesses identified in this audit to improve overall audit readiness. Responsible Party: Executive Director, Board of Directors (oversight) Planned Completion Date: Compliance calendar implemented March 11, 2026; ongoing monitoring thereafter.
Management has maintained appropriately trained and experienced personnel to ensure the financial close process has been completed accurately and timely.
Management has maintained appropriately trained and experienced personnel to ensure the financial close process has been completed accurately and timely.
Controls Over Reporting Federal Agency: U.S. Department of Transportation Federal Program Name: Airport Improvement Program Assistance Listing Number: 20.106 Federal Award Identification Number and Year: AIP 45, AIP 46, AIP 47, AIP 48, AIP 44, AIP 52, AIP 50, AIP 42, AIP 49, 2024 Pass-Through Agency...
Controls Over Reporting Federal Agency: U.S. Department of Transportation Federal Program Name: Airport Improvement Program Assistance Listing Number: 20.106 Federal Award Identification Number and Year: AIP 45, AIP 46, AIP 47, AIP 48, AIP 44, AIP 52, AIP 50, AIP 42, AIP 49, 2024 Pass-Through Agency: Minnesota Department of Transportation Pass-Through Numbers: AIP 45, AIP 46, AIP 47, AIP 48, AIP 44, AIP 52, AIP 50, AIP 42, AIP 49 Award Period: Year-Ended December 31, 2024 Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: It is recommended the Authority have a secondary person reviewing these reports before they are submitted to the federal agency. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Authority will evaluate its internal staff capacity to determine if an internal control policy over reviews is beneficial. Name of the contact person responsible for corrective action: Kyle Christiansen, Executive Director Planned completion date for corrective action plan: December 31, 2025
Name of contact person: Michael Crooker, County Administrator Corrective Action: The County will work to ensure timely filing of required reports in the future. Proposed completion date: Management intends to have the policy in place immediately.
Name of contact person: Michael Crooker, County Administrator Corrective Action: The County will work to ensure timely filing of required reports in the future. Proposed completion date: Management intends to have the policy in place immediately.
WMMHC will implement additional review procedures for grant expenditures to ensure timely filing and compliance with federal requirements.
WMMHC will implement additional review procedures for grant expenditures to ensure timely filing and compliance with federal requirements.
Talmud Torah Darkei Avos-Monsey respectfully submits the following corrective action plan for the year ended August 31, 2024. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: September 01, 2023 - August 31, 2024 The finding from the August 31, 2024 sched...
Talmud Torah Darkei Avos-Monsey respectfully submits the following corrective action plan for the year ended August 31, 2024. Hirsch | Dinter & Co. CPAs: 21 Remsen Avenue, Suite #302, Monsey, New York 10952 Audit Period: September 01, 2023 - August 31, 2024 The finding from the August 31, 2024 schedule of findings and questioned costs is discussed below. Finding 2024-001: Federal Awards Program Audit U.S. Department of Agriculture Child Nutrition Cluster Programs Deficiency: See Finding 2024-001 Recommendation: The Organization should develop a compliance calendar that includes financial reporting deadlines and set automatic reminders in advance of each deadline to aid in properly planning and timing submission of reporting packages. Additionally, the Organization should engage the audit firm well before the fiscal year end, and the auditors should put this engagement on their calendar well in advance of the due date. The Organization should establish a timeline with the auditors that aligns with internal deadlines to ensure sufficient time to conduct the audit. The Organization’s Board of Directors should be more actively engaged in the auditing and reporting process to establish a greater degree of accountability and oversight. Anticipated Completion Date: 05/31/2026 Actions Taken: The Organization has begun implementing the above-mentioned recommendations. The Organization will ensure that it has a working compliance calendar to assist in meeting the reporting deadline. Additionally, the Organization has engaged the audit firm for their upcoming fiscal year-end, and the audit firm has put it on its calendar to begin the audit process well in advance. The Organization’s board of directors has agreed to oversee the auditing and reporting processes to a greater extent. With these actions, the Organization expects to comply with the Uniform Guidance for single audits deadline for the fiscal year end August 31, 2025. Mr. Yaakov Rotenberg, food service director, has been designated to monitor the plan of corrective action for this finding. He can be reached at 845-371-2476. Contact Person Responsible for Corrective Action: Yaakov Rotenberg, Food Service Director
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