Corrective Action Plans

Finding 1226974 (2025-005)

Material Weakness 2025

CT

Questioned Costs Subrecipient Monitoring Eligibility

Management has updated the policies and procedures manual to address this finding. For each housing unit, we are using the Department of Housing and Urban Development (HUB) rent reasonableness form at lease signing. This form will be updated annually for each unit. We will also be following the HUD ...

Management has updated the policies and procedures manual to address this finding. For each housing unit, we are using the Department of Housing and Urban Development (HUB) rent reasonableness form at lease signing. This form will be updated annually for each unit. We will also be following the HUD fair market rent determinations.

View Audit 409146

Finding 1226972 (2025-004)

Material Weakness 2025

Operation Hope of Fairfield, Inc.

CT

Questioned Costs Subrecipient Monitoring Reporting § 200.512

Operation Hope has retained a new audit firm and developed a new schedule to ensure future audits are completed in a timely manner and reports are submitted by the due date.

View Audit 409146

Finding 1226485 (2025-001)

Material Weakness 2025

Beacon Health System, Inc.

IN

Subrecipient Monitoring Eligibility Reporting

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. S...

The Corporation screens applicants for eligibility by following the state of Indiana guidelines as provided through the INWIC system used to enter, track, and store information about applicants. Based on guidance contained in 7 CFR Section 246, states were encouraged to move to a paperless system. Specifically, federal guidance contained in 7CFR 246.7 (i)(4) and (5)(i) outlines acceptable documentation to be included on certification forms as “a description of the document(s) used to determine residency and identity or a copy of the document(s) used or the applicant’s written statement when no documentation exists,” and “a description of the document(s) used to determine income eligibility or a copy of the document(s) in the file.” The State of Indiana has followed that guidance and does not require the Corporation to retain copies of the WIC applicant’s proof of eligibility. Therefore, the auditors were not able to test internal controls over compliance or compliance over the eligibility compliance requirement through re-performance and have issued a qualified opinion based on the scope limitations. Compliance with State of Indiana participant eligibility requirements is the responsibility of Rebecca Lies, WIC Coordinator. As the Corporation follows the State of Indiana’s paperless system as described above, no further corrective action will be taken.

View Audit 409117

Finding 1226484 (2025-001)

Material Weakness 2025

Finger Lakes Migrant Health Care Proj INC Dba Finger Lakes Comm Health

NY

Procurement, Suspension & Debarment Subrecipient Monitoring

Health Resources and Services Administration Mary Zelazny, CEO respectfully submits the following corrective action plan for the year ended December 31, 2025: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2025 The findings from the December 31, 2025, sched...

Health Resources and Services Administration Mary Zelazny, CEO respectfully submits the following corrective action plan for the year ended December 31, 2025: CohnReznick LLP 1301 Avenue of the Americas New York, NY 10019 Audit Period: December 31, 2025 The findings from the December 31, 2025, schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS FEDERAL AWARD PROGRAM AUDITS Item 2025-001 Procurement, Suspension and Debarment (Significant Deficiency) During our audit, we noted that there is no evidence that any exclusion search was conducted from January 2025 to May 2025. Recommendation We recommend that FLCH train its employees in relation to their policies and procedures on conducting exclusion screening and on proper documentation thereof. Action Taken Management agrees with the finding. As of the effectivity date below, procedures have been revised and personnel have been trained to help ensure the accuracy, completeness and timeliness of exclusion searches. The Compliance department has added periodic internal auditing of the process to their calendar. Effective Date: June 1, 2025 Sincerely yours, Name: Mary Zelazny Title: CEO. Finger Lakes Community Health, Inc. (f/k/a Finger Lakes Migrant Health Care Project, Inc.)

View Audit 409116

Finding 1226462 (2025-002)

Material Weakness 2025

City of Marion

SC

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting

The City relies heavily on supervisory oversight. The City has in place many internal controls to help reduce risks of financial reporting objectives and provide safeguards for the City's assets. Some of the controls are a supervisor has to review and sign off on all bank statements and reconciliati...

The City relies heavily on supervisory oversight. The City has in place many internal controls to help reduce risks of financial reporting objectives and provide safeguards for the City's assets. Some of the controls are a supervisor has to review and sign off on all bank statements and reconciliations, and any journal entries. All accounts payable invoices and reports are reviewed by at least two people.

View Audit 409088

Finding 1226452 (2025-001)

Material Weakness 2025

CITY OF AUBURN CITY HALL

IN

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.303

FINDING 2025-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Lorrie K. Pontius Contact Phone Number and Email Address: 260-925-6450 x1101 lkpontius@ci.auburn.in.us Views of Responsible Officials: “We ...

FINDING 2025-001 Finding Subject: Coronavirus State and Local Fiscal Recovery Funds - Suspension and Debarment Contact Person Responsible for Corrective Action: Lorrie K. Pontius Contact Phone Number and Email Address: 260-925-6450 x1101 lkpontius@ci.auburn.in.us Views of Responsible Officials: “We concur with the finding.” Description of Corrective Action Plan: The Corrective Action Plan will require verification through the Excluded Parties List System (EPLS) in SAM.gov before any award, contract execution, renewal, or contract modification is approved. Verification will be printed and/or saved as a PDF copy of the SAM.gov search results showing the date of the verification and the search outcome. Then verification documentation will be sent to a secondary reviewer electronically and maintained in the contract file according to records retention policy. Anticipated Completion Date: As a corrective measure, verification through the EPLS in the System for Award Management (SAM.gov) will be conducted immediately as of the completion date of this CAP, June 3, 2026 and prior to any award, contract execution, renewal, or modification.

View Audit 409087

Finding 1226440 (2025-002)

Material Weakness 2025

Will County

IL

Subrecipient Monitoring

Contact Person Responsible for Corrective Action: Tim Mack Contact Phone Number: (815)774-7892 Views of Responsible Official: We concur with finding 2025-002 and offer the following context and corrective action plan: Condition: Will County (“County”) received funding under the Community Development...

Contact Person Responsible for Corrective Action: Tim Mack Contact Phone Number: (815)774-7892 Views of Responsible Official: We concur with finding 2025-002 and offer the following context and corrective action plan: Condition: Will County (“County”) received funding under the Community Development Block Grant (CDBG) program (ALN 14.218) and issued more than $1 million in first-tier subawards to subrecipients during the audit period. Several individual subawards exceeded $30,000. The County did not perform or document FFATA subaward reporting for these awards and does not have an applicable exemption from FFATA reporting requirements. Description of Corrective Action Plan: The County will report subawards, as required, under this program for FY25 and going forward. The County will create a tracking document that will reflect all subrecipients of the program and the amounts of first-tier subaward. For subawards exceeding $30,000, the document will indicate the date that the required reporting was performed. Anticipated Completion Date: November 30, 2026

View Audit 409054

Finding 1226401 (2025-002)

Material Weakness 2025

NEIGHBORHOOD CHRISTIAN LEGAL CLINIC, INC.

IN

Subrecipient Monitoring § 200.334

Finding 2025-002: SLFRF Record Retention Description of Finding: Elevation timecards for employees for the pay period ending 4/3/2025 were not adequately retained during the required three-year period. Statement of Concurrence or Nonconcurrence: Management concurs with the finding. Corrective Action...

Finding 2025-002: SLFRF Record Retention Description of Finding: Elevation timecards for employees for the pay period ending 4/3/2025 were not adequately retained during the required three-year period. Statement of Concurrence or Nonconcurrence: Management concurs with the finding. Corrective Action: Management concurs with the finding. The inability to test controls in this instance was the result of a change in software for timekeeping that the clinic made during the fiscal year from Tsheets to Paycor. Quickbooks was unable to provide access to the retired system once the transition to Paycor was completed. Where the grantor has required timesheet data to be provided and submitted as part of grant reports, the information was saved and submitted. Where the auditors selected data for testing that had not been required by a grantor as part of a report, access was not able to be obtained by the Clinic in the previous system for testing. Fortunately, however, these controls were already in place in the new system and have been in continuous use since the programs inception, therefore no additional steps need to be taken to ensure compliance moving forward as compliance resulted from lack of access to test the control, not an actual process or procedure not in place. Responsible Personnel: Erin Hall, Executive Director, ehall@nclegalclinic.org, (317) 429-4130 Projected Completion Date: complete as of the date of this plan, July 15, 2026

View Audit 408989

Finding 1226400 (2025-006)

Material Weakness 2025

Council Bluffs Community School District

IA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs

Finding Summary – During the audit, it was determined that an employee used a District purchasing card to make unauthorized personal purchases that were subsequently charged to the Twenty-First Century Community Learning Centers federal program. Existing monitoring and approval procedures did not id...

Finding Summary – During the audit, it was determined that an employee used a District purchasing card to make unauthorized personal purchases that were subsequently charged to the Twenty-First Century Community Learning Centers federal program. Existing monitoring and approval procedures did not identify the improper expenditures. As a result, approximately $7,000 of unallowable costs were charged to the federal award, resulting in a significant deficiency in internal control over compliance related to allowable costs and cost principles. Contact Person Responsible for Corrective Action – Dr. Chace Ramey, Superintendent Corrective Actions Planned – The District has implemented additional review and monitoring procedures over purchasing card transactions and federal program expenditures. Supporting documentation is reviewed to ensure expenditures are allowable, properly approved, and directly related to program purposes. District administration will continue to monitor compliance with federal requirements to reduce the risk of unallowable costs being charged to federal awards. Anticipated Completion Date of Corrective Action Plan – June 30, 2026.

View Audit 408984

Finding 1226292 (2025-006)

Material Weakness 2025

City of Blackduck

MN

Questioned Costs Subrecipient Monitoring Material Weakness

Recommendation: We recommend that the City implement controls over USDA reports to ensure that they are reviewed prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will work to ensure t...

Recommendation: We recommend that the City implement controls over USDA reports to ensure that they are reviewed prior to submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The City will work to ensure that the management reports are reviewed prior to submission. Name of the contact person responsible for corrective action: Christina Regas, City Administrator Planned completion date for corrective action plan: December 31, 2026.

View Audit 408960

Finding 1226288 (2025-001)

Material Weakness 2025

City of Greensburg

IN

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.303

FINDING 2025-001 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Amy Borns Contact Phone Number and Email Address: 812-663-8582 ext 1 & aborns@greensburg.in.gov Views of Responsible Officials: We concur with th...

FINDING 2025-001 Finding Subject: COVID-19 Coronavirus State and Local Fiscal Recovery Funds - Reporting Contact Person Responsible for Corrective Action: Amy Borns Contact Phone Number and Email Address: 812-663-8582 ext 1 & aborns@greensburg.in.gov Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: When the SLFRF Compliance report is completed by the Clerk-Treasurer, either the Accounts Payable/Receivable Specialist or the Personnel Administrator will double check it and sign off (or send an email) concurring with the report. Anticipated Completion Date: This will be completed no later than April 30, 2027.

View Audit 408956

Finding 1226244 (2025-002)

Material Weakness 2025

American Physical Society

MD

Subrecipient Monitoring Matching / Level of Effort / Earmarking § 200.303

Finding Number: 2025-002 Compliance Requirement: Subrecipient Monitoring Corrective Action Plan APS acknowledges the finding and has reviewed its procedures related to NSF prior-approval requirements for post-award subawards. In the instances identified, the subawards were not identified at the prop...

Finding Number: 2025-002 Compliance Requirement: Subrecipient Monitoring Corrective Action Plan APS acknowledges the finding and has reviewed its procedures related to NSF prior-approval requirements for post-award subawards. In the instances identified, the subawards were not identified at the proposal stage and arose after the NSF award had already been issued. APS notes that the NSF Proposal and Award Policies and Procedures Guide (PAPPG) does not explicitly state that grantees must obtain separate prior written approval for post-award subawards that were not identified in the original proposal. As a result, APS personnel did not recognize that additional NSF authorization was required under these circumstances. APS has strengthened its grant administration procedures to ensure compliance with sponsor requirements. APS has implemented additional review procedures requiring grant administration personnel and Principal Investigators to assess prior-approval requirements before executing any post-award subaward. APS will document this review and, when required, obtain and retain written sponsor authorization prior to issuing a subaward. In addition, APS has enhanced training for grants management personnel regarding NSF award administration requirements and will maintain documentation evidencing compliance with all applicable prior-approval requirements. APS will continue to monitor subaward activity throughout the life of each award to ensure that sponsor approvals are obtained and retained timely and that all federal award requirements are met. APS will implement the corrective action plan on August 31, 2026. Management's contact responsible for the implementation of the Corrective Action Plan: Name: Jane Hopkins Gould Position: Chief Financial & Operating Officer Telephone number: 301-209-3276

View Audit 408898

Finding 1226198 (2025-001)

Material Weakness 2025

City of Gloucester, Massachusetts

MA

Subrecipient Monitoring § 200.332

Condition: The City did not maintain risk assessments to evaluate each subrecipients risk of noncompliance and level of monitoring required and did not maintain any documentation indicating that monitoring occurred for five subrecipients. Corrective Action Planned: Management agrees with the finding...

Condition: The City did not maintain risk assessments to evaluate each subrecipients risk of noncompliance and level of monitoring required and did not maintain any documentation indicating that monitoring occurred for five subrecipients. Corrective Action Planned: Management agrees with the finding. Although staffing changes affected overall grant oversight, responsibility for monitoring these subrecipients had been assigned; however, the required risk assessments and monitoring activities were not completed or documented. The city has clarified responsibility for subrecipient oversight and will require documented risk assessments, monitoring procedures, and supervisory review for all future federal subawards. Anticipated Completion Date: June 2027 Contact: Alex Koppelman, Community Development Director

View Audit 408837

Finding 1226195 (2025-002)

Material Weakness 2025

Opening Doors, Inc.

CA

Questioned Costs Subrecipient Monitoring Eligibility

Auditor's Recommendation: Strengthen controls over eligibility determinations by requiring Program Managers to document and retain evidence of review and approval of all intake forms/applications before services are provided. Management should also implement periodic monitoring procedures to ensure ...

Auditor's Recommendation: Strengthen controls over eligibility determinations by requiring Program Managers to document and retain evidence of review and approval of all intake forms/applications before services are provided. Management should also implement periodic monitoring procedures to ensure review approvals are consistently documented and maintained for audit purposes. Management Response: ODI is diligent in understanding and implementing the steps necessary to review and collect the required documentation to determine client eligibility for programs. Due to the large number of clients serviced and the volume of documents collected and reviewed, many of the programs track eligibility via proprietary on line portals provided by the funders to capture and document the steps performed to determine eligibility. These portals automatically determine whether a client is eligible based on the information provided. The Program Managers see the client eligibility on the portal when they assign caseworkers to the clients, but there is no formal Program Manager signature provided or captured in the portal. Corrective Action: • Regarding the specific program 90ZQ(l}011-01-0 Support for Trauma-Affected Refugees (STAR} referenced in this finding, client eligibility is determined by requirements established by the Office of Refugee Resettlement (ORR} that apply to other programs administered by ODI. To address the auditor's recommendation regarding this program, ODI will set up a procedure to review and retain documentation for clients entering the STAR program or who were referred from other ORR programs showing they are eligible to receive the STAR services. •Regarding the specific program ALSP23-0001 Afghan Legal Services Project (ALSP}, ODI has serviced, and is still servicing, approximately 500 clients. Although ODI asserts that it has and retains the documentation to demonstrate client eligibility for this program, to address the auditor's recommendation, ODI will set up a procedure to track and document that the program manager will approve. Responsible Personnel: Mao Vang, Health & SOT Program Director; Alyssa Eckels, ILS Program Director Implementation Date: Immediate implementation

View Audit 408833

Finding 1226186 (2025-002)

Material Weakness 2025

Low Rent Housing Agency of Burlington

IA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Questioned Costs

To properly ensure internal controls, all segregation of duties will be documented beyond what is currently being done. For additional oversight of monthly reconciliation, it will be documented that this has had a secondary review. Additionally, a board member or another individual will review month...

To properly ensure internal controls, all segregation of duties will be documented beyond what is currently being done. For additional oversight of monthly reconciliation, it will be documented that this has had a secondary review. Additionally, a board member or another individual will review monthly bank statements, invoices, and related documentation. The board will review policy and focus on stricter internal controls to prevent any form of fraud.

View Audit 408828

Finding 1226182 (2025-002)

Material Weakness 2025

National Network to End Domestic Violence, Inc.

DC

Subrecipient Monitoring § 200.332

NNEDV management have received training on the importance of sub-recipient monitoring, along with how and when it is to be performed. The outsourced CPA will work with program directors to ensure all subrecipient monitoring is completed by the end of summer. Anticipated Completion Date: 8/31/2026. R...

NNEDV management have received training on the importance of sub-recipient monitoring, along with how and when it is to be performed. The outsourced CPA will work with program directors to ensure all subrecipient monitoring is completed by the end of summer. Anticipated Completion Date: 8/31/2026. Responsible Contact Person: Ellen Yin-Wycoff, Assistant VP of Programs & Operations

View Audit 408826

Finding 1226178 (2025-001)

Material Weakness 2025

International Development Enterprises and Subsidiaries

CO

Subrecipient Monitoring § 200.303 § 200.332

Identifying Number: 2025-001 Subrecipient Monitoring Controls Finding: During fiscal year 2025, iDE passed federal funds to subrecipients under active federal awards that remained operational during a portion of the year prior to the termination of the underlying grant agreements. Although iDE revie...

Identifying Number: 2025-001 Subrecipient Monitoring Controls Finding: During fiscal year 2025, iDE passed federal funds to subrecipients under active federal awards that remained operational during a portion of the year prior to the termination of the underlying grant agreements. Although iDE reviewed subrecipient liquidation reports and reimbursement requests supporting expenditures incurred prior to award termination, iDE did not perform or document formal subrecipient risk assessments. Further, because risk assessments were not performed, iDE did not establish or implement monitoring procedures commensurate with assessed risk, such as documented reviews of performance information, follow-up on compliance matters, review of Single Audit reports, or other monitoring activities required by Uniform Guidance. Corrective Actions Taken or Planned: Name of Responsible Official: Melanie Mackintosh, Controller Anticipated Completion Date: December 31, 2026 Views of Responsible Officials and Planned Corrective Action: 1. Following the 2024 subrecipient monitoring finding, iDE created an updated subrecipient monitoring policy and sponsored global trainings. 2. There was no opportunity for correction of subrecipient monitoring of USAID grants in 2025 due to the USAID shutdown.

View Audit 408819

Finding 1226107 (2025-002)

Material Weakness 2025

City of Hempstead, Texas

TX

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303 § 200.328

Finding 2025-002: Insufficient Documentation of Management Review of Section 3 Quarterly and Annual Reporting Planned Corrective Action: Management concurs with the finding. Although the related grant concluded during fiscal year 2025, the City will implement procedures to ensure that future federal...

Finding 2025-002: Insufficient Documentation of Management Review of Section 3 Quarterly and Annual Reporting Planned Corrective Action: Management concurs with the finding. Although the related grant concluded during fiscal year 2025, the City will implement procedures to ensure that future federal program reports, including any applicable Section 3 or similar compliance reports, are subject to documented management review and approval prior to submission. The procedures will require the preparer to provide each report and supporting documentation to City management for review, and evidence of approval, such as a signed review checklist, email approval, or electronic sign-off, will be retained in the grant files. The City Secretary will be responsible for ensuring that documented review and approval procedures are applied to future federal reporting requirements. Anticipated Completion Date: July 2026

View Audit 408755

Finding 1226090 (2025-003)

Material Weakness 2025

Town of Clarksville

IN

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.303 § 200.329

FINDING 2025-003 Sherry Lockard, 812-283-1500, slockard@townofclarksville.com A. Coronavirus State and Local Fiscal Recovery Funds (IDOH fire dept grant) The Town concurs with the finding. INDIANA STATE BOARD OF ACCOUNTS 23 The Town will create a form for the Fire Department to use to have a second ...

FINDING 2025-003 Sherry Lockard, 812-283-1500, slockard@townofclarksville.com A. Coronavirus State and Local Fiscal Recovery Funds (IDOH fire dept grant) The Town concurs with the finding. INDIANA STATE BOARD OF ACCOUNTS 23 The Town will create a form for the Fire Department to use to have a second person review any reporting and requests for reimbursements when federal funds are involved. The form will be an attachment at the end of this document, therefore no further action is necessary.

View Audit 408741

Finding 1226089 (2025-002)

Material Weakness 2025

Town of Clarksville

IN

Subrecipient Monitoring Questioned Costs Material Weakness § 200.1 § 200.303

FINDING 2025-002 Sherry Lockard, 812-283-1500, slockard@townofclarksville.com A. Coronavirus State and Local Fiscal Recovery Funds The Town concurs with the finding. The Town was not aware contracts had to be signed by December 2024 for all “obligations”. The Town was under the impression the obliga...

FINDING 2025-002 Sherry Lockard, 812-283-1500, slockard@townofclarksville.com A. Coronavirus State and Local Fiscal Recovery Funds The Town concurs with the finding. The Town was not aware contracts had to be signed by December 2024 for all “obligations”. The Town was under the impression the obligations were submitted on the annual SLRF report, and that only the funds had to be spent for submitted obligations on the SLRF page by December 31, 2026. The Town was not able to obtain a contract that far in advance of the work to start, let alone be completed. At this time, we will await instructions from the Federal Agency as to what the Town needs to do regarding the expenses made after the ambiguous “obligation deadline”. For all future grants, the Town will designate the staff member who is in charge of that specific grant to create a checklist of requirements and to maintain that list until the grant is complete. (ATTACHMENT A)

View Audit 408741

Finding 1226085 (2025-026)

Material Weakness 2025

State of California

CA

Internal Control / Segregation of Duties Special Tests & Provisions Questioned Costs § 200.303

Special Tests and Provisions California Governor’s Office of Emergency Services On December 10, 2025, Cal OES implemented communication protocol improvements by reemphasizing correct threshold applicability prior to payment during team meetings. In addition, by August 31, 2026, Cal OES will revise i...

Special Tests and Provisions California Governor’s Office of Emergency Services On December 10, 2025, Cal OES implemented communication protocol improvements by reemphasizing correct threshold applicability prior to payment during team meetings. In addition, by August 31, 2026, Cal OES will revise its Project Threshold standard operating procedure to include a review control that verifies the applicability of project thresholds, specifically the Large Project threshold, based on the appropriate timing criteria. Cal OES will also provide training to all grants processing and support staff on the revised procedure, including how to correctly identify and enter Large Project Thresholds, verify disaster data against approved sources, and apply the appropriate thresholds for specific declaration dates. Refresher training will be provided as needed thereafter. Furthermore, guidance on Large Project Thresholds will be incorporated into the onboarding process for all new staff. Estimated Implementation Date: August 2026 Contact: - Heidi Palchik, Chief, Recovery Financial Administration Branch, lnteragency Recovery Coordination Section

View Audit 408731

Finding 1226084 (2025-025)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Procurement, Suspension & Debarment Reporting § 200.302 § 200.303 § 200.328 § 200.329

Reporting California Governor’s Office of Emergency Services Based on CSA's Federal Compliance Audit Report for the Fiscal Year Ended June 30, 2024 - Finding 2024-020, Cal OES revised its FFATA reporting procedures and has taken several actions to strengthen internal controls, resolve discrepancies ...

Reporting California Governor’s Office of Emergency Services Based on CSA's Federal Compliance Audit Report for the Fiscal Year Ended June 30, 2024 - Finding 2024-020, Cal OES revised its FFATA reporting procedures and has taken several actions to strengthen internal controls, resolve discrepancies among reporting systems, and ensure staff are fully trained to maintain compliance with all FFATA reporting requirements. In March of 2025, Cal OES developed the Financial Administrative Branch (FAB) FFATA SOP (Attachment #1) for FFATA reporting which outlines steps for collecting subrecipient data, preparing reports, and submitting reports within the required time frames. In addition, Cal OES enhanced its existing FFATA reporting procedures using a software platform to provide accurate data reports for federally funded grant projects. These reports are then used to ensure accurate reporting and timely updates to existing FFATA records. To ensure clear assignment of accountability, Cal OES FAB analysts are responsible for completing and submitting FFATA reporting accurately, with all required fields completed, and obtaining review and approval from their respective peer reviewer analysts and managers to verify accuracy and completeness. Furthermore, in June of 2025, Cal OES FAB staff were provided with a comprehensive FFATA training course to ensure staff understand the process and reporting requirements for FFATA (Attachment #2). Cal OES continues to provide training for staff responsible for submitting FFATA reports during onboarding and on an as-needed basis. Because the revised FFATA reporting procedures were not fully implemented by the close of Fiscal Year 2024-2025, Cal OES was not able to capture all projects concluding the reporting cycle. Moreover, the procedures have been fully implemented and in effect since the start of Fiscal Year 2025-2026. Estimated Implementation Date: Implemented Contact: - Heidi Palchik, Chief, Recovery Financial Administration Branch lnteragency, Recovery Coordination Section

View Audit 408731

Finding 1226083 (2025-024)

Material Weakness 2025

State of California

CA

Allowable Costs / Cost Principles Period of Performance Subrecipient Monitoring § 200.303 § 200.77

Period of Performance California Governor’s Office of Emergency Services In July of 2024, Cal OES implemented EMPOWER, a new electronic time reporting system. EMPOWER captures employees' daily time worked, and activities identified with service locations (funding code) by cost category. The establis...

Period of Performance California Governor’s Office of Emergency Services In July of 2024, Cal OES implemented EMPOWER, a new electronic time reporting system. EMPOWER captures employees' daily time worked, and activities identified with service locations (funding code) by cost category. The established EMPOWER Standard Operating Procedure instructs Cal OES Administrative Services staff on how to set the service location incident period start date, which creates system controls to not allow any activities to be entered prior to the start date. To address the transaction identified by CLA and prevent recurrence, Cal OES is troubleshooting and testing potential solutions to develop a systematic fix in EMPOWER. In addition, Cal OES will provide refresher training for all first-line managers to improve their oversight of funding codes and cost categories and ensure their staff submit time entries accordingly. Cal OES Administrative Services will also integrate a resource checklist into its monthly pre-labor review and posting process to add an extra layer of transaction oversight. Currently, Cal OES Administrative Services reviews and reconciles all cost category claims and supporting documentation before submitting to FEMA for obligation. This continuous review ensures Cal OES flags and corrects ineligible or out-of-period transactions before requesting reimbursement. Furthermore, Cal OES will review and correct the identified transaction. Estimated Implementation Date: October 2026 Contact: - Mary Rucker, Assistant Director Administrative Services, Finance & Logistics Administration

View Audit 408731

Finding 1226082 (2025-023)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Eligibility Questioned Costs § 200.303

Eligibility California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS wo...

Eligibility California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS would leverage data to monitor application processing times. The data will be used to select counties for focused reviews targeting application processing times and procedures to ensure counties are performing eligibility determinations timely and accurately. DHCS has implemented multiple monitoring activities to address the recommendation and strengthen oversight of county processing of Medi-Cal applications. In May 2024, DHCS issued Medi-Cal Eligibility Division Letter (MEDIL) 24-12, ending the temporary hold harmless provisions and resumed standard county performance accountability. Subsequently, DHCS issued ACWDL 24-17, which established the Department's transition to using system-generated eligibility data, rather than county self-certification, to monitor application timeliness. Under this approach, DHCS evaluates county performance using statewide eligibility data, publishes application timeliness performance through statewide dashboards, and uses the data to identify counties for focused reviews. Focused reviews evaluate both the timeliness and accuracy of county eligibility determinations. Counties that do not meet established performance expectations are subject to corrective actions consistent with the Welfare and Institutions Code (WIC) section 14154 performance monitoring framework, including the application of statutory performance corrective action plans (CAPS), and financial penalties where applicable. Collectively, these actions establish an ongoing oversight process that enables DHCS to monitor county compliance with Medi-Cal application timeliness requirements, identify performance issues, require counties to implement corrective actions to address any deficiencies identified through focused reviews, and promote continued improvement in the timely and accurate processing of Medi-Cal applications. In 2025, DHCS issued MEDIL I 25-19, Reinstatement of the Aid Code Clean-Up Effort, which reinstated the Department's statewide process for identifying beneficiaries assigned to obsolete pre-Affordable Care Act (ACA) aid codes, transitional aid codes, or other records that may require reevaluation of eligibility. As part of this effort, DHCS provides counties with standardized reports on a bi-monthly basis to assist in identifying records that require review and action. Counties are required to review records, and either transition beneficiaries to the appropriate Medi-Cal aid code or discontinue eligibility, as applicable. Through the reinstated Aid Code Clean-Up process, DHCS performs ongoing statewide monitoring of aid code usage, identifies obsolete or inappropriate aid codes, and requires counties to take the appropriate action to ensure these beneficiaries are enrolled under the correct Medi-Cal aid category. Estimated Implementation Date: Fully Implemented Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Finding 1226080 (2025-022)

Material Weakness 2025

State of California

CA

Subrecipient Monitoring Questioned Costs Allowable Costs / Cost Principles § 200.303

Activities Allowed and Unallowed California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL noti...

Activities Allowed and Unallowed California Department of Health Care Services DHCS reinstated county performance standards effective June 1, 2024, through Medi-Cal Eligibility Division Letter (MEDIL 24-12) and issued All County Welfare Directors Letter (ACWDL) 24-17 on November 25, 2024. ACWDL notified counties DHCS would leverage data to monitor application processing times. The data will be used to select counties for focused reviews targeting application processing times and procedures to ensure counties are performing eligibility determinations timely and accurately. DHCS has implemented multiple monitoring activities to address the recommendation and strengthen oversight of county processing of Medi-Cal applications. In May 2024, DHCS issued Medi-Cal Eligibility Division Letter (MEDIL) 24-12, ending the temporary hold harmless provisions and resumed standard county performance accountability. Subsequently, DHCS issued ACWDL 24-17, which established the Department's transition to using system-generated eligibility data, rather than county self-certification, to monitor application timeliness. Under this approach, DHCS evaluates county performance using statewide eligibility data, publishes application timeliness performance through statewide dashboards, and uses the data to identify counties for focused reviews. Focused reviews evaluate both the timeliness and accuracy of county eligibility determinations. Counties that do not meet established performance expectations are subject to corrective actions consistent with the Welfare and Institutions Code (WIC) section 14154 performance monitoring framework, including the application of statutory performance corrective action plans (CAPS), and financial penalties where applicable. Collectively, these actions establish an ongoing oversight process that enables DHCS to monitor county compliance with Medi-Cal application timeliness requirements, identify performance issues, require counties to implement corrective actions to address any deficiencies identified through focused reviews, and promote continued improvement in the timely and accurate processing of Medi-Cal applications. In 2025, DHCS issued MEDIL I 25-19, Reinstatement of the Aid Code Clean-Up Effort, which reinstated the Department's statewide process for identifying beneficiaries assigned to obsolete pre-Affordable Care Act (ACA) aid codes, transitional aid codes, or other records that may require reevaluation of eligibility. As part of this effort, DHCS provides counties with standardized reports on a bi-monthly basis to assist in identifying records that require review and action. Counties are required to review records, and either transition beneficiaries to the appropriate Medi-Cal aid code or discontinue eligibility, as applicable. Through the reinstated Aid Code Clean-Up process, DHCS performs ongoing statewide monitoring of aid code usage, identifies obsolete or inappropriate aid codes, and requires counties to take the appropriate action to ensure these beneficiaries are enrolled under the correct Medi-Cal aid category. Estimated Implementation Date: Fully Implemented Contact - Sarah Crow, Medi-Cal Eligibility Division, Division Chief - Harold Higgins, Medi-Cal Eligibility Division, Branch Chief - Amy Halim, Medi-Cal Eligibility Division, Section Chief

View Audit 408731

Corrective Action Plans

Filters