Corrective Action Plans

VIEWS OF RESPONSIBLE OFFICIALS Based on the audit report submitted, it is recommended that the Cash Management Section Procedures Manual be amended, and that the segregation of employee duties be identified. To this end, work has begun on reading and amending the Manual. It will be updated considering both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS In Process Develop an operational procedures manual for each program under Uniform Guidance. Include flow outlining key processes. Assign personnel responsible for each function and establish periodic review mechanisms. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Families and Children (ADFAN, by the Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS Develop a subrecipient contract template that guarantees compliance. Establish a fiscal and administrative subrecipient manual and procedure that describe fund management and compliance criteria. This manual will include monitoring procedures and standards forms. Establish an indirect cost policy to standardize the evaluation and approval for subrecipient. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS Develop and deliver a comprehensive training program for all relevant staff (finance staff, program staff interacting with subgrantees, procurement staff) on the requirements of 2 CFR 200, with a particular focus on subgrantee monitoring and procurement standards. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Doris Jiménez, Finance Director Administration for the Care and Comprehensive Development of Children (ACUDEN, by its Spanish Acronym)

VIEWS OF RESPONSIBLE OFFICIALS It is recommended, among other things, to establish internal controls that provide certainty, effective monitoring, data validation, and accountability for those employees who execute the reporting processes. To this end, the personnel responsible will be convened and written processes will be issued to expedite the information requests and ensure their rapid submission. This will be in accordance with both state and federal regulations. Once the agreements are finalized, they will be submitted to the auditing firm. IMPLEMENTATION DATE During Fiscal Year 2025-2026. RESPONSIBLE PERSON Administration for Socioeconomic Development of the Family (ADSEF, by its Spanish Acronym)

Finding 2023.003 - Special Tests and Provisions - Sliding Fee Scale Documentation Recommendation The Center should establish a system of internal controls to ensure that all sliding fee discounts are properly calculated and supported based on family size and income. Action Taken I will work directly with the Director of Clinical Operations, Kei Wee, to conduct a comprehensive review of the Center's existing sliding fee scale policy to ensure alignment with federal guidelines and best practices, clarifying documentation requirements, including acceptable forms of income verification and definition of family size. The Clinical Operations Director, Kei Wee, will develop and implement a step-by-step standard operating procedure (SOP) for staff to consistently assess and apply sliding fee discounts. The SOP will include clear instructions for verifying documentation, calculating discount eligibility, and recording determinations in the patient's record. The Clinical Operations Director, Kei Wee's management team, will conduct monthly spot audits of a sample of sliding fee files to verify correct application and documentation. The managers will report the findings to management for corrective follow-up and provide training for registration/front-desk staff and billing personnel on the updated policy and procedures as needed.

Correction Action Plan – Finding 2023-001 “Document Policies and Procedures Over Federal Awards” Correction Action to be taken: We have been updating and developing written policies and procedures related to Federal awards as required under Uniform Guidance. Expected Completion Date: We anticipate that the policies and procedures will be completed and approved by June 30, 2026. Contact Person: Julie Hebert, Finance Director

FINDING 2023-002 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Findings: Significant Deficiency Condition: City of Bloomington completed quarterly reporting in a timely manner substantiated by the City’s expenditure detail. However, management could not differentiate between subrecipients and standard vendor purchases. Context: During our testing procedures over CSLFRF reporting, we noted that segregation of duties is not present in the Federal reporting process. The Deputy Controller prepared and submitted the reports without a secondary review taking place. As a result, the City did not report expenditures for the grant that were consistent with the expenditures reported on the SEFA and could not properly identify subrecipient expenditures. Views of Responsible Officials and Planned Corrective Actions: Management will develop an internal controls process to ensure that there’s segregation of duties within the reporting process for federal programs. Responsible party and timeline for completion: The City’s Controller will oversee the implementation of the corrective action plan, which will be implemented starting during calendar year 2025.

Finding 2023-001 Information on the federal program: Federal Agency: Department of the Treasury Pass-Through Entity: N/A – Direct Grant Federal Program: Coronavirus State and Local Fiscal Recovery Funds (CSLFRF) Assistance Listing Number: 21.027 Compliance Requirement: Subrecipient Monitoring Audit Findings: Material Weakness, Noncompliance Condition: The City of Bloomington was unable to identify subrecipients of CSLFRF funding for the purposes of financial reporting and compliance with requirements under 2 CFR 200.332. The City could not distinguish between a subrecipient and a general vendor. Management misreported subrecipient activity on the SEFA, failed to include required contractual language for subrecipient awards in executed agreements, and did not perform monitoring procedures over the subrecipients management identified during audit testing procedures. Context: The 10 subrecipients represent approximately 18%, $1,025,070, of the total award expenditures of $5,590,828, in 2023. The condition reported was prevalent for each subrecipient participating in the award. Views of Responsible Officials and Planned Corrective Actions: Management agrees with the finding and will draft a policy and develop an internal controls process regarding subawards and the monitoring of subrecipients to ensure the compliance requirements are met. Responsible party and timeline for completion: The City’s Controller will be responsible for overseeing the implementation of the corrective action plan, which will be implemented starting during calendar year 2025.

Finding 2023-003 Name of Responsible Individual: Carolina Liriano, Grant Manager; Holly Forester, Controller; Sheri Brady, VP and Chief Program Officer Corrective Action: CDF hired an Outsourced Grant Manager starting January 2025 who will assume comprehensive oversight of all facets of grant administration and compliance. The grant manager's duties will include ensuring that all reimbursement requests are substantiated by adequate documentation, such as actual invoices, payroll registers, and payment records. Key actions include:  Establishing a systematic process for the collection, organization, and retention of all requisite documents.  Implementing internal review and approval procedures to guarantee that every reimbursement request undergoes thorough vetting and receives approval prior to submission, with explicit documentation of the review process.  Instructing both existing and new personnel on these newly instituted procedures to prevent future inconsistencies. Anticipated Completion Date: December 31, 2025.

Oversight Agency for Audit Tri-County Housing, Inc. dba Total Concept & Subsidiaries respectfully submits the following corrective action plan for the year ended December 31, 2023. Name of independent accounting firm: Haynie & Company Audit Period: January 1, 2023 through December 31, 2023. The finding from the December 31, 2023 Schedule of Findings and Questioned Costs is discussed below. Finding 2023-1 Comments of the finding and recommendation: Management agrees with the finding. Action taken: We will assign the Executive Director to oversee all federal reporting deadlines and implement a centralized compliance calendar with automated reminders. Internal policies will be updated to require a formal review of reporting documents at least 45 days prior to submission deadlines. Additionally, relevant staff will receive training on Uniform Guidance requirements, and quarterly compliance meetings will be held to monitor progress. These actions are intended to ensure timely and accurate future submissions in accordance with federal regulations. If the oversight agency has questions regarding this plan, please email Steven Cordova, executive director of Tri-County Housing, Inc. dba Total Concept & Subsidiaries at scordova@totalconcept.net. Sincerely yours, Tri-County Housing, Inc. dba Total Concept & Subsidiaries

CORRECTIVE ACTION PLAN Name of auditee: Friends of the Mission Finding: 2023-003 Name of audit firm: Propp Christensen Caniglia LLP Period covered by the audit: January 1, 2023 through December 31, 2023 CAP prepared by: Scott Thurmond, Executive Director Telephone: (916) 416-0901 Comments: Management agrees with the finding. Actions: Management has taken steps to ensure the SEFA is prepared accurately and timely.

STDC concurs with the finding regarding incomplete intake documentation due to the absence of case worker signatures on multiple client intake forms under the Area Agency on Aging (AAA) programs. While client eligibility and demographic information were present, the lack of formal sign-off by the assigned case worker represents a lapse in documentation compliance and internal control. STDC management acknowledges the importance of complete and accurate documentation to uphold program integrity and compliance with the Older Americans Act. We are fully committed to strengthening internal controls, reinforcing training, and implementing procedural safeguards to ensure that all eligibility determinations and service authorizations are properly reviewed and documented. To address this, STDC will reinforce existing policies requiring case worker authorization of client intakes, implement a formal quality assurance checkpoint before service initiation, and provide refresher training to all intake and case management staff. These steps will ensure compliance with documentation standards required under the Older Americans Act and STDC’s own internal procedures. Corrective Action Plan Finding Number: 2023-04 Planned Completion Date: July 31, 2025 Responsible Official: Aging and Disability Services Director Corrective Actions: 1. Reinforce Policy Compliance through Staff Training The Aging and Disability Services Director will conduct mandatory refresher training for all intake and case management staff. The training will emphasize the importance of complete documentation, specifically the requirement to sign and date all applicable forms, including: o Intake Forms 2270 and 2276 o Rights and Responsibilities Form 2275 o Client Information Release Form 2277 o Care Plan o Caregiver Assessment o Consumer Needs Evaluation (CNE) o Evaluation of the Home (Housing Assessment) Staff training shall be verified for completion using: training attendance logs, training agenda, and post-training quiz results. 2. Implement a Secondary Review Process (Quality Assurance Checkpoint) The Aging and Disability Services Director will establish a secondary quality assurance review by the Contract Manager or other designated staff prior to initiating services. The reviewer will confirm that all required forms are fully completed and include both client and case worker signatures. 3. Update Intake Documentation Checklist and Procedures-Attached The Aging and Disability Services Director will revise the internal Required Documentation Checklist to include a checkbox for verifying the presence of AAA staff signatures and dates on all applicable forms. The updated checklist will be implemented in all new client intake files. CASE FILE CHECKLIST 1. Referral and Screening The referral and screening process begins with the Information, Referral, and Assistance (I&R/A) staff, who receive the client’s initial inquiry or service request. Once initial details are collected, the referral is assigned to a designated AAA case manager for follow-up. Screening The case manager reviews the client’s records to verify information gathered during the referral. This step helps determine eligibility (typically for individuals aged 60 and over) and whether the client qualifies for AAA services or should be referred externally. The screening must include: o Medical history o Employment background o Home environment o Self-care ability o Socioeconomic and financial status o Services received in the past o General demographics and needs o Past and current health conditions o Physical, emotional, and cognitive functioning o Living arrangements and home safety o Health insurance coverage and benefits Referral and screening documentation must be included in the client’s file to support coordination, follow-up, and accountability. 2. Intake – Form 2270 (Applicable to Caregiver Support Coordination) This form is required and must be completed by AAA staff or the case manager to collect demographic information necessary to determine eligibility. The form must include: o Initial Intake Completion – Form 2270 o Client Rights and Responsibilities (read and checked off as explained) o Part I – Recipient Identification o Part II – Services Requested o Part III – Emergency Contact Information o Part IV – Relationship to Care Recipient o Part V – Care Recipient Identification AAA staff signature and date 3. Intake – Form 2276 (Applicable to Care Coordination Support) This form is required and must be completed by AAA staff or the case manager to collect demographic information necessary to determine eligibility. The form must include: o Initial Intake Completion – Form 2276 o Client Rights and Responsibilities (read and checked off as explained) o Part I – Recipient Identification o Part II – Services Requested o Part III – Emergency Contact Information o Part IV – If referred, enter referred by; if not, leave blank o AAA staff signature and date Forms must be fully and accurately completed and include the printed name or signature of the AAA staff completing the intake, along with the date. 4. Client Rights and Responsibilities – Form 2275 This form is provided and explained to the client. A copy must be given to the client. The form must include: o Explanation of client rights and responsibilities o Client signature and date Must be signed and dated by the participant/client. 5. Client Information Release – Form 2277 This form serves as authorization to release client information to support assessment, service arrangement, and coordination of care. The form must include: o Individual’s name and WellSky ID o Completion of Parts A, B, and C o Client signature and date in Part C A copy must be provided to the client. 6. Care Plan (15–25 minutes – form attached) The care plan is developed collaboratively with the client and/or caregiver and is based on preferences, identified needs, and available resources. It outlines specific services to be provided and desired outcomes. The Care Plan Form must include: o Complete client information o Type of service (e.g., Respite, Homemaker, Personal Assistance, or other services such as Residential Repair, Health Maintenance, or ERS) o Number of units or hours per day/week (if applicable) o Duration of services o Objectives and care-related goals o Self-care resources o Desired results and measurable outcomes The form must be signed and dated by the client and/or caregiver and AAA staff/Care Coordinator. 7. Caregiver Assessment – AIAAA CAQ E 3.0 (15–25 minutes – form attached) Only applicable for Caregiver Support Coordination case files. This assessment identifies caregiver needs, strengths, limitations, and stressors to support effective care planning. The form must include: o Complete caregiver information o Caregiver needs and profile o Skills and training assessment o Caregiver stress interview o Priority status o Optional targeting categories o Additional notes, if applicable Must include the printed name or signature of the AAA staff completing the assessment and the date of completion. 7. Consumer Needs Evaluation (CNE) (form attached) The CNE documents the client’s impairment level and helps determine eligibility for services. The evaluation must include: o Completion of Parts I–V o Classification of impairment level (low, moderate, or high), based on functional needs o Consideration of mobility, self-care, cognitive ability, and support systems The form must be signed and dated by the AAA staff member completing the evaluation. 8. Comprehensive Assessment & Statement of Need (form attached) This assessment provides a holistic view of the client’s condition and support needs. The form must include: o Complete client information o Documentation of physical, mental, and medical conditions o Identification of mobility limitations o Functional/physical status – check all that apply o List of current services or treatments being received o Family caregiver support o Medication listing, if applicable AAA staff must complete and check all relevant sections to ensure full and accurate documentation. 9. Evaluation of the Home (Housing Assessment – if applicable) Required for requests related to residential repairs or identifying health/safety concerns in the home. The form must include: o Residential status o Client name and address o List of items needing repair The form must be signed and dated by the homeowner/tenant (if applicable) and the AAA staff completing the evaluation.

Condition: The Organization could not provide one salary authorization from for sample selection of 40 employees. Corrective Action Planned: The Organization has implemented a process to ensure that all salary authorizations are properly obtained and stored. When there is any change in an employee's status or salary, an Employee Status Form is completed and signed by the employee, their supervisor, and Human Resources, and when required by the COO and CEO. Additionally, the salary authorization form is added to a secure shared file drive. The shared file drive includes a section where all salary changes are listed. Both HR and Finance initial off to confirm that each salary change is supported by the proper documentation during the payroll review process. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.

Condition: No documentation of employee time approval by supervisors could be provided. The payroll clerk processes the payroll and finance director approves through the releasing of the payroll. However, there is no formal documentation of the overall review of the payroll process and the supervisors' approval to time recorded by employees. Corrective Action Planned: The Organization has implemented a new payroll process using the ADP system. Employees are now required to approve their own time within the ADP portal, and this approval is documented. Following this, supervisors review and approve their employee's time, which is also documented in the portal. Human Resources then prepares the payroll, reviewing all entries and initialing a shared file of payroll items and providing backup for changes. Once HR confirms accuracy, they notify Finance. Finance then reviews the payroll, with the Finance Manager providing the final approval within ADP once all items are confirmed. The entire process is fully documented, with approvals recorded within the ADP by employees and supervisors and the shared file drive where HR and Finance intimal off on the reviewed payroll times, ensuring a traceable record of the entire payroll approval process. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.

Condition: The Organization did not maintain property documentation to support the review of the report prior to submission to the grantor, other than the review done by the preparer. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal controls and facilitate segregation of duties and best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review as also implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.

Condition: The Organization did not maintain proper documentation in support of reporting requirements. Corrective Action Planned: The Organization has hire a new Chief Financial Officer as well as additional supporting staff within the finance department. The accounting staff was restructured in November 2024 with the addition of a Finance Manager and Senior Accountant to strengthen internal control and facilitate segregation of duties best practices for day-to-day activities. In addition to review of month-end journal entries, reporting requirements with additional review was also implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.

Condition: The Organization lacks consistently applied processes and procedures related to the application of the sliding fee scale. The Organization also lacks a clear review process related to the sliding fee scale to identify errors quickly to allow for corrections to be made in a timely manner. Corrective Action Planned: The Organization has hired a new Chief Financial Officer as well as additional supporting staff within the finance department. The Billing and Collections Policy was updated to waive co-pays for students in the School-Based Program. The Billing Department is in the process of auditing and implementing quarterly feedback & training sessions for the Operations Department for training and compliance for the Sliding Fee Discount Program. This process was implemented in 2025. Person Responsible for Corrective Action: Joe Derry, Chief Financial Officer. Anticipated Completion Date: Implemented.

Finding Number: 2023-003 Planned Corrective Action: City Auditor will stay in contact with Municipal Court Administrator and the Police Captain to ensure they submit Quarterly Reports on a timely basis. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess

Finding Number: 2023-002 Planned Corrective Action: City Auditor has confirmed the ARPA 3/31/24 and 3/31/25 Project and Expenditure Reports submitted agree to City Accounting records. Anticipated Completion Date: July 3, 2025 Responsible Contact Person: City Auditor Sherri Hess

Finding caption: The Authority did not have adequate internal controls for ensuring compliance with federal maintenance of effort requirements. Name, address, and telephone of Authority contact person: Rina Yu, Senior Accountant 20811 84th Avenue South, Suite 110 Kent WA 98032 253-856-4303 Corrective action the auditee plans to take in response to the finding: General Response: Puget Sound Fire respectfully disagrees with the Auditor's decision to elevate the two issues identified below to the level of a finding. Puget Sound Fire believes it substantially complied with the MOE and other grant requirements identified in issue 1 and worked closely with the granting agency, FEMA, to comply with all grant requirements. Based on the specific responses below, and Puget Sound Fire's good faith and reasonable efforts to cooperate and comply with the grant requirements, we respectfully request that the items be addressed in a management letter rather than a finding. Issue 1: Maintenance of Effort Puget Sound Fire respectfully disagrees with the Auditor's proposed finding. Puget Sound Fire did maintain and document the Maintenance of Effort attestation as described in the AFG grant's Notice of Funding Opportunity and followed best practices for tracking fiscal budget information as previously prescribed by SAO personnel. Puget Sound Fire's compliance is demonstrated in the 3-year budget history within the grant application/contract itself and Puget Sound Fi re provided SAO support Maintenance of Effort calculations for the years the grant was awarded. Puget Sound Fire Puget Sound Fire's governing board also approved budget increases year over year for the duration of the grant that exceeded the 80% average requirement. There is no 2 CFR Part 200 guidance on MOE other than what is included in the NOFO, and as an attestation, and the 3-year budget history was acceptable by FEMA, the grantor. Additionally, a finding is not warranted as following receipt of the same finding for the 2021 audit Puget Sound Fire adopted the SA O's feedback and has been following that guidance since then. Basing a finding for the current audit for actions that have been corrected pursuant to a prior audit is unreasonable. Puget Sound Fire complied with the MOE requirements following the 2021 finding and has no ability to go back to 2021 and change the past. Puget Sound Fire also notes that Puget Sound Fire's MOE efforts were reviewed, approved and monitored by FEMA, the grantor without issue. Puget Sound Fire has worked with and will continue to work with the grantor moving forward to implement best practices in calculating and maintaining MOE. AFG NOFO Statement - Maintenance of Effort A maintenance of effort is required under this program for all recipients, unless modified by a waiver, subject to waiver eligibility.An applicant seeking an award under this NOFO shall agree to maintain during the term of the grant, the applicant's aggregate expenditures relating to the activities allowable under this NOFO at not less than 80 percent of the average amount of such expenditures in the two fiscal years preceding the fiscal year in which the grant award is received. For more information on waiver eligibility, please see Appendix C-Award Administration Information, Section I. Economic Hardship Waivers of Cost Share and Maintenance of Effort Requirements for the FP&S Grant Program for more information. Anticipated date to complete the corrective action: Puget Sound Fire thanks the Washington State Auditor's Office for its thorough review of fiscal years 2021 through 2023. We are committed to implementing the recommended corrective actions, enhancing our internal controls, and addressing all identified deficiencies. Corrective actions for the three issues identified by the SAO have been initiated and will be fully implemented by January 1, 2026. Issue 1: Maintenance of Effort (MOE) Puget Sound Fire currently maintains and documents the MOE attestation in accordance with applicable Federal Notices of Funding Opportunities. To further improve compliance, we will work directly with our grantors to ensure MOE calculations align with best practices and updated guidance. This action will be completed by January 1, 2026.

Finding ref number: 2023-002 Finding caption: The City did not have adequate internal controls and did not comply with federal wage rate requirements. Name, address, and telephone of City contact person: Vicky Carlsen, Director of Finance 801 228th Avenue SE Sammamish, WA 98075 (425) 295-0590 Corrective action the auditee plans to take in response to the finding: The City has implemented process changes that requires project managers to forward appropriate wage documentation to Finance along with invoices for payment. Finance is able to verify the wage document prior to issuing payment for invoices. Anticipated date to complete the corrective action: Already implemented

The Alliance did monitor the subrecipients, but the documentation was not properly saved. This policy has since been revised to save the monitoring documentation to the grant management sof tware.