Corrective Action Plans

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2025-003 Suspension & Debarment Cluster: Other major program referenced below Sponsoring Agency: Department of Health and Human Services Award Names: Doorway for Substance Use-Related Supports and Services Award Numbers: Cheshire Medical Center 05-95-920510-7040000 Assistance Listing Title: Opioid S...
2025-003 Suspension & Debarment Cluster: Other major program referenced below Sponsoring Agency: Department of Health and Human Services Award Names: Doorway for Substance Use-Related Supports and Services Award Numbers: Cheshire Medical Center 05-95-920510-7040000 Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2024-2025 Pass-through entity: New Hampshire Department of Health and Human Services Management agrees with the finding related to Suspension & Debarment. Dartmouth Health experienced significant leadership turnover and changeover in the contracting and procurement function in fiscal year 2025. This was the primary cause of suspension and debarment checks not being completed before entering into agreements with new vendors. The Office of Research Finance will provide training to procurement and contracting staff to further emphasize the importance of performing vendor checks before entering into agreements. Individual Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: September 30, 2026
2025-001 Timeliness of Effort Certification Cluster: Research and Development (also applies to other major programs referenced below) Sponsoring Agency: All research and development cluster sponsoring agencies and Department of Health and Human Services (for the other major program referenced below)...
2025-001 Timeliness of Effort Certification Cluster: Research and Development (also applies to other major programs referenced below) Sponsoring Agency: All research and development cluster sponsoring agencies and Department of Health and Human Services (for the other major program referenced below) Award Names: All research and development cluster awards and Doorway for Substance Use-Related Supports and Services Award Numbers: All research and development cluster awards, Cheshire Medical Center 05-95-920510-7040000 Assistance Listing Title: All research and development cluster assistance listing titles and Opioid STR Assistance Listing Number: All research and development cluster assistance listing numbers and 93.788 Award Year: 2024-2025 Pass-through entity: All research and development cluster pass-through entities and New Hampshire Department of Health and Human Services This is a repeat finding of 2024-002 and in the prior year corrective action plan we had anticipated correcting this matter by March 31, 2025. Due to additional training needing to be administered to providers, we had to revise our date of completion to September 30, 2026. Management agrees with the finding related to the timeliness of effort certification. Management has continued to provide training and education to both operational and clinical leadership regarding timely effort certification. Dartmouth-Hitchcock currently has two effort certification systems: one used for research and one used to track other metrics. This has caused confusion among those required to certify effort for federal awards as they often believe that they had already certified their effort for research purposes . Management will provide additional education sessions and provide further clarification to the research community on the importance of timely effort certification and the differences in each effort reporting system. Individual Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: September 30, 2026
2025-002 Equipment Management Cluster: Research and Development Sponsoring Agency: All research and development cluster sponsoring agencies Award Names: All research and development cluster awards Award Numbers: All research and development cluster awards Assistance Listing Title: All research and d...
2025-002 Equipment Management Cluster: Research and Development Sponsoring Agency: All research and development cluster sponsoring agencies Award Names: All research and development cluster awards Award Numbers: All research and development cluster awards Assistance Listing Title: All research and development cluster assistance listing titles Assistance Listing Number: All research and development cluster assistance listing numbers Award Year: 2024-2025 Pass-through entity: All research and development cluster pass-through entities This is a repeat finding of 2024-004 and 2022-001 and in the prior year corrective action plan we had anticipated correcting this matter by June 30, 2025. Management agrees with the finding related to equipment management. Management conducted a biannual physical inventory count of specific federally purchased research equipment in Fiscal Year 2024, however the complete population of equipment funded with federal research and development dollars were not inspected. By September 30, 2025, the Dartmouth Health system created a federal equipment tracking procedure, and updated property records to include details required by 2 CFR section 200.313. Management will perform a full physical inventory of research equipment for the year ending September 30, 2026 and update the clinical inventory database to reflect the results of the inventory to be able to remediate the finding. Individual Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: September 30, 2026
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Ville Platte respectfully submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suit...
Oversight Agency for Audit, Senior Citizens Housing Development Corporation of Ville Platte respectfully submits the following corrective action plan for the year ended September 30, 2025. Name and address of independent public accounting firm: Bellows Associates, P.A., 5401 N University Drive, Suite 201, Coral Springs, Florida 33067 Audit period: October 1, 2024 through September 30, 2025 The finding from the September 30, 2025 schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. SECTION III – FINDINGS AND QUESTIONED COSTS – MAJOR FEDERAL AWARD PROGRAMS AUDIT FINDING No. 2025-001:Section 202 Supportive Housing for the Elderly, ALN 14.157 Recommendation: The Project should implement procedures for compliance with all HUD regulations and ensure that all supporting documents are appropriately retained. Action Taken: Management has implemented procedures to ensure compliance with HUD requirements related to utility allowances and document retention. The Project will perform and document an annual utility allowance review and analysis in accordance with HUD regulations. Supporting documentation used in the analysis, including utility rate information and calculation worksheets, will be maintained in the Project's compliance files and retained in accordance with HUD record-retention requirements. Management has also established procedures to ensure that all compliance-related documentation is properly organized, reviewed, and retained to support future audits and monitoring reviews. Responsibility for maintaining the utility allowance analysis and related supporting documentation has been assigned to designated management personnel, and periodic reviews will be performed to verify that required records are complete and accessible. These corrective actions are expected to be fully implemented by September 30, 2026. If the Oversight Agency for Audit has questions regarding this plan, please call Irene Phillips at 954-835-9200. Sincerely yours, Irene Phillips CFO
Corrective Action Plan WK&T respectfully submits the following corrective action plan for the year ended December 31, 2025. Finding: 2025-001 –Suspension and Debarment Responsible Individuals: Bhavini Sokhey, Chief Financial Officer Anticipated Completion Date: Implemented Finding Summary: Lack of d...
Corrective Action Plan WK&T respectfully submits the following corrective action plan for the year ended December 31, 2025. Finding: 2025-001 –Suspension and Debarment Responsible Individuals: Bhavini Sokhey, Chief Financial Officer Anticipated Completion Date: Implemented Finding Summary: Lack of documented policies and procedures related to suspension and debarment Corrective Action Plan: •The Company has developed and implemented formal written policies and procedures to addresscompliance with federal suspension and debarment requirements. •Prior to awarding any contract funded with federal or state funds, the Company will verify that thevendor or contractor is not suspended or debarred by reviewing the SAM.gov Exclusions database.Documentation of the verification will be retained in the procurement file. •The Company will require all contractors participating in federally or state-funded projects toexecute a certification confirming they are not debarred, suspended, proposed for debarment,declared ineligible, or voluntarily excluded from participation in such programs. •The procurement and grant administration staff are responsible for performing and documentingthese procedures. Compliance will be reviewed as part of the Company's procurement process andongoing grant oversight to ensure adherence to federal and state requirements.
2025-004 – COMPLIANCE AND CONTROLS OVER REPORTING Corrective Action Plan: The Organization has developed a centralized reporting calendar identifying all required report filing deadlines. Designated staff will utilize the reporting calendar to monitor and ensure the timely submission of all required...
2025-004 – COMPLIANCE AND CONTROLS OVER REPORTING Corrective Action Plan: The Organization has developed a centralized reporting calendar identifying all required report filing deadlines. Designated staff will utilize the reporting calendar to monitor and ensure the timely submission of all required reports. The reporting calendar will be incorporated into the Organization's succession planning and reviewed regularly to ensure compliance with all reporting requirements and continuity during staff transitions. Responsible Party(ies): • Executive Director • Finance Manager Anticipated Date of Completion: September 30, 2026
Finding 1221699 (2025-001)
Material Weakness 2025
Views of Responsible Officials: Management appreciates the auditors' recommendations and recognizes the importance of consistently documenting supervisory review and approval of employee timesheets.The finding relates to the documentation and retention of supervisory approval for certain employee ti...
Views of Responsible Officials: Management appreciates the auditors' recommendations and recognizes the importance of consistently documenting supervisory review and approval of employee timesheets.The finding relates to the documentation and retention of supervisory approval for certain employee timesheets selected for testing. The Organization appreciates the opportunity to strengthen the documentation of an existing supervisory review process to ensure approvals are consistently evidenced and retained. To address the recommendation, the Organization has reinforced supervisory expectations, updated internal procedures related to timesheet approvals, and implemented periodic monitoring to verify that supervisory approvals are consistently documented and retained. Management believes these enhancements appropriately address the recommendation and further strengthen the Organization's existing internal control environment while reinforcing its commitment to sound internal controls and compliance with applicable grant requirements.
Corrective Action Plan: Management acknowledges the deficiency. The City has historically performed suspension and debarment verification as part of its contract review process prior to contract execution; however, documentation evidencing completion of the verification was not retained in the contr...
Corrective Action Plan: Management acknowledges the deficiency. The City has historically performed suspension and debarment verification as part of its contract review process prior to contract execution; however, documentation evidencing completion of the verification was not retained in the contract file. To strengthen this control, the City has implemented procedures requiring documentation of suspension and debarment verification for all federally funded contracts and grant-related procurements. Staff will retain a dated screenshot or other evidence of the System for Award Management (SAM.gov) search in each applicable contract file prior to contract execution. Additionally, the City's Procurement Policy was updated and approved by the City Council in October 2025 to further strengthen procurement procedures and federal grant compliance requirements. Finance staff will periodically review contract files to verify that the required documentation has been retained. Personnel Responsible for Corrective Action: Nick Hawkins, Finance Manager Anticipated Completion Date: October 31, 2025
Finding 1221659 (2025-001)
Material Weakness 2025
Wakemed
NC
Finding Number: 2025-001 Condition: Management concurs with the finding and has implemented a new grant governance committee and process for identifying grant components before entering into grant agreements. Management also created a new grant department with staff devoted to researching, applying ...
Finding Number: 2025-001 Condition: Management concurs with the finding and has implemented a new grant governance committee and process for identifying grant components before entering into grant agreements. Management also created a new grant department with staff devoted to researching, applying for, monitoring, and reporting on all grants. The accounting function for grants will be done by this team as well but with continued oversight by the Executive Director, Accounting. Contact person responsible for corrective action: Stephanie Sessoms, Chief Financial Officer; Lynn Bailey, Executive Director, Accounting Anticipated Completion Date: 1/12/2026
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Impl...
We agree that Elm City Communities should have a control environment that allows the books to be closed and regulatory reports filed on a timely basis. In August 2025 we completed a conversion from Elite to Yardi. This caused us to take longer than normal for our year end close process. Planned Implementation Date of Corrective Action: Immediately Person Responsible for Corrective Action: Shenae Draughn, President.
• Management Response - SERCAP will improve lease accounting controls by: Creating and maintaining accurate model spreadsheet of centralized lease inventory for all operating and financing leases. Establishing written procedures requiring all lease agreements, amendments, renewals, and extensions to...
• Management Response - SERCAP will improve lease accounting controls by: Creating and maintaining accurate model spreadsheet of centralized lease inventory for all operating and financing leases. Establishing written procedures requiring all lease agreements, amendments, renewals, and extensions to be communicated to the Finance Department immediately upon execution. Performing an annual review of all lease agreements to determine whether modifications require remeasurement under ASC 842. Preparing documented lease calculations and reconciliations for supervisory review. Updating accounting policies and procedures related to lease accounting and providing additional staff training regarding ASC 842 requirements. In addition, setup a policy and procedure for the review and documentation review of all contracts for a potential embedded lease transaction. SERCAP has hired new staff for capacity and support. • Contact Person: • Contact Phone Number: • Expected Completion Date: Charles Denny, Jr. - Finance & Operations 540-345-1184 ext. 128 September 30, 2026
• Management Response - Management concurs with the finding and recognizes the importance of strengthening controls over revenue recognition for conditional grants and contributions. SERCAP will implement the following corrective actions: Develop and implement a standardized Grant Revenue Recognitio...
• Management Response - Management concurs with the finding and recognizes the importance of strengthening controls over revenue recognition for conditional grants and contributions. SERCAP will implement the following corrective actions: Develop and implement a standardized Grant Revenue Recognition Checklist for all new grant awards to identify conditional barriers, allowable costs, reporting requirements, and revenue recognition criteria. Maintain a centralized grant tracking schedule that identifies grant conditions, expenditures incurred, revenue recognized, refundable advances, and remaining deferred revenue. Perform monthly reconciliations between grant schedules and the general ledger. Implement a documented two-level review process whereby the preparer completes the reconciliation and a supervisory reviewer verifies the accuracy and completeness before month-end close. Provide additional training to finance and program management staff regarding ASC 958 revenue recognition requirements for conditional contributions. Update internal accounting procedures to document the review and approval process for recognizing grant revenue. These procedures will be incorporated into the monthly financial close process and monitored throughout FY2026. SERCAP has hired new staff for capacity and support • Contact Person: Charles Denny, Jr. - Finance & Operations • Contact Person: Beth Pusha - Loan Fund • Contact Phone Number: 540-345-1184 • Expected Completion Date: September 30, 2026
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete ...
Finding 2025-001 Significant Deficiency in Internal Control over Compliance, Noncompliance - Reporting Name of Contact Person: Tawnie J Attla Corrective Action Plan: When we hire, sign agreements that include the completion of duties. So that one doesn’t take the time to learn and then not complete all tasks before abandoning their position. Before HVC takes on additional grants and duties, the administration (TA and TA Assistant) will learn the processes and portals for the current grants and recurring ones. Create how to guides to include with the new grant binders, for reporting and portal use. Have calendars for each grant. Utilize one big calendar on the wall that includes all the grant reporting periods and the annual requirements for sam.gov (log in requirement). Continue trying to fill positions and delegate workload. Proposed Completion Date: September 30, 2026.
El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, t...
El Proyecto del Barrio, Inc. acknowledges the finding related to the incorrect administration of sliding fee discounts. We are committed to strengthening the administration of the sliding fee program to ensure full compliance with grant requirements. To address these issues and prevent recurrence, the following corrective actions are being implemented: 1. Revised Application and Documentation Requirements: o The Sliding Fee Program application forms are being updated to include structured sections for staff to record income from supporting documentation (e.g., pay stubs, tax returns), rather than relying on the patient to write their income on the application, which will greatly reduce incorrect income stated on support. Staff will be responsible for calculating annual gross income based on supporting documentation and have a checklist to ensure documentation is complete and retained/uploaded in the system. 2. Two-Step Review Process: o A staff member (the “Preparer) will calculate the annual gross income, determine the household size, and determine the eligible sliding fee discount, and a second staff member (the “Reviewer”) will independently review and verify the Preparer’s calculations and determinations based on the supporting documentation. Both parties will document their review of the application to establish accountability. 3. Staff Training and Ongoing Competency Checks: o Comprehensive refresher training will be provided to all staff involved in the sliding fee program process, including the use of the poverty guidelines, income calculation methods, the new forms, entering income and household size into the system, and uploading support to the system. 4. Formal Ongoing Monitoring and Review: o The Billing Department will conduct regular audits of completed sliding fee applications and eligibility determination forms to ensure compliance with policies. Errors will be tracked and addressed through corrective action and coaching. Person Responsible: Ricardo Ornelas Position of Responsible Party: Chief Financial Officer Completion Date: August 31, 2026
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communi...
Person(s) responsible for corrective action: Justin Parker, Executive Director, Lucy Yanez, Contract Specialist, and Kari Neumeyer, Communications Manager Management’s Response/Corrective Action Plan: The NWIFC has revised its procedure to ensure timely submission of the annual report: • The Communications Manager completes the annual report before the reporting period deadline. • The Executive Director will review and approve the annual report before the deadline and communicate approval of the annual report to both the Contract Specialist and Communications Manager. • The Contract Specialist will send the annual report to the BIA by the deadline and retain approval forms or records. Anticipated completion date: June 2026.
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate ...
Community Development Block Grants (CDBG) – Assistance Listing No. 14.228 Recommendation: CLA recommends that the County establish and implement procedures to ensure continued compliance with occupancy requirements, including:  Obtaining and retaining certificates of occupancy or other appropriate documentation to verify primary residence status as part of the CDBG/HOME loan reconciliation workbook process.  Implementing periodic monitoring procedures for loan recipients.  Maintaining documentation in loan files to support compliance throughout the affordability period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agrees with the finding and has implemented loan file monitoring procedures to verify occupancy compliance. Name of the contact person responsible for corrective action: Melanie Marquez Planned completion date for corrective action plan: 6/30/2026
2025-001 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Subrecipient Monitoring: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA will establish a policy and implement procedures for subrecipient monitoring and risk assessment and a record will be maintained of all awa...
2025-001 ALN 10.937 USDA Partnerships for Climate-Smart Commodities Subrecipient Monitoring: Non-Compliance with Grant Requirements Corrective Action Plan: NSPA will establish a policy and implement procedures for subrecipient monitoring and risk assessment and a record will be maintained of all award agreements identifying or documenting subrecipients’ compliance obligation. Estimated Completion Date: October 2025 Management Contact: Tim Lust, CEO
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and...
To address the noted deficiencies in tenant file documentation, staff and supervisors will continue to follow established processes. Supervisors continue to track and monitor productivity and progress. The current supervisor has implemented clear and concise instructions and rules for completing and managing files. All forms are now saved in tenant files, and not on individual laptops as they were in the past. The supervisor has also implemented schedules and tracking systems for monthly voucher submissions, annual recertifications, quarterly income checks and other processes in the occupancy workflow. In addition, the supervisor and the lead staff for housing compliance perform regular checks on tenant application paperwork and random checks on tenant files to ensure accuracy and completeness and correct any mistakes. Ongoing staff training, support and mentoring continues.
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melen...
Views of responsible officials and planned corrective action: The Authority accepts the recommendation of the auditor. The Authority will increase oversight in the Public Housing Capital Fund Program to ensure that established internal control policies are being followed on a timely basis. Ivy Melendez, Executive Director, will be responsible to implement this corrective action by September 30, 2026.
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should...
Coronavirus State and Local Fiscal Recovery Funds (ALN 21.027) Recommendation: We recommend that the Organization establishes a documented review process for eligibility determination. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. However, it should be noted that we are in compliance with the requirements of Ramsey County, Minnesota (the administrator of the ARPA program) as to documentation, reporting and other requirements. Documentation of review of income eligibility is not required by Ramsey County. Action taken in response to finding: We will immediately implement a sign off procedure by staff when they review income eligibility. Name of the contact person responsible for corrective action: Chris Schmidt Planned completion date for corrective action plan: Immediate
The City implemented a new review, tracking and documentation process for all procurements during FY 2023-24. Staff have been performing checks of all vendors, regardless of the nature of the funding, for the project against SAM.GOV to check for disbarment. A PDF of the results for each vendor is sa...
The City implemented a new review, tracking and documentation process for all procurements during FY 2023-24. Staff have been performing checks of all vendors, regardless of the nature of the funding, for the project against SAM.GOV to check for disbarment. A PDF of the results for each vendor is saved in a project folder attached to each procurement. These files are stored on an internal network drive. Management feels the process in place addresses this finding. Responsible Person: Alexis Lucero Expected Implementation Date: 07/01/2026
WIOA Cluster – Assistance Listing No. 17.258, 17.259, and 17.278 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management document review of subrecipient Single Audit reports when availabl...
WIOA Cluster – Assistance Listing No. 17.258, 17.259, and 17.278 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management document review of subrecipient Single Audit reports when available Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DEDO has implemented procedures to ensure that reviews of subrecipient Single Audit reports are documented annually and maintained in greater detail than the Single Audit review currently incorporated into DEDO's existing risk assessment process. Name(s) of the contact person(s) responsible for corrective action: Travon Earl Planned completion date for corrective action plan: 6/23/26
Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management update and formalize subrecipient monitoring procedu...
Temporary Assistance for Needy Families (TANF) - Assistance Listing No. 93.558 Compliance Requirement: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control over Compliance Recommendation: We recommend that management update and formalize subrecipient monitoring procedures to align with actual monitoring practices performed and ensure monitoring activities are consistently documented in accordance with Uniform Guidance requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: DHS Financial Services will formalize updates to the Subrecipient Monitoring policy and procedures (currently in draft status) to align with the requirement for monitoring all high-risk subrecipients annually. Name(s) of the contact person(s) responsible for corrective action: Robert Baker Planned completion date for corrective action plan: 9/30/2026
Finding Reference Number: 2025-002 Program: Assistance Listing 16.556 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic repo...
Finding Reference Number: 2025-002 Program: Assistance Listing 16.556 Finding: Late Submission of Federal Financial Report (FFR) and Programmatic Report Corrective Action Planned: Management agrees with the findings. To ensure timely submission of all required federal financial and programmatic reports, the organization will implement the following corrective actions: • Both Andrianna Clark and Tanesha McDonald have been added to the reporting system to provide backup coverage and shared responsibility for report preparation and submission. • In addition, ongoing cross-training is being conducted to ensure that multiple staff members are knowledgeable about reporting requirements, deadlines, and submission procedures. This cross-training will reduce the risk of delays caused by staff absences, turnover, or other unforeseen circumstances. • Management will continue to monitor reporting deadlines and maintain internal procedures to ensure all future federal financial and programmatic reports are submitted accurately and on time, in compliance with grant requirements. Anticipated Completion Date: June 17, 2026 Responsible Official: Andrianna Clark and Tanesha McDonald
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