Corrective Action Plans

Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors...

Improve Controls over Accounting Records Department’s Response: ESAC is in agreement with the recommendation, and with the new Director of Administration and Finance and outside bookkeeper in place, ESAC will complete monthly reconciliations for all journals, sub-journals, and accounts. Entry errors will be adjusted each period to ensure that account and ledger totals are properly maintained and recorded. Views of Responsible Offices and Corrective Action Plan: ESAC has reviewed its controls over bank reconciliations, accounts payable and grants receivable. Controls and the policies and procedures have been reviewed with the new Director of Administration and Finance and outside bookkeeper and is confident that new procedures will be adhered to ensure timely reconciliations. Name of Responsible Person: Peg Drisko, CEO Projected Implementation Date: May 2026

View Audit 401734

Finding 1214940 (2024-005)

Material Weakness 2024

First Choice Community Healthcare, Inc.

NM

Special Tests & Provisions Subrecipient Monitoring Eligibility

2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income doc...

2024-005—Special Tests and Provisions—Sliding Fee Discount Program Corrective Action: Management acknowledges the finding. FCCH agrees that the claim in question did not reflect the appropriate sliding fee discount because the billing department was not notified that the patient submitted income documentation within the 30-day eligibility window. FCCH recognizes the importance of ensuring that all departments consistently follow established Sliding Fee Discount Program (SFDP) procedures. To address this issue, FCCH has implemented the following corrective actions: • Reinforce communication protocols between front desk/eligibility staff and the billing department to ensure that any income documentation received after the date of service is promptly communicated and documented. • Provide refresher training to front desk, eligibility, and billing staff on SFDP requirements, including the 30-day documentation rule and the process for updating patient classifications. • Initiated an internal review of a sample of medical claims to assess whether similar errors occurred and to confirm that corrective measures are effective. FCCH remains committed to full compliance with 42 CFR Part 51c.303(f) and its internal Sliding Fee Discount and Related Billing and Collections Program Policies and Procedures. Management will continue monitoring to ensure ongoing adherence and prevent recurrence. Person Responsible: Tammy Collins, Revenue Cycle Director Completion Date: September 30, 2026

View Audit 401709

Finding 1214910 (2024-001)

Material Weakness 2024

City of Galion

OH

Procurement, Suspension & Debarment Subrecipient Monitoring

The City was not aware that the Buy America Preference language must be included in the terms and conditions with our project. We have been in contact with our engineering firm and discussed this necessity. Beginning January 1, 2026, the Safety-Service Director will assure that the Buy America Prefe...

The City was not aware that the Buy America Preference language must be included in the terms and conditions with our project. We have been in contact with our engineering firm and discussed this necessity. Beginning January 1, 2026, the Safety-Service Director will assure that the Buy America Preference will be included in future contracts where federal funds are expended. The Safety-Service Director will check for SAM exclusions and will request a waiver to this requirement if necessary.

View Audit 401666

Finding 1214878 (2024-001)

Material Weakness 2024

Auburn Community Hospital

NY

Subrecipient Monitoring Reporting Significant Deficiency § 200.512

We agree with the finding. The Hospital's annual financial statements were not issued until February 2026 and we were not able to complete the single audit filing until that time. The Hospital doesn't anticipate delays in the future.

View Audit 401608

Finding 1214857 (2024-003)

Material Weakness 2024

Town of Uxbridge

MA

Subrecipient Monitoring Procurement, Suspension & Debarment Cash Management § 200.302 § 200.303

CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. Th...

CORRECTIVE ACTION PLAN The Town of Uxbridge, Massachusetts respectfully submits the following corrective action plan for the year ended June 30. 2024. Audit period: July 1, 2023 through June 30, 2024 The finding from the June 30, 2024, schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the number assigned in the schedule. Audit Finding Reference: 2024-003 Document Policies and Procedures Over Federal Awards Views of responsible officials: The Town agrees with the recommendation to implement written policies and procedures to be in accordance with the Uniform Guidance. Planned Implementation Date of Corrective Action: The Town plans to implement recommendations for the next fiscal year. Official Responsible for Implementing Corrective Action: Kurt Ginthwain Finance Director/Town Accountant

View Audit 401553

Finding 1214764 (2024-003)

Material Weakness 2024

Council on American-Islamic Relations, California

CA

Subrecipient Monitoring Reporting Matching / Level of Effort / Earmarking § 200.512

Finding No.2024-003: Noncompliance with Annual Financial Statements Audit and Single Audit Submission Requirements Finding: The single audit reporting package for the year ended December 31, 2023, was submitted by CAIR-CA in August 2025. CAIR-CA also failed to complete its financial and single audit...

Finding No.2024-003: Noncompliance with Annual Financial Statements Audit and Single Audit Submission Requirements Finding: The single audit reporting package for the year ended December 31, 2023, was submitted by CAIR-CA in August 2025. CAIR-CA also failed to complete its financial and single audit for the year ended December 31, 2024 within the required nine month deadline under 2 CFR 200.512. As of September 30, 2025, no single audit report has been issued or filed, resulting in noncompliance with federal audit requirements. Views of Responsible Officials and Corrective Action Plan: Management has developed and implemented corrective actions to address this finding. As of January 1, 2026, formal procedures for FAC submission have been established, including defined roles, internal deadlines, and review protocols. A compliance tracking system has been implemented to monitor key reporting deadlines, and staff have received training on federal requirements. Management will continue to monitor adherence to these procedures to ensure timely submission in future reporting periods. Implementation date: January 1, 2026

View Audit 401487

Finding 1214718 (2024-006)

Material Weakness 2024

DEFENSORES DE LA CUENCA INC

MD

Subrecipient Monitoring Cash Management Matching / Level of Effort / Earmarking § 200.303

Corrective Action Plan: Management acknowledges the lack of documented evidence of review and approval for disbursements. The organization has implemented a process requiring email-based approvals from appropriate managers to ensure all expenditures are reviewed and authorized. In addition, the orga...

Corrective Action Plan: Management acknowledges the lack of documented evidence of review and approval for disbursements. The organization has implemented a process requiring email-based approvals from appropriate managers to ensure all expenditures are reviewed and authorized. In addition, the organization is in the process of evaluating and implementing an electronic system to streamline and document approvals for accounts payable and credit card transactions. These steps will strengthen internal controls and ensure proper documentation of all approvals in accordance with organizational policies and federal requirements. Responsible Official: Abel Olivo, Executive Director, with support from the outsourced accounting firm Anticipated Completion Date: May 31, 2026

View Audit 401471

Finding 1214685 (2024-004)

Material Weakness 2024

City of Texas City, Texas

TX

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties § 200.328

CSLFRF Reporting (ALN 21.027) Condition The required Treasury report was not submitted due to insufficient tracking mechanisms and lack of internal controls. Corrective Action Plan To ensure timely and accurate CSLFRF reporting, the City will: • Establish a Treasury reporting calendar with all requi...

CSLFRF Reporting (ALN 21.027) Condition The required Treasury report was not submitted due to insufficient tracking mechanisms and lack of internal controls. Corrective Action Plan To ensure timely and accurate CSLFRF reporting, the City will: • Establish a Treasury reporting calendar with all required deadlines. • Assign a designated preparer and reviewer for each reporting cycle. • Provide training on the Treasury reporting portal. • Implement a pre-submission checklist to ensure completeness and accuracy. • Conduct semiannual internal reviews of reporting processes and documentation. Responsible Staff Chief Financial Officer (CFO) Target Completion Date July 31, 2026

View Audit 401408

Finding 1214684 (2024-003)

Material Weakness 2024

City of Texas City, Texas

TX

Allowable Costs / Cost Principles Internal Control / Segregation of Duties Subrecipient Monitoring § 200.302 § 200.303

Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with ...

Duplicate Payments to Vendors Condition Duplicate vendor payments occurred due to inadequate segregation of duties and inconsistent invoice naming conventions. Corrective Action Plan The Accounts Payable unit will strengthen internal controls to prevent duplicate payments and ensure compliance with federal cost principles. Actions include: • Enforcing segregation of duties within the AP workflow. • Implementing standardized invoice naming conventions. • Requiring secondary review for all grant-related invoices. • Conducting quarterly post-payment audits to detect and correct errors. • Implementing ERP system enhancements to flag potential duplicates. • Hiring an AP Manager to manage and improve the AP processes. Responsible Staff Chief Financial Officer (CFO) Target Completion Date June 30, 2026

View Audit 401408

Finding 1214683 (2024-002)

Material Weakness 2024

City of Texas City, Texas

TX

Reporting Internal Control / Segregation of Duties Subrecipient Monitoring

CDBG Performance Reporting (ALN 14.228) Condition The PR28 and CAPER reports were submitted 11 months late. This is a repeat finding and resulted from insufficient controls and inadequate staff training. Corrective Action Plan To ensure timely and compliant reporting, the following actions will be t...

CDBG Performance Reporting (ALN 14.228) Condition The PR28 and CAPER reports were submitted 11 months late. This is a repeat finding and resulted from insufficient controls and inadequate staff training. Corrective Action Plan To ensure timely and compliant reporting, the following actions will be taken: • Developing written procedures for PR28 and CAPER preparation and submission. • Implementing a compliance calendar with required reporting deadlines. • Assigning both primary and secondary preparers to ensure redundancy. • Providing HUD IDIS training to relevant staff. • Conducting supervisory review prior to submission. • Hired a Grants Compliance Specialist to support ongoing compliance.(10/2025) Responsible Staff Grants Administrator Target Completion Date August 31, 2026

View Audit 401408

Finding 1214660 (2024-001)

Material Weakness 2024

UNIVERSITY OF NORTH CAROLINA HEALTH CARE SYSTEM

NC

Subrecipient Monitoring Reporting Significant Deficiency § 200.512

Views of Responsible Officials Management agrees with the federal award finding identified in the audit. The System Fund will file the audit reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with audit partner and frequently...

Views of Responsible Officials Management agrees with the federal award finding identified in the audit. The System Fund will file the audit reporting package shortly after issuance and ensure that any future audits are completed and filed timely, by working closely with audit partner and frequently accessing the substantive status, stage of completion or any other pertinent aspect of the audit necessary to meet the filing deadline.

View Audit 401395

Finding 1214503 (2024-001)

Material Weakness 2024

Home Start INC

CA

Internal Control / Segregation of Duties Subrecipient Monitoring

Management acknowledges that personnel turnover during the fiscal year resulted in temporary gaps in segregation of duties and continuity of financial oversight. Since September 2024, the accounting team has achieved stability in key positions, significantly improving consistency in financial proces...

Management acknowledges that personnel turnover during the fiscal year resulted in temporary gaps in segregation of duties and continuity of financial oversight. Since September 2024, the accounting team has achieved stability in key positions, significantly improving consistency in financial processes and oversight. In addition, the Organization is implementing Blackbaud Financial Edge in FY2027, which will enhance internal controls through system-based workflows, role-based permissions, and audit trails. These system improvements, combined with stabilized staffing, will strengthen segregation of duties and reduce reliance on manual compensating controls. Management is committed to maintaining appropriate staffing levels, cross-training team members, and clearly defining backup responsibilities to ensure continuity of financial operations and compliance with internal control standards. Actions Taken - Stabilized accounting and finance team staffing beginning September 2024 - Implemented cross-training and defined backup roles for key financial functions - Increased supervisory review and oversight during periods of transition - Initiated implementation of Blackbaud Financial Edge with enhanced internal control capabilities (go-live planned for FY2027)

View Audit 401203

Finding 1214265 (2024-001)

Material Weakness 2024

Sacramento Lgbt Community Center

CA

Reporting Subrecipient Monitoring Significant Deficiency

Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit report to the federal clearing house in May 2026, eight months after it was due. Statement of Concurrence or Nonconcurrence: The Organization concurs with this ﬁnding. In 2025, the Organization hired...

Description of Finding: The Organization submitted its Audited Financial Statements and Single Audit report to the federal clearing house in May 2026, eight months after it was due. Statement of Concurrence or Nonconcurrence: The Organization concurs with this ﬁnding. In 2025, the Organization hired a new accounting ﬁrm with a ﬁrm commitment to system integration to improve efficiency in month-end and year-end close, as well as upgrades to its time keeping and payroll system that allows for real time posting of allocated time directly to the accounting software. In prior years, this was a manual process. This automation will eliminate the lag time in posting payroll allocations to the general ledger and greatly reduce the end of year closing process timeline. David Heitstuman, Chief Executive Officer, Phone 916 442-0185, email David.heitsuman@sacccenter.org

View Audit 400996

Finding 1213989 (2024-005)

Material Weakness 2024

Exeter Township School District

PA

Reporting Subrecipient Monitoring Significant Deficiency

2024-005 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Education Stabilization Fund - U.S. Department of Education passed through the Pennsylvania Department of Education COVID-19 - Elementary and Secondary School Emergency Relief Fund (ARP ESSER) ALN 84.425U; Contract #223-21-0141; Grant Perio...

2024-005 REPORTING - SIGNIFICANT DEFICIENCY Federal Program Education Stabilization Fund - U.S. Department of Education passed through the Pennsylvania Department of Education COVID-19 - Elementary and Secondary School Emergency Relief Fund (ARP ESSER) ALN 84.425U; Contract #223-21-0141; Grant Period 03/13/20 - 09/30/24 COVID-19 - ARP ESSER Learning Loss Set Aside ALN 84.425U; Contract #225-21-0141; Grant Period 03/13/20 - 09/30/24 Criteria The District is required to submit an annual performance report to the Commonwealth of Pennsylvania (the “State”) with data on expenditures, planned expenditures, subrecipients, and uses of funds, including for mandatory reservations. Condition During the year ended June 30, 2024, the District submitted a report for the funds used during the year ended June 30, 2023. The report submitted by the District contained expenditure amounts that did not agree to the amounts reported on the schedule of expenditures of federal awards for the year ended June 30, 2023 as well as other key reporting line items. Recommendation We recommend the District keep a reconciliation of grant awards available to expenditure incurred. The accurate use of funding source codes will assist in that process. We also recommend the District continue working toward more timely financial and compliance audits. Management Response When the district received the audit, the 2023 federal reports were already submitted. The District made the adjustments for non-allowable expenses in the 2023 SEFA and took out the non-allowable in the 2024 State reports. The District has begun using and reconciling funding source codes related to grants more timely.

View Audit 400862

Finding 1213958 (2024-002)

Material Weakness 2024

City of Ceres

CA

Subrecipient Monitoring Reporting

Management will file the audited financial statements for the year ended June 30, 2024, as soon as possible. The underlying causes included prolonged resource constraints within the Finance Department, turnover in key accounting positions, challenges associated with the ERP system implementation, an...

Management will file the audited financial statements for the year ended June 30, 2024, as soon as possible. The underlying causes included prolonged resource constraints within the Finance Department, turnover in key accounting positions, challenges associated with the ERP system implementation, and delays in reconciling certain major balance sheet accounts. To address these issues, the City engaged an external financial consultant to assist in completing outstanding bank reconciliations and restoring timely financial reporting. Management is also implementing additional corrective measures, including reprioritizing workloads, enhancing oversight of monthly close activities, and establishing standardized reconciliation checklists for all major balance sheet accounts. Management anticipates that this finding will extend through the Fiscal Year 2025, and possibly Fiscal Year 2026 financial statement reporting cycles, with full resolution expected in Fiscal Year 2027.

View Audit 400807

Finding 1213950 (2024-009)

Material Weakness 2024

Creek County

OK

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.214 § 200.308 § 200.317 § 200.501

It has been brought to our attention that we need an additional policy that covers conflict of interests and govern the performance of its employees engaged in the selection, award, and administration of contracts. We have taken this recommendation and are implementing the proper language, for all e...

It has been brought to our attention that we need an additional policy that covers conflict of interests and govern the performance of its employees engaged in the selection, award, and administration of contracts. We have taken this recommendation and are implementing the proper language, for all employees to acknowledge in our County Handbook. We will strengthen this control and add this be updated yearly, so that all conflict can be disclosed. Creek County prides itself in moving toward complete transparency and holding each employee accountable to disclose all information needed to make a proper selection of purchases. Creek County Clerk’s Office will work with the District Attorney’s Office for proper language.

View Audit 400799

Finding 1213933 (2024-001)

Material Weakness 2024

Alliance for Rights and Recovery, Inc.

NY

Subrecipient Monitoring Reporting Internal Control / Segregation of Duties

2024-001 – Data Collection Forms Finding: Our audit procedures noted Alliance for Rights and Recovery, Inc. did not certify or submit the required Data Collection Form for the fiscal year ended December 31, 2023 related to the 2023 Single Audit. As of the date of our 2024 audit, the Data Collection ...

2024-001 – Data Collection Forms Finding: Our audit procedures noted Alliance for Rights and Recovery, Inc. did not certify or submit the required Data Collection Form for the fiscal year ended December 31, 2023 related to the 2023 Single Audit. As of the date of our 2024 audit, the Data Collection Form and accompanying reporting package remain unsubmitted. Recommendation: We recommend that the organization implement procedures to ensure the timely preparation, certification, and submission of the annual Data Collection Form and reporting package. This should include assigning responsibility for tracking deadlines, establishing a completion checklist, and documenting management review prior to submission. Action Taken: The Agency will assign the CFO the responsibility of reviewing all 9melines and documents needed for the annual audit.

View Audit 400777

Finding 1213903 (2024-004)

Material Weakness 2024

Redevelopment Authority of the County of Berks

PA

Procurement, Suspension & Debarment Subrecipient Monitoring Significant Deficiency

The Authority has revised its policy for Section 3 and will include the policy and requirements in all applicable agreements, pre-bid documents, and resulting contracts. Section 3 requirements will also be reviewed during pre-construction meetings for any applicable projects.

View Audit 400734

Finding 1213895 (2024-001)

Material Weakness 2024

Redevelopment Authority of the County of Berks

PA

Internal Control / Segregation of Duties Subrecipient Monitoring Reporting § 200.303

In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annu...

In general, management agrees with the finding. It should be noted that internal controls for supervisory review of reporting requirements were in place but were not written controls or processes. Reporting for the CDBG Program is accomplished through the preparation of the annual Comprehensive Annual Performance and Evaluation Report (CAPER). Written policies and procedures for the CAPER have been developed. Reporting for the Emergency Rental Assistance Program is accomplished through an online reporting system of the U.S. Treasury and by email to the Pennsylvania Human Services Department. This finding has since been resolved in 2025, with a new policy developed and implemented on December 12, 2025.

View Audit 400734

Finding 1213844 (2024-005)

Material Weakness 2024

The Salvation Army Golden State Division

CA

Period of Performance Subrecipient Monitoring Allowable Costs / Cost Principles § 200.308 § 200.309 § 200.403

Planned Corrective Action: The Division will implement their control of ensuring that they only charge allowable costs incurred during the approved budget period of a federal award’s period of performance or will obtain authorization from the grantor for any costs incurred before the grant's approve...

Planned Corrective Action: The Division will implement their control of ensuring that they only charge allowable costs incurred during the approved budget period of a federal award’s period of performance or will obtain authorization from the grantor for any costs incurred before the grant's approved budget period. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Controller

View Audit 400681

Finding 1213811 (2024-003)

Material Weakness 2024

The Salvation Army Golden State Division

CA

Eligibility Subrecipient Monitoring Material Weakness

Planned Corrective Action: The Division will design and implement a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and maintain such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Divisi...

Planned Corrective Action: The Division will design and implement a precise control to ensure that participants self-certify that they meet the grant eligibility requirements and maintain such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Controller

View Audit 400681

Finding 1213788 (2024-002)

Material Weakness 2024

The Salvation Army Golden State Division

CA

Internal Control / Segregation of Duties Subrecipient Monitoring Allowable Costs / Cost Principles § 200.502

Planned Corrective Action: The Division will design and implement a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Co...

Planned Corrective Action: The Division will design and implement a precise control to ensure that the amount of food distributed is properly reviewed and that the Division maintains such evidence. Anticipated Completion Date: 9/30/2026 Responsible Contact Person: Al Agpoon, Golden State Division Controller

View Audit 400681

Finding 1213651 (2024-001)

Material Weakness 2024

City of Anacortes

WA

Procurement, Suspension & Debarment Subrecipient Monitoring

Corrective action the auditee plans to take in response to the finding: The violation of Suspension and Debarment came from the hiring of a contract service provider in relation to a grant funded project, but was not specifically a Public Works contract. The City of Anacortes' past practice has been...

Corrective action the auditee plans to take in response to the finding: The violation of Suspension and Debarment came from the hiring of a contract service provider in relation to a grant funded project, but was not specifically a Public Works contract. The City of Anacortes' past practice has been to verify Suspension and Debarment for all public works projects, regardless of funding source. The City of Anacortes is committed to ensuring compliance with all applicable statutes and regulations, and therefore has made the organizational change to centralize grant management with contract management, to heighten awareness of those grant requirements relative to let contracts. Additionally, the City has made the commitment to expand the Suspension and Debarment check to all contracts, not just public works, to ensure future compliance can be illustrated.

View Audit 400573

Corrective Action Plans

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