Corrective Action Plans

Finding 1205005 (2025-001)

Material Weakness 2025

Wyoming Coalition Against Domestic Violence and Sexual Assault

WY

Subrecipient Monitoring § 200.303

Finding: 2025-001 - Reporting (Special Reporting under FFATA) - Significant Deficiency in Internal Controls Over Compliance and Instance of Noncompliance Recommendation: We recomment the Coalition strengthen internal controls over federal award reporting by: * Implementing procedures to identify sub...

Finding: 2025-001 - Reporting (Special Reporting under FFATA) - Significant Deficiency in Internal Controls Over Compliance and Instance of Noncompliance Recommendation: We recomment the Coalition strengthen internal controls over federal award reporting by: * Implementing procedures to identify subawards subject to FFATA reporting requirements when agreements are executed. * Assigning responsibility for timely submission of required subaward reports through the Subaward Reporting System within SAM.gov. * Providing training to grant management and finance personnel on FFATA reporting requirements. *Implementing a monitoring or review control to ensure required reports are submitted timely. Corrective Action Plan: The following will be added and implemented as part of our Subgrant Award Monitoring procedure: The WCADVSA will consistently meet the requirement of FFATA to file all Subgrant Awards over the amount of $30,000 or more with SAM.gov within one week of the effective date of the finalized Award Agreement. Anticipated Completion: The WCADVSA completed the FFATA requirement for filing subgrant award reports in SAM.gov on March 26, 2026. Responsible Party: Linda Hawkins, Executive Director

View Audit 396665

Finding 1204981 (2025-001)

Material Weakness 2025

Ou Medicine, Inc.

OK

Procurement, Suspension & Debarment § 200.214 § 200.303 § 200.317 § 200.318 § 200.319

As part of the Uniform Guidance audit, OU Health will maintain and provide documentation outlining the process by which eligible vendors will be identified and selected. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will update policies in...

As part of the Uniform Guidance audit, OU Health will maintain and provide documentation outlining the process by which eligible vendors will be identified and selected. To ensure internal controls are documented to the level necessary under current audit standards, OU Health will update policies in accordance with applicable standards, as well as develop a checklist to document the selection of vendors and the associated purchases made for federal programs. The supporting documentation will be reviewed by management to ensure vendor selection and procurement activities comply with Uniform Guidance requirements. The checklist and all correspondence will be retained with the report and within the Audit Folder.

View Audit 396655

Finding 1204978 (2025-003)

Material Weakness 2025

Puerto Rico Medical Services Administration

PR

Reporting Subrecipient Monitoring Allowable Costs / Cost Principles § 200.302 § 200.303 § 200.305 § 200.328 § 200.329

Conduct a full review of all FEMA funds received in FY 2024-2025 to properly reclassify them as Federal Revenue/Income in the General Ledger. Implement a mandatory review of FEMA Project Worksheets (PWs) and Obligation Notifications to distinguish between "Reimbursements" and "Capital Advances" upon...

Conduct a full review of all FEMA funds received in FY 2024-2025 to properly reclassify them as Federal Revenue/Income in the General Ledger. Implement a mandatory review of FEMA Project Worksheets (PWs) and Obligation Notifications to distinguish between "Reimbursements" and "Capital Advances" upon receipt. Create separate General Ledger (GL) accounts for FEMA disaster/project and Federal Funds to track expenditures vs. drawdowns in real-time. Establish a semi-annual meeting between the FEMA Coordinator and Finance departments to verify that all FEMA-funded work performed matches the reported expenditures. Update the SEFA preparation process to ensure FEMA expenditures are reported in the period they were incurred, regardless of when the reimbursement was received. Provide specialized training for the finance team on Federal Funds accounting.

View Audit 396649

Finding 1204963 (2025-001)

Material Weakness 2025

City of Manteca

CA

Cash Management Reporting Matching / Level of Effort / Earmarking § 200.303

Finding #SA2025-001 Cash Management and Accuracy of Federal Financial Reports Assistance Listing Number: 20.507, 20.526 Assistance Listing Title: COVID-19 – Federal Transit Formula Grants (Urbanized Area Formula Program) – Federal Transit Cluster Name of Federal Agency: Department of Transportation ...

Finding #SA2025-001 Cash Management and Accuracy of Federal Financial Reports Assistance Listing Number: 20.507, 20.526 Assistance Listing Title: COVID-19 – Federal Transit Formula Grants (Urbanized Area Formula Program) – Federal Transit Cluster Name of Federal Agency: Department of Transportation Federal Award Identification Number: CA-2022-083-00, 2020-206, 2020-212 • Name(s) of the contact person: Melissa Munoz, Interim Assistant Finance Director • Corrective Action Plan: The City will develop procedures to ensure all grant-funded expenditures are included on drawdown request and prepared quarterly. Finance staff plan to have regular check-ins with department staff administering federal grants to obtain status updates on expenditures and drawdowns, and reconcile activities accordingly. • Anticipated Completion Date: 06/30/2026

View Audit 396634

Finding 1204960 (2025-001)

Material Weakness 2025

City of South El Monte

CA

Reporting Internal Control / Segregation of Duties § 200.303 § 200.510

The City is taking corrective action in response to this finding by strengthening its grant management procedures. The Director of Community Development and Public Works is responsible for overseeing these improvements, which include enhancing coordination among the Public Works Analyst, Grants Coor...

The City is taking corrective action in response to this finding by strengthening its grant management procedures. The Director of Community Development and Public Works is responsible for overseeing these improvements, which include enhancing coordination among the Public Works Analyst, Grants Coordinator, and the City's contracted engineering firm to clearly distinguish between federally and state-funded Highway Safety Improvement Program (HSIP) activities and ensure that program information aligns with current federal award documents. Key measures include requiring identification of funding sources in Staff Reports submitted to City Council prior to grant application submission, assigning unique project numbers and classifications within the City's financial system (Incode), implementing a reconciliation process to accurately align project expenditures with their funding sources before inclusion in the Schedule of Expenditures of Federal Awards (SEFA), and providing targeted staff training along with a standardized SEFA preparation checklist. All corrective actions are set for implementation effective March 18, 2026. Personnel responsible for implementation: Gerardo Marquez Position of personnel responsible: Director of Community Development and Public Works Expected date of implementation: March 18, 2026

View Audit 396633

Finding 1204921 (2025-001)

Material Weakness 2025

Franciscan Missionaries of Our Lady Health System, Inc.

LA

Cash Management § 200.303 § 200.305

Corrective Action Plan In the event that the System receives federal cash advances prior to the cash expenditures, the System will perform an additional financial review of any advanced payments compared to the related expenditures. Should accounting identify advances not yet spent, they will inquir...

Corrective Action Plan In the event that the System receives federal cash advances prior to the cash expenditures, the System will perform an additional financial review of any advanced payments compared to the related expenditures. Should accounting identify advances not yet spent, they will inquire with the grant administrator responsible for the grant to review their advance fundings, any potential resulting interest calculations. Anticipated Completion Date June 30, 2026 Name of Contact Person for Corrective Action Amanda Hymel, Corporate Controller

View Audit 396525

Finding 1204910 (2025-101)

Material Weakness 2025

Graham County Community College District

AZ

Student Financial Aid Reporting Special Tests & Provisions § 200.303

Financial Statement Findings 2025-01 The District’s control procedures over IT systems and data were not sufficient, which increases the risk that the District may not adequately protect those systems and data. Contact: Thomas Thompson, Chief Information Officer Anticipated completion date: June 30,...

Financial Statement Findings 2025-01 The District’s control procedures over IT systems and data were not sufficient, which increases the risk that the District may not adequately protect those systems and data. Contact: Thomas Thompson, Chief Information Officer Anticipated completion date: June 30, 2026__________________________________________ Corrective Action Plan: The District will prioritize the development and formal documentation of IT policies and procedures addressing logical access controls, system security, and vendor management. These policies will align with recognized industry standards and will include processes to ensure consistent implementation and compliance. a) User access assignment and review b) Timely removal of access c) Enhance verification of assignment through available and to-be-developed reporting tools d) The District will review and enhance formal procedures for evaluating, awarding, and monitoring IT vendor contracts. This will include documenting vendor qualifications, defining security expectations in contracts, and performing periodic reviews to ensure vendors comply with contractual and security requirements. e) Management will implement supervisory review controls to ensure adherence to IT policies and procedures. Federal Award Findings 2025-101 The District did not timely report required student information to the federal agency, risking students not being asked to repay financial assistance. Contact: Sharon Montoya, Director, Financial Aid & Veteran Services Anticipated completion date: June 30, 2026__________________________________________ Corrective Action Plan: The District will implement procedures to ensure all student enrollment status changes are reported to the National Student Loan Data System (NSLDS) within the required 60-day timeframe. This includes establishing a standardized reporting schedule and utilizing system-generated reports to monitor pending status changes. a) Assign monitoring and oversight responsibilities in the Financial Aid department b) Implement ongoing monitoring control within the Financial Aid department c) Monthly inquiring into the Financial Aid department process by Fiscal Control

View Audit 396510

Finding 1204905 (2025-009)

Material Weakness 2025

County of Ventura

CA

Procurement, Suspension & Debarment Eligibility § 200.214 § 200.303

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirement:...

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirement: Procurement, Suspension, and Debarment Type of Finding: Material Weakness and Instance of Noncompliance Department’s Management Response: Ventura County Health Care Agency (HCA) management agrees with the recommendation for the County to strengthen its policies and procedures to ensure that the verification of the debarment and suspension is documented and retained, the history of procurement transactions is documented and retained in its official record, and that contracts include all applicable provisions of 2 CFR 200 Appendix II. View of Responsible Officials and Corrective Action: HCA Management will implement documentation procedures to support the evaluation and selection of vendors. These procedures will include but are not limited to, ensuring that debarment and suspension verifications are properly documented and retained, procurement transaction histories are maintained in official records, and all contracts include the applicable provisions required under 2 CFR 200 Appendix II. Name of Responsible Persons: Mike Taylor, HCA CFO John Fankhauser, HCA Director Implementation Date: March 2026 – Add documentation of suspension and debarment check for applicable contracts.

View Audit 396507

Finding 1204904 (2025-008)

Material Weakness 2025

County of Ventura

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirements...

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: VCPH Management agrees with the recommendation for the Department to strengthen its policies and procedures to ensure all required reports are reviewed, approved and retained as evidence in the applicable grant folder. View of Responsible Officials and Corrective Action: VCPH Management will implement a requirement that all applicable reports must include documented review and approval (e.g. email approval, signed cover sheet, or workflow confirmation) before submission and retention of such approval evidence in the applicable grant folder location. Name of Responsible Persons: Maria Macias, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: April 2026

View Audit 396507

Finding 1204903 (2025-007)

Material Weakness 2025

County of Ventura

CA

Reporting § 200.303 § 200.502 § 200.510

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirement:...

Program: COVID-19 - Epidemiology and Laboratory Capacity for Infectious Disease (ELC) Assistance Listing No.: 93.323 Federal Grantor: U.S. Department of Health and Human Services Passed-through: California Department of Public Health Award No.: COVID-19ELC114 Award Year: 2021 Compliance Requirement: Other - Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) §200.510(b) - Schedule of Expenditures of Federal Awards Type of Finding: Material Weakness in Internal Control Over Compliance Department’s Management Response: Management agrees with the recommendation to enhance internal controls to ensure federal expenditures are reported accurately and completely on the SEFA in accordance with the Uniform Guidance. View of Responsible Officials and Corrective Action: To ensure compliance with §200.510(b) of the Uniform Guidance, the Auditor Controller’s Office will issue additional detailed instructions clarifying the period covered by the amounts to be reported when requesting departmental information for the County’s SEFA. These clarifications will support consistency, accuracy, and improved internal controls over federal expenditure reporting. Name of Responsible Persons: Jason McGuire, Deputy Director, Auditor-Controller Implementation Date: August 2026

View Audit 396507

Finding 1204902 (2025-006)

Material Weakness 2025

County of Ventura

CA

Special Tests & Provisions Cash Management Material Weakness § 200.303

Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Materia...

Program: Health Center Program Cluster Assistance Listing No.: 93.224 Federal Grantor: U.S. Department of Health and Human Services Passed-through: N/A Award No.: 5 H80CS00247-22-00 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Sliding Fee Discounts Type of Finding: Material Weakness in Internal Control over Compliance and Material Non-Compliance Department’s Management Response: Health Care Agency (HCA) management agrees and acknowledges the findings related to the application and review of sliding fee discounts under the Self-Pay Discount Program. The Department recognizes the importance of consistent application of sliding fee discount schedules and proper documentation of review processes to ensure full compliance with federal requirements. The Department is committed to maintaining strong internal controls and ensuring adherence to all applicable policies, procedures, and regulatory standards governing the Sliding Fee Discount Program. View of Responsible Officials and Corrective Action: HCA Management agrees with the finding and will implement corrective actions to strengthen internal controls and ensure consistent application of the sliding fee discount program. The following actions will be taken: • Reinforcement of Policies and Procedures: Re-educate all applicable staff on existing sliding fee discount program policies, including proper calculation and application of discounts. First re-education session was held on February 4, 2026. • Standardization of Workflow: Update and implement standardized workflows and job aids within the registration and billing processes to ensure discounts are applied accurately and consistently. Standardized workflows completed on February 2, 2026. • Enhanced Review and Oversight: Establish a formalized secondary review process for sliding fee discount determinations, including required documentation and supervisory sign-off. Supervisor sign off on sliding fee applications by April 1, 2026. • Ongoing Training: Incorporate sliding fee discount program requirements into onboarding and annual refresher training for relevant staff beginning April 1, 2026. • Audit and Monitoring: Conduct monthly internal audits of sliding fee discount applications to monitor compliance and identify any trends or gap by May 1, 2026. These corrective actions are designed to ensure compliance with federal requirements, improve consistency in application, and strengthen overall internal controls. Name of Responsible Persons: Octavius Gonzaga, Ambulatory Care CFO – Establishes sliding fee discount program policy, procedures, and fee schedules. Erika Herincx, Ambulatory Care Revenue Cycle Manager – Responsible for the oversight of the training program and ensures the listed activities in the Corrective Action Plan are executed. Implementation Date: February 4 - March 30, 2026 – Training of front-end staff and clinic management. April 1, 2026 – Implementation of supervisor sign off for each sliding fee application. April 1, 2026 – Re-Training of Medical Billing Specialists on adjustments. May 1, 2026 – Monthly sampling of encounters December 1, 2026 – Year-to-date report and internal audit

View Audit 396507

Finding 1204900 (2025-005)

Material Weakness 2025

County of Ventura

CA

Reporting Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

Program: Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii Assistance Listing No.: 14.228 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Pass-Through California Department of Housing and Community Development Award No.: 17-MITP...

Program: Community Development Block Grants/State’s Program and Non-Entitlement Grants in Hawaii Assistance Listing No.: 14.228 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Pass-Through California Department of Housing and Community Development Award No.: 17-MITPPS-21029, 18-DRWD-23003, 21-CDBG-HK-0010 Award Year: 2022, 2024 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: Management agrees with the recommendation to revise its procedures to include evidence documenting the individual who reviewed and approved required reports prior to submission. View of Responsible Officials and Corrective Action: a. With regards to the CDBG-CV2 and CDBG-MIT reports managed by the County Executive Office Community Development Division, procedures were revised beginning in April 2025 due to prior year findings 2024-007 and 2024-008 to incorporate documented review and approval requirements for all applicable federally required reports. These enhanced internal controls are being phased in across all relevant reporting processes, with full implementation completed by the end of June 2025. These changes are intended to ensure that evidence of review and approval is consistently retained and that reporting is accurate, complete, and compliant with federal requirements. The reports identified in the finding were completed prior to the stated corrective action. b. With regards to the VC Heal Activity reports managed by Ventura County Workforce Development (VCWD) management, the required reports were prepared by the subrecipient (Career TEAM) using the standardized HCD format and underwent multiple levels of review, the County acknowledges that documentation of the specific individual review and approval prior to submission was not consistently retained. To strengthen internal controls to ensure all required reports include documented evidence of review and approval prior to submission, VCWD management will: • Implement a standardized review and approval protocol requiring documented sign‑off by designated VCWD management prior to submission. • Require Career TEAM to use a formal certification or routing process identifying the preparer and reviewer. • Maintain centralized documentation identifying the report preparer, reviewer/approver, and date of review. • Incorporate these requirements into internal procedures and contractor guidance. • Conduct periodic internal monitoring to verify compliance. Name of Responsible Persons: a. Kimberlee Albers, Deputy Executive Officer b. VCWD staff responsible for the CDBG program Career TEAM (Subrecipient – Report Preparation) Implementation Date: a. April – June 2025 b. April 2026

View Audit 396507

Finding 1204897 (2025-004)

Material Weakness 2025

County of Ventura

CA

Matching / Level of Effort / Earmarking Special Tests & Provisions Significant Deficiency § 200.303 § 200.326

Finding 2025-004 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...

Finding 2025-004 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC-06-0507, B-24-UC-06-0507, 95-6000807 Award Year: 2024 Compliance Requirement: Special Tests and Provisions - Wage Rate Requirements Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Department’s Management Response: The County Executive Office agrees with the recommendation to strengthen its internal controls to ensure compliance with wage rate requirements. View of Responsible Officials and Corrective Action: The County Executive Office Community Development Division will conduct a comprehensive review and update of its Federal Labor Standards Policy and Procedure (FLSPP), with completion targeted no later than July 1, 2026. The updated FLSPP will include a requirement for County staff to obtain and retain certified payroll submissions monthly for all construction activities subject to prevailing wage requirements. Although the formal policy update will not be effective until July 1, staff will begin implementing this control immediately. Name of Responsible Persons: Kimberlee Albers, Deputy Executive Officer Tracy McAulay, Housing Solutions Director Ying Vang, Management Analyst (Community Development Block Grant) Michael Skinner, Management Analyst (HOME Investment Partnerships Program) Implementation Date: April 2026

View Audit 396507

Finding 1204890 (2025-003)

Material Weakness 2025

County of Ventura

CA

Subrecipient Monitoring Reporting Significant Deficiency § 200.303

Finding 2025-003 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-05...

Finding 2025-003 Program: CDBG-Entitlement/Special Purpose Grants Cluster Assistance Listing No.: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Passed-through: Direct Award and Pass-Through City of San Buenaventura Award No.: B-20-UC-06-0507, B-20-UW-06-0507, B-21-UC-06-0507, B-22-UC-06-0507, B-23-UC-06-0507, B-24-UC-06-0507, 95-6000807 Award Year: 2024 Compliance Requirements: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: The County Executive Office Community Development Division agrees with the recommendation to revise its procedures to include evidence to document the individual who reviewed and approved required reports prior to submission. View of Responsible Officials and Corrective Action: Procedures were revised beginning in April 2025 due to prior year findings 2024-007 and 2024-008 to incorporate documented review and approval requirements for all applicable federally required reports. These enhanced internal controls are being phased in across all relevant reporting processes, with full implementation completed by the end of June 2025. These changes are intended to ensure that evidence of review and approval is consistently retained and that reporting is accurate, complete, and compliant with federal requirements. The reports identified in the finding were completed prior to the stated corrective action. Name of Responsible Persons: Kimberlee Albers, Deputy Executive Officer Implementation Date: April – June 2025

View Audit 396507

Finding 1204883 (2025-002)

Material Weakness 2025

County of Ventura

CA

Allowable Costs / Cost Principles Internal Control / Segregation of Duties § 200.303 § 200.430

Finding 2025-002 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: A...

Finding 2025-002 Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Activities Allowable or Unallowed and Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control Over Compliance Department’s Management Response: HCA’s Ventura County Public Health (VCPH) Management agrees with the recommendation to strengthen the established policies and procedures to ensure all timecards consistently document evidence of supervisor approval. View of Responsible Officials and Corrective Action: The timesheet identified during this audit were submitted in the County’s payroll system prior to the completion of the 2024 fiscal year audit and related finding 2024-003; therefore, the related corrective actions had not yet been implemented at the time of submission. In response to the prior year’s finding, VCPH Management implemented enhanced controls to ensure compliance with timecard approval requirements moving forward from that date. Payroll staff now sends reminder notifications to supervisors, managers, and VCPH Management before and after each pay period closing to identify and resolve unapproved timecards. Management has also reinforced expectations through additional training for supervisors and managers. When a primary supervisor is unavailable, the established alternate approver process will be used to ensure timely approvals. VCPH Management will continue monitoring compliance with these procedures, and these requirements will be reviewed again with all supervising staff at the next scheduled WIC Supervisor Meeting. Name of Responsible Persons: Laura Flores, Manager, VCPH Rigoberto Vargas, Director, VCPH Implementation Date: May 1, 2025 – Instructions were provided to all supervisors at the WIC Supervisor Team Meeting May 7, 2026 – Timecard instructions will again be discussed at the WIC Supervisor Team Meeting

View Audit 396507

Finding 1204882 (2025-001)

Material Weakness 2025

County of Ventura

CA

Procurement, Suspension & Debarment § 200.303 § 200.327

Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Procurement and Su...

Program: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Assistance Listing No.: 10.557 Federal Grantor: U.S. Department of Agriculture Passed-through: California Department of Public Health Award No.: 22-10307 Award Year: 2022 Compliance Requirement: Procurement and Suspension and Debarment Type of Finding: Material Weakness in Internal Control over Compliance and Instance of Non-Compliance Department’s Management Response: Ventura County Health Care Agency (HCA) management agrees with the recommendation for the County to strengthen its policies and procedures to ensure that the verification of the debarment and suspension is documented and retained, the history of procurement transactions is documented and retained in its official record, and that contracts include all applicable provisions of 2 CFR 200 Appendix II. View of Responsible Officials and Corrective Action: HCA Management will implement documentation procedures to support the evaluation and selection of vendors. These procedures will include but are not limited to, ensuring that debarment and suspension verifications are properly documented and retained, procurement transaction histories are maintained in official records, and all contracts include the applicable provisions required under 2 CFR 200 Appendix II. Name of Responsible Persons: Mike Taylor, HCA CFO John Fankhauser, HCA Director Implementation Date: March 2026 – Add documentation of suspension and debarment check for applicable contracts April 2026 – Include applicable provisions described in 2 CFR 200 Appendix II to contracts

View Audit 396507

Finding 1204848 (2025-001)

Material Weakness 2025

Nami Chicago

IL

Allowable Costs / Cost Principles § 200.303

NAMI Chicago acknowledges the finding regarding documentation of approvals for expenses charged to federal awards. The exceptions identified occurred during the first half of the fiscal year, prior to the January 1, 2025, implementation of our enhanced Internal Control and Disbursement Policy develo...

NAMI Chicago acknowledges the finding regarding documentation of approvals for expenses charged to federal awards. The exceptions identified occurred during the first half of the fiscal year, prior to the January 1, 2025, implementation of our enhanced Internal Control and Disbursement Policy developed in direct response to the FY24 audit recommendations, which were finalized and communicated in early 2025. Since January 1, 2025, NAMI Chicago has successfully implemented a mandatory digital approval workflow for all grant-funded expenditures to ensure contemporaneous documentation. Management is confident that these strengthened protocols, which were fully operational for the latter half of FY2025 and continue to date, have resolved the underlying issue. We expect no further instances of this finding in future audit cycles.

View Audit 396483

Finding 1204821 (2025-009)

Material Weakness 2025

Urshan College

MO

Eligibility Reporting Significant Deficiency § 200.303

2025-009 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation ...

2025-009 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University reviewed its awarding and reconciliation processes following the identified discrepancy between COD and the institutional ledger, which resulted from packaging based on an earlier ISIR transaction without confirming the most recent ISIR data. To address this, the University has partnered with FA Solutions and implemented enhanced controls within Regent, including system checks to flag updated ISIR information and require confirmation of the most current transaction prior to packaging.Additionally, reconciliations and related reporting provided by FA Solutions will be reviewed for accuracy and completeness. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 3/31/2026

View Audit 396458

Finding 1204820 (2025-008)

Material Weakness 2025

Urshan College

MO

Cash Management Matching / Level of Effort / Earmarking Student Financial Aid § 200.303

2025-008 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that the University should implement formal review procedures to document that the Cash Management reconciliation and drawdown reviews are bei...

2025-008 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that the University should implement formal review procedures to document that the Cash Management reconciliation and drawdown reviews are being performed to correct errors in a timely manner and to minimize the likelihood of errors going undetected. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University performs cash management reconciliation and drawdown reviews; however, formal documentation of these reviews has not been consistently maintained. To address this, the University is implementing formal review procedures that include documented evidence of reconciliation and drawdown review activities. As part of this process, reconciliations and drawdowns prepared by FA Solutions will be reviewed by the Financial Aid Office for accuracy and completeness prior to submission and reporting. These procedures will be formalized within a standardized SOP, which will outline review timelines, responsibilities, and required documentation to ensure errors are identified and resolved in a timely manner and to reduce the risk of discrepancies going undetected. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 4/30/2026

View Audit 396458

Finding 1204819 (2025-007)

Material Weakness 2025

Urshan College

MO

Special Tests & Provisions Significant Deficiency Matching / Level of Effort / Earmarking § 200.303

2025-007 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University design controls to ensure an adequate review process is in place to ensure compliance over stale checks that need to be returne...

2025-007 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University design controls to ensure an adequate review process is in place to ensure compliance over stale checks that need to be returned to the Department of Education after 240 days. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University is implementing enhanced controls to ensure compliance with stale-dated Title IV credit balance checks. This includes establishing a monthly review process in coordination with Accounts Payable, Accounts Receivable, and the Financial Aid Office to identify any outstanding checks approaching or exceeding the 240-day threshold. As part of this process, a tracking mechanism will be maintained to monitor the status and issuance dates of all Title IV credit balance checks. The University will make reasonable efforts to contact students and reissue checks, as appropriate, to ensure funds are received. Any checks that remain uncashed and meet the stale-dated threshold will be voided and returned to the U.S. Department of Education in accordance with federal requirements. These procedures will be formalized within a standardized SOP to ensure consistent and timely compliance moving forward. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid, Accounts Receivable Clerk, and Accounts Payable Clerk Planned completion date for corrective action plan: 4/30/2026

View Audit 396458

Finding 1204818 (2025-006)

Material Weakness 2025

Urshan College

MO

Student Financial Aid Eligibility Significant Deficiency § 200.303

2025-006 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University review its current procedures for awarding Title IV funds and implement any changes necessary to ensure federal funds are award...

2025-006 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University review its current procedures for awarding Title IV funds and implement any changes necessary to ensure federal funds are awarded and disbursed in accordance with federal regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has conducted a review of its procedures for awarding Title IV funds, with particular attention to the awarding of Summer Pell. Through this review, we identified that Summer Pell was not awarded to eligible students during the applicable period, due in part to a misunderstanding of awarding requirements during a transition in third-party processing support. Urshan has since partnered with FA Solutions to strengthen oversight and ensure alignment with federal awarding requirements. Updated procedures have been implemented to ensure all eligible students are properly evaluated for Title IV aid, including Summer Pell, across all applicable terms. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 8/31/2026

View Audit 396458

Finding 1204817 (2025-005)

Material Weakness 2025

Urshan College

MO

Special Tests & Provisions Subrecipient Monitoring Significant Deficiency § 200.303

2025-005 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that the University review the GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit ...

2025-005 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that the University review the GLBA requirements and ensure their WISP includes all required elements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University has completed a comprehensive review and revision of its Written Information Security Program (WISP) to ensure alignment with all applicable requirements under the Gramm-Leach-Bliley Act (GLBA). While these updates were finalized after the end of FY25, the revised WISP now includes all required elements. The University has also received confirmation from the U.S. Department of Education’s Cybersecurity Compliance team that the updated program meets minimum GLBA compliance requirements. Moving forward, the University will maintain and periodically review its WISP to ensure ongoing compliance with federal standards. Name(s) of the contact person(s) responsible for corrective action: Dewayne Presson & Keith Braswell | Urshan IT Department Planned completion date for corrective action plan: 3/31/2026

View Audit 396458

Finding 1204816 (2025-004)

Material Weakness 2025

Urshan College

MO

Special Tests & Provisions Student Financial Aid Significant Deficiency § 200.303

2025-004 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that the University review policies and procedures related to R2T4 calculations to ensure calculations are performed accurately. Explanation o...

2025-004 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend that the University review policies and procedures related to R2T4 calculations to ensure calculations are performed accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Urshan has partnered with FA Solutions, an experienced third-party processor. Through this partnership, we have strengthened our processes and implemented additional checks and balances to ensure that R2T4 determinations are identified, calculated, and processed in a timely and compliant manner. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 3/31/2026

View Audit 396458

Finding 1204815 (2025-003)

Material Weakness 2025

Urshan College

MO

Student Financial Aid Matching / Level of Effort / Earmarking Special Tests & Provisions § 200.303

U.S. Department of Education 2025-003 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University review current processes for reporting to NSLDS and implement procedures to ensure submissions are...

U.S. Department of Education 2025-003 Federal Direct Student Loans – Assistance Listing No. 84.268 Federal Pell Grant Program – Assistance Listing No. 84.063 Recommendation: We recommend the University review current processes for reporting to NSLDS and implement procedures to ensure submissions are reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Urshan is currently in the onboarding process to partner with the National Student Clearinghouse, which will improve the timeliness and accuracy of our enrollment reporting to NSLDS. In addition, we are developing and implementing a standardized SOP that establishes defined reporting schedules (at least every 60 days), clearly outlines roles and responsibilities, and includes reconciliation procedures to ensure data accuracy. Name(s) of the contact person(s) responsible for corrective action: Levi Powell, Director of Financial Aid Planned completion date for corrective action plan: 7/31/2026

View Audit 396458

Finding 1204806 (2025-003)

Material Weakness 2025

University Enterprises Corporation at Csusb

CA

Cash Management Reporting § 200.302 § 200.303 § 200.305

Federal Program Title: R&D Cluster, Child Care Access Means Parents in School, and TRIO Cluster Assistance Listing Number: R&D, 84.335, and 84.TRIO Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Recommendation: We recommend that the UEC strengthen its c...

Federal Program Title: R&D Cluster, Child Care Access Means Parents in School, and TRIO Cluster Assistance Listing Number: R&D, 84.335, and 84.TRIO Type of Finding: • Significant Deficiency in Internal Control over Compliance • Other Matters Recommendation: We recommend that the UEC strengthen its cash management and financial reporting procedures to ensure reimbursement requests include only costs incurred in the appropriate fiscal period, are supported by adequate documentation, and are submitted in a timely manner. The UEC should also enhance review controls to verify proper period recognition of costs before submitting reimbursement requests. Views of Responsible Officials: There is no disagreement with the audit finding. Action Taken in Response to Finding: University Enterprises Corporation (UEC) has implemented and is continuing to strengthen internal controls over cash management, reimbursement timing, and supporting documentation. Corrective actions include the implementation of a revised subaward management process to improve documentation, period alignment, and pre-submission review, strengthening controls to ensure reimbursement requests include only costs incurred within the appropriate fiscal period, reinforcing documentation and validation requirements prior to submission, establishing clearer expectations and monitoring for timely reimbursement processing, and clarifying roles and responsibilities to support consistent compliance. Contact(s) Responsible for Corrective Action: Director of Sponsored Programs Administration Planned Completion Date for Corrective Action: June 30, 2026.

View Audit 396456

Corrective Action Plans

Filters