Corrective Action Plans

Corrective Action Plan 2024-006 – Unallowable Expenditures National School Lunch Program (Significant Deficiency) Federal Program Information: Funding Agency: U.S. Department of Agriculture Title: National School Lunch Program FAL Number: 10.555 & 10.553 Passthrough: N/A Award Year: 2024 Responsible Official’s Plan: Due to the timing of the finding, the District is performing a permanent cash transfer in March to be compliant with the National School Lunch Program. Additionally, the specific corrective action plan provides details for how we have ensured the unallowable expenses for the National School Lunch Program will not occur again. Specific corrective action plan for finding: This was the result of an error in changing an employee's position from one department to another. Moving forward, the Human Resources Department will notify Payroll of any changes in position and will require TWO SIGNATURES prior to making any changes in pay coding. The two signatures are from the Director of Human Resources and the Director of Finance. Timeline for completion of corrective action plan: The permanent cash transfer process has begun and will be completed by March 31, 2025. The form to ensure two signatures are captured prior to making changes in pay coding is already created and being utilized. Employee positions responsible for meeting the timeline: Director of Finance – Cooper Jones Director of Human Resources – Lisa Salazar

2024-002 No indirect cost allocation methodology Criteria: According to CFR Part 200.405(d), if a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. However, when these proportions cannot be determined because of the interrelationship of the work involved, then, notwithstanding paragraph (c), the costs may be allocated or transferred to benefited projects on any reasonable documented basis. Client Response: The agency will use FTE as an allocation method for such expenses calculated as such: (FTE hours for program/Total FTE hours x Total Expense of Line Item). Proposed Implementation Date – December 1, 2024 Name of Contact Person – John Edwards, Sr. Email:jledwards@umadaop.org Phone: 419-255-4444

Finding - Activities Allowed or Unallowed & Allowable Costs/Cost Principles: Payroll, Assistance Listing Number 93.243; June 30, 2024, award year; U.S. Department of Health and Human Services Criteria or Specific Requirement In accordance with 2 CFR 200.405, A cost is allocable to a Federal award if the cost is assignable to that Federal award with the relative benefits received. These costs must be incurred specifically for the Federal award. Condition Found Of the Seventeen payroll charges selected for testing, the allocation of payroll charged to the Federal grant did not align with the percentage of time incurred specifically for the Federal grant in four instances. Views of Responsible Officials and Planned Corrective Actions It was determined that the allocation percentage assigned in our payroll system did not match the calculated payroll expensed to the grant. Corrective measures: 1) contacted our payroll administrator and determined the cause to be that an allocation percentage was applied to the employee and the employee was also assigning their time via their time sheet effectively calculating twice, first on the total payroll and again on the allocated amount. The employee was instructed not to enter the allocation since it is already done in the payroll system. 2) A monthly review and calculation will be performed by program management and accounting to verify cost allocations are correct. Responsible Official: Korin Ihloff, CFO Expected Completion Date: The issue was addressed immediately.

Response: Management agrees with the finding and acknowledges that a significant deficiency was identified related to unallowable payroll costs. This issue occurred due to a timing delay in processing an Employment Transaction Report (ETR). The payroll transfer, originally intended to be effective in April 2024, was not processed until September 2024 of the following fiscal year. As a result, one grant was overcharged, while another grant was undercharged, leading to a misallocation of funds. To prevent similar issues, we will conduct monthly payroll reviews to ensure correct allocation of expenses and provide comprehensive staff training to reinforce the importance of timely and accurate payroll processing. Regular internal reviews and follow-ups will be conducted to monitor the effectiveness of these corrective actions, ensuring any further training or system improvements are implemented as needed. Contact person responsible for corrective action: Lynne Duong, Post Award & Compliance Manager Anticipated completion date: December 31, 2024

Action Taken in Response to Finding: In 2023, invoices were submitted using a format aligned with initial guidance from the Colorado Department of Human Services (CDHS), reflecting a per-learner, activity-based approach. Beginning in October 2024, updated guidance required invoices to be based on actual costs incurred, including the use of supporting documentation such as timesheets and receipts to substantiate costs. As of October 2025, CDHS updated reimbursement requirements to no longer require supporting documentation at the time of invoice submission. However, complete supporting documentation is maintained and provided upon request for monitoring or audit purposes. Standardized Excel-based tools provided by CDHS are utilized for reimbursement submission (Invoice and Ledger). Transaction-level cost tracking was implemented to ensure allowable and eligible costs are recorded and supported. Financial and grant-related policies were previously maintained and were subsequently standardized and incorporated into Financial Policies and Procedures in 2023, with a comprehensive Grant Management framework implemented in May 2026. Control Enhancement: Beginning in 2025, all costs applied toward matching requirements are recorded and tracked at the transaction level within the accounting system and are fully supported by source documentation. Matching contributions must: • Be based on actual, allowable, and allocable costs • Be verifiable from accounting records • Not include estimated or budgeted amounts A standardized approach has been implemented to ensure that matching costs are derived from the same underlying financial data used for reimbursable costs. Monitoring & Review: • Matching costs are reviewed by the Senior Accountant prior to inclusion in reimbursement requests • A secondary monthly review is performed by the Director of Finance & Operations to validate accuracy, allowability, and compliance with matching requirements • Any discrepancies between recorded costs and matching allocations are identified and resolved prior to submission Testing & Validation: • Beginning June 2026, quarterly internal reviews will be conducted to test a sample of matching costs for compliance with documentation and allowability requirements • Testing will confirm that matching costs are fully supported and traceable to accounting records • Results will be documented and tracked, and any identified deficiencies will require corrective action Documentation & Evidence: • Supporting documentation for matching costs is maintained in Microsoft Teams • Matching calculations and supporting detail are retained and available for audit or monitoring • Review and approval are evidenced via email approval and retained as part of the audit record Control Owner(s): • Director of Finance & Operations • Finance Team Responsible Party: Helen Young Hayes, Founder / Chief Executive Officer, in coordination with the Director of Finance & Operations and Finance Staff Anticipated Completion Date: All corrective actions will be implemented by June 30, 2026. Ongoing monitoring, quarterly testing, and policy updates will continue. Status: • Transaction-level tracking of matching costs: Implemented 2025 • Updated invoicing methodology: Implemented October 2024; revised October 2025 • Cost Sharing policy: Implemented May 2026 • Grant Management framework; Incorporated in Financial Policy and Procedures on May 2026. • Quarterly internal reviews will be conducted to test a sample of matching costs for compliance with documentation and allowability requirements: June 2026

Management’s Response or Department’s Response The County agrees with the finding and recommendation. Views of Responsible Officials and Corrective Action Plan The County will implement a formalized monitoring program and agreement template to identify subrecipients based on criteria in § 200.332. The County will provide a comprehensive training to program managers to implement the monitoring program and subrecipient agreement template. In addition, the County will include direction to project managers to review current awards to identify existing subrecipients that were not provided a subrecipient agreement with all of the required elements from CFR § 200.332. Anticipated Completion Date/Completion Date June 30, 2026 Contact Information of Responsible Official Name: Donald McNair Title: County Clerk & Auditor-Controller Phone: 209-533-6593

As of the 2024-2025 fiscal year, the agency has created a sustainable cost allocation process that will be in place moving forward. New policies were created, including a system for analysis of allocations throughout the year. Person(s) Responsible: Claire Versaw, CFO Timing for Implementation: Currently in place as of 7/1/2024

Item 2023-006 Activities Allowed or Unallowed/Allowable Costs/Cost Principles Head Start ALN# 93.600 US Department of Health & Human Services (Repeat 2022- 008) Federal Grant/Contract Number: 10CH011215-03-03; 10CH011215-03 C3; 10CH011215-04; 10HE000901-01-C6 Grant period – 2022 & 2023 The HS program has established an internal process of requester/approver in place to review transaction requested. Documents then get reviewed again by HR or Finance staff based on the transaction type before getting processed.

Reference Number: 2023-011 Finding: Improve Controls and Compliance with Approval of Allowable Costs Name of Contact Person: Lorina Esposito Corrective Active Plan: The City will implement a policy mandating documented approval for all invoices before they are paid or charged to federal programs. In addition, the City will conduct regular, scheduled reviews of invoice processing to verify compliance with allowable cost procedures and address any deviations promptly. Training will be provided to staff involved in invoice approval and payment processes to ensure understanding and adherence to these internal control requirements. Proposed Completion Date: 6/30/26

FINDING 2023-005 – Allowable Costs: Significant Deficiency over Internal Controls over Compliance Condition/context – In a sample of 25 payroll disbursements and 25 non-payroll disbursements, it was found that time and effort for 11 salaried employees were not supported by documentation for the allocation. The sample of non-payroll disbursements had 4 transactions without the documented methodology or support for the allocation between programs. Corrective Action Plan: • Implemented a formal time and effort reporting process (Allocation Method) for all employees whose salaries are charged to more than one funding source, in compliance with federal requirements. • Developing and enforcing a standardized cost allocation methodology for shared non-payroll expenses, ensuring documentation is retained for all allocation decisions. • Training program and finance staff on allowability and allocation requirements under 2 CFR Part 200. • Periodically reviewing cost allocations to ensure continued reasonableness and compliance with applicable grant terms. • Policy and Procedures updated/Staff Training on new Timesheet processes Name of Contact Person: Chris Flaherty, Chief Executive Officer 707.890.6491 Laura Williams, Chief Financial Officer 707.335.0010 Projected Completion Date: Corrected: September 2025

We will allocate shared costs appropriately among federal awards

Corrective Actions Taken or Planned Management concurs with the finding and has already initiated enhancements to its review process to ensure that expense reports are consistently reviewed and approved by both supervisors and finance personnel prior to being charged to federal awards. These steps are designed to further strengthen internal controls and support compliance with federal requirements. In addition, Finance staff are formalizing procedures to reconcile payroll charges on a regular basis to ensure compliance with federal requirements and to confirm that all charges to federal programs are supported by actual time and effort records. Responsible person: Jackie Ramirez, Operations & Finance Associate Director Expected Implementation date: October 31, 2025

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

2023-006 Management Response: Management respectfully disagrees with this Finding. • Under Condition, the finding states, “Time and effort is being tracked and maintained by employees, including hours charged to the specific efforts for the programs.…” This is not accurate. Employees report their time worked each day, including the amount of time they worked on different projects if applicable. Employees report this in our commercial HRIS/Payroll system, where it is maintained and where it is reviewed and approved by the employee’s manager. The employees report the time they worked and which project(s) they worked on, their managers review and approve the time and the distribution, and the data is tracked and maintained in our HRIS/Payroll system (ExponentHR). • Also under Condition, the finding states, “The specific amount of employee salaries and wages that are allocated to specific federal programs for reimbursement, and which are less than the amounts reflected in time and effort records, are determined by members of the finance staff.” It is correct that we would have to invoice sponsors for less than the total cost of an employee’s allocated time and effort if a sponsor’s budget is not sufficient to cover that full amount. This is the correct procedure to follow. Employees correctly continue documenting their hours worked on a specific project even if the budget is expended and the accounting staff can no longer bill the sponsor. If a particular grant does not have sufficient sponsor funds, then the Grants Accounting staff reduce the bill accordingly. • Also under Condition, the finding states, “The rationale for the amount actually allocated for reimbursement, if less than the amount reflected in time and effort records, is not documented”. This is incorrect. Our monthly invoices to each sponsor accumulate, with each invoice clearly showing not only that month’s expense but also the year-to-date expense and remaining balance, which forces the sponsor invoice to stop at an amount less than the total cost of employees’ time and effort when the budget is exhausted. • Also under Condition, the finding states, “Review and approval of the allocation of employee compensation to specific federal programs reimbursement requests is not maintained.” Each employee records their hours worked, and the project(s) on which they worked those hours, in our HRIS/Payroll system. The employee’s manager reviews and approves both the hours worked and the projects on which the hours were worked. This review and approval is maintained in our HRIS/Payroll system. Financial staff calculate the amount to allocate to specific federal programs based on these HRIS/Payroll system records (or other records such as clinical units produced, based on the terms of each grant). Separate accounting staff review the sponsor invoice and post the Receivable once they deem the invoice correct. • Under Cause, the finding states, “…..the Organization has not implemented a structured process for documenting the extent to which allowable [emphasis added] compensation costs will be allocated for reimbursement to specific federal programs in instances where the allowable compensation cost exceeds the amount allocated for reimbursement.” This means that we do not have a process for documenting how much of a payroll expense already deemed allowable on a particular grant will actually be invoiced there. We disagree and believe that the presence and documentation of a limited sponsor budget, along with cumulative tracking and documentation of compensation expenses against that budget, proves and documents why sometimes full compensation costs are not charged to a grant. • Under Possible Effect, the finding addresses possible effects of “the absence of documented allocation methodologies.” We don’t agree that our process could lead to improper allocation between federal programs (as the finding states) nor to misstating federal expenditures (as the finding states). When a sponsor’s budget is insufficient to cover its appropriately allocated compensation costs, those costs are paid from unrestricted, non-federal funds. As also noted in the finding, no questioned costs were identified.

STDC acknowledges the audit finding regarding the inclusion of sales tax on a utility invoice that was initially charged to multiple federal programs through the administrative cost pool. While the vendor issued credit for the sales tax in question, the original charge had already been distributed across multiple grants, and appropriate reallocations were not documented at the time of audit review. Documentation of the credit was made in the subsequent month’s billing cycle and applied to the listed programs. STDC takes seriously its obligation to ensure compliance with Uniform Guidance cost principles and recognizes the need to improve internal controls regarding invoice review and post-payment credit reconciliation. The Finance Department is taking immediate steps to make necessary reallocations to correct the grant charges and to implement control procedures that prevent future errors of this nature. Corrective Action Plan Finding Number: 2023-05 Planned Completion Date: July 31, 2025 Responsible Official: Director of Finance Corrective Actions to Be Implemented: 1. Immediate Reallocation of Sales Tax Credit The Finance Department will correct accounting entries to reallocate the $51.47 vendor credit back to the same federal grants charged. Journal entries will be completed and documented by July 31, 2025. 2. Invoice Review Protocol All vendor invoices will now be reviewed prior to payment for unallowable costs such as sales tax. Reviewers must initial a compliance checklist confirming allowability. 3. Credit Tracking and Reallocation Procedure Establish a formal mechanism for tracking vendor credits and documenting the reallocation of any prior charges to federal programs. Credits will be logged in STDC’s finance system (AccuFund) to the corresponding grants. 4. Staff Training Finance and grant staff will be trained on Uniform Guidance cost principles with specific attention to tax-exempt status and handling of credits. Training will be held annually and as part of onboarding. 5. Quarterly Reconciliation Review The Finance Department will implement quarterly reconciliation reviews to ensure that any sales tax mistakenly paid is credited back and accurately reallocated.   Policy Insert: Sales Tax Review and Vendor Credit Reallocation Procedure Purpose: To ensure that all costs charged to federal awards are allowable and that any vendor credits (e.g., for sales tax) are correctly applied and documented in accordance with 2 CFR §200.403 and §200.405. Procedure: 1. Invoice Review Prior to Payment Accounting Technicians must review all invoices for unallowable items, including sales tax. Any invoice that includes sales tax must be returned to the program department for correction or payment adjusted accordingly by their vendors. 2. Vendor Credit and Grant Reallocation Upon receipt of a credit from a vendor, the credit must be reviewed for its original allocation(s) to federal grants. The credit amount must be allocated proportionally back to each grant that was charged. A reallocation journal entry must be documented and approved by the Finance Director. 3. Documentation and Recordkeeping Copies of invoices, credits, allocation entries, and internal review checklists must be retained with supporting documentation as required by STDC’s Local Record Retention Schedule. 4. Oversight The Finance Director will review the implementation of this policy on a quarterly for completeness and compliance.

Auditor's Recommendation: The auditor recommends the Organization enhance the design of its control activities and procedures over the allocation percentage forms used throughout the year to ensure the staff know how to apply percentages and are using the correct approved allocation form for the period in the year. Management’s Response: A process was implemented in fiscal year 2024 to address this issued and included the following: • The allocation form was updated and is now clearly labeled with the period and type of expense for which it applies. • The Executive Director communicated the revision of all forms to staff involved in the allocation process, followed by a training session to ensure understanding and proper application of the form. • A monthly review of the process, whereby allocation forms were audited for current updates and application consistency. Due date of completion: August 31, 2024 Responsible Official: Executive Director, Michelle Crain

Plan: Contracts are reviewed and updated annually by the compliance officer. Anticipated Date of Completion: 4/28/2025 Name of Contact Persons: Michael Holmes Management Response: Due to the repeated extensions of certain government grants and contracts, there were delays in securing contract renewals with updated budget allocations. This issue has now been addressed with the completion and submission of revised budgets and grants.

Plan: BCPN confirms that indirect costs are calculated in accordance with government guidelines outlined in 2 CFR Part 200. Anticipated Date of Completion: 4/26/2025 Name of Contact Persons: Ieesha Jones Management Response: Due to adopting to use a calendar year instead of a fiscal year, BCPN's indirect costs for FY24 will be reflected in the financial statements for the period ending June 30, 2024, rather than December 31, 2023. We confirm that the indirect costs are being billed and spent in compliance with the guidelines outlined in the government contract and there is no need for funds to be returned.

The Department will enforce policies and procedures to ensure that the calculated rates are in agreement with the approved indirect cost rate.

California Department of Transportation (Caltrans) has determined that federal award information is not always disseminated to the project managers. Caltrans will review current policies and procedures of each division and revise, if necessary, so that best practices are followed. Caltrans Internal Audits Office will be working with Local Assistance’s single audit report monitoring process and take on the responsibility to monitor for all Caltrans divisions. Estimated Implementation Date: June 2025 Contact: Ben Shelton, Chief – Caltrans Internal Audits Office Division of Risk and Strategic Management

Due to limited staffing resources, the Organization was not able to ensure maintenance of adequate documentation. The Organization has made efforts to ensure that proper documentation is maintained and accessible by necessary staff.

In 2025, the Chief Financial Officer in conjunction with the entire fiscal team is looking into an allocation methodology for OTPS that would be suitable for AEA. Laura Perozo, Chief Financial Officer, is monitoring this process and will make this correction by June 30, 2025.

Item: 2023-003 Assistance Listing Number: 93.940 Programs: HIV Prevention Activities Health Department Based Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Arizona Department of Health Services Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR § 200.405 – Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2024 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.

Item: 2023-002 Assistance Listing Number: 93.914 Programs: HIV Prevention Emergency Relief Project Grants Federal Agency: U.S. Department of Health and Human Services Pass-Through Agency: Maricopa County Compliance Requirement: Allowable Activities and Costs Criteria or Specific Requirement: In accordance with 2 CFR § 200.405 – Allocable Costs - (d) If a cost benefits two or more projects or activities in proportions that can be determined without undue effort or cost, the cost must be allocated to the projects based on the proportional benefit. Condition: Costs charged to the federal program were based on an allocation methodology that was not properly updated for the current period. Name of Contact Person: Rosalie Johnson, Chief Financial Officer Phone Number: (602) 595-8109 Anticipated Completion Date: January 1, 2024 Views of Responsible Officials and Corrective Actions: Management agrees with the finding. The Organization will update allocations timely going forward.

Finding 2023‐001 Material weakness in internal controls over compliance and instances of noncompliance related to allowable costs/cost principles compliance requirements. Corrective Action Plan: We will implement the process of allocating bonuses in proportion to the time and effort charged to the grant unless otherwise agreed upon with the grantors. We will also implement the process of allocating overhead costs such as for the audit and insurance that benefit federal programs and others, based on the proportional benefit received. Anticipated Completion Date: December 31, 2024 Name(s) of the Contact Person(s) Responsible for Corrective Action: Josh Freese, Finance Manager