Corrective Action Plans

Southeastern Arizona Behavioral Health Services, Inc. (SEABHS) became part of the La Frontera family of companies as of 10/01/2019. Effective with fiscal year ended September 30, 2021, SEABHS has filed the required Single Audit report as part of their annual audit cycle. Michael Prudence, EVP/CFO and Connie Prince, Director of Finance, are currently in discussions with the Department of Housing and Urban Development to determine the appropriate approach to filing the audit for the fiscal year ended September 30, 2020 and expects to have a resolution reached by June 2024. SEABHS will continue to file their single audit if the required filing thresholds are met.

FINDING 2022-002 Individuals Responsible for Corrective Action Plan: Kristine Steinmann, Director, Georgia Alliance of Boys & Girls Clubs Corrective Action: Management will continue to closely monitor the situation and implement more stringent internal controls and administrative oversight with respect to subrecipient monitoring. Anticipated Completion Date: December 1, 2023

U.S. Department of Treasury. Program Name: COVID 19: Emergency Rental Assistance Program. Assistance Listing Number: 21.023. Finding: 21.023. Criteria: In accordance with Uniform Guidance 2 CFR 200.516 - Audit Findings, known or likely fraud affecting a Federal Award, as well as known questioned costs that are greater than $25,000 must be reported as audit findings in the schedule of findings and questioned costs. Condition: Although the County has controls in place to ensure compliance with their Emergency Rental Assistance Program's policies and procedures, which include fraud prevention procedures, fraud did occur. During 2022, the County discovered (and reported to the auditors) that eight (8) landlord applicants committed fraudulent activity that included the submission of documents that were modified electronically prior to their submission, stolen identity, misrepresentation and inability to repay funds within a timely manner. Funds were disbursed to these applicants prior to the County becoming aware of the fraud. Cause: Eight (8) landlord applicants committed fraudulent activity. Effects: Eight (8) applicants received funding, although the fraudulent activity was committed by the applicants. Questioned Costs: $144,692. Recommendation: We recommend the County strengthen procedures and/or implement additional procedures to reduce the potential of fraud occuring. Auditee's Reponse: In addition to continuing to follow the County's policies and procedures developed in accordance with Emergency Rental Assistance guidelines established by the U.S. Department of Treasury, the County implemented additional procedures in May 2022 to enhance fraud prevention activities. The updated procedures required HomeFirst Gwinnett, the subrecipient managing the Emergency Rental Assistance Program, to perform additional verification and approval procedures to detect fraudulent applications before they are presented for payment. HomeFirst Gwinnett would no longer accept documentation that had been completely generated electronically as sole proof of property ownership and added another level of file review of property deed records for landlord property owners utilizing the authorized property deed record website. All assistance above $10,000 will require final review/approval by the HomeFirst Gwinnet director or manager. As new applicants input their information into the County's vendor portal, the Treasury Division in the Department of Financial Services would verify the validity of those records and would not allow the registration to complete unless they met the required criteria. Any suspicious activity was reported to management promptly, and for suspected fraudulent applicants, those applicants accounts were locked as a preventative control so that no future transactions could be processed while the account was under investigation. For individual landlords, ACH payment was no longer an option and they were required to physically present present a valid picture ID to receive a check at the Program Office. Additional training on the revised procedures was provided to program staff. While the additional prevention measures noted above did deter fraudulent attempts made on the program, Gwinnett County tracked and reported eight landlord cases of suspected fraud in 2022. The suspected fraud was forwarded to the Gwinnett County Police Department's (GCPD) Financial Crimes Unit. Any funds recovered will be returned to the U.S. Department of the Treasury. Gwinnett County's emergency rental assistance program, Project RESET 2.0 (PR2.0), concluded on Thursday, December 29, 2022.

Finding 2022-002: Late Residual Receipt Payment Auditee?s Response: Shalom II Housing, Inc. (the Organization) is in agreement with the finding and the recommendation. During 2021, the Organization did on review their surplus cash calculation on a regular basis, resulting in a late deposit. Subsequently, the Organization deposited $13,939 to their residual receipts account. Planned Corrective Action Plan: The Organization will deposit $13,939 to their residual receipts account. Name of Responsible Person: Renee St. John, Chief Financial Officer Name of Department Contact: Renee St. John, Chief Financial Officer Current Status: In Progress. Management is working on depositing the necessary funds into their residual receipts account. In addition, management is working on developing a procedure to calculate surplus cash on a monthly basis to ensure surplus cash is properly calculated. This is expected to be completed during fiscal year 2023.

Oak Park Elementary School District 97 06-016-0970-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2022 Corrective Action Plan Finding No.: 2022 - 004 Condition: The District procured $125,877 in goods from a vendor and did not comply with their internal procurement policy. Plan: The Senior Director of Finance will work with the Food Service Coordinator to review vendor contracts and solicit bids from multiple vendors to ensure compliance with the District?s internal procurement policy and federal requirements. Anticipated Date of Completion: 6/30/2023 Name of Contact Person: Patrick King, Senior Director of Finance

CORRECTIVE ACTION PLAN Audit Firm: Winkel Green & Company LLP Audit Period: January 1, 2022 through December 31, 2022 CAP Prepared by: Name: Beth Fetzer-Rice Position: Executive Director Current Findings on the Schedule of Findings, Questioned Costs and Recommendations 1. Finding 2022-001 a. Comments on the Finding and Recommendation. Uniform Guidance stipulates that reimbursements are paid to subrecipients in a timely manner. The Organization did not pay subrecipients in a timely manner for the months of April through December 2022, resulting in $234,254 of untimely reimbursements. b. Action Taken or Planned on the Finding The Organization will meet with subgrantees to establish increased control processes, including outlining documentation requirements, timeframes for reimbursement submission, identifying correct staff contacts for timely communications, and formalizing a timeframe for approving/distributing subrecipient disbursements. The Organization has paid all reimbursements through December 2022 as of August 30, 2023.

Cause Kirkhaven was experiencing significant cash constraints and was not able to make debt payments and escrow payments as they were due. Effect Kirkhaven is out of compliance with the HUD regulatory agreement. Recommendation We recommend that Kirkhaven utilize grant funding if allowable to become up to date in debt principal payments and escrow payments. Management Response Kirkhaven was and continues to be in communication with both HUD and mortgage servicer (Berkadia) with regards to the lack of payment of the October to December mortgage and escrow required payments amounting to $192,947 due to the cash flow challenges. They are aware of the executed CHOW Letter of Intent. Subsequent to year-end, Kirkhaven has made the required interest only payments for October to December and continues to make the monthly interest payments. Kirkhaven also has applied for relief of the required escrow payments, but was subsequently denied. Management will continue to monitor cash flow and if feasible make mortgage principal and escrow payments as able, however, the VAPAP grant proceeds did not include funds for debt payments. Managements position is that since the executed CHOW, intention is to use proceeds to pay of the mortgage balance, that paying the principal earlier versus later is less critical.

Finding 2022-004: Allowable Costs - Significant Deficiency in Internal Control over Allowable Costs/Cost principles Official's Response and Corrective Action Plan: Prior accounting staff was gone by December 2021. New financial staff was hired and in place in the 4th quarter of April 2022. We made changes in the accounting department during the past year to improve the overall functionality. Since we tripled our amount of grants, it was necessary to increase the accounting staff to maintain them, as well as increase overall efficiencies. We now have a staff of 4 accountants, as well as a new CFO with nonprofit/grant experience. The late filling of vacant positions delayed some of our internal processes during their training. We added monthly meetings with internal staff to make sure we have a good communication flow and appropriate documentation for new and existing grants which are monitored monthly Anticipated Completion Date: June 30, 2023

Brookwood School District 167 07-106-1670-02 CORRECTIVE ACTION PLAN FOR CURRENT YEAR AUDIT FINDINGS Year Ending June 30, 2022 Corrective Action Plan Finding No.: 2022-002 Condition: The District's expenditure population was less than amounts claimed by $5,617. The District was unable to identify and support expenditures for this difference. Plan: The District will implement additional review procedures to ensure that expenditure claims submitted for reimbursement agree to supported transactions within the accounting system for allowable costs under the award. Anticipated Date of Completion: June 30, 2023 Name of Contact Person: Mr. Kevin Slattery, C.S.B.O. Business Manager

Management should implement procedures to ensure that deposits are made in a timely manner.

Funding Summary: The district needed to create, update, and/or implement procedures for Inventory & Procurement of Equipment purchased with federal funds. Responsible Individual: Teresa Taylor, Business Manager Corrective Action Plan: The district made every attempt to follow the federal requirements for 2 CFR 200.317-327 related to procurement, 2 CFR 200.3613 (d) related to Inventory tracking, while the actual written procedures were either created or updated as required and implemented. The Superintendent and/or Business Manager review all requisitions to ensure they meet federal compliance. Anticipated Completion Date: January 26th, 2023

Finding 2022-020 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Expenditure Processing for Medical Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end date of the PHE, as MDHHS completes renewals for existing cases. MDHHS could not terminate Medicaid benefits during the PHE, and annual renewals have not been completed since the start of the PHE, resulting in most Medicaid cases not being touched until the 14-month unwind period allotted by the Centers for Medicare and Medicaid Services at the end of the PHE. MDHHS identified and updated its manual process of transferring expenditures from the Medicaid Cluster to the Children?s Health Insurance Program in June 2021; and will continue this manual process, on a quarterly basis, by completing a summary-level adjustment determined by analyzing CHAMPS payment data and Bridges eligibility data until all existing cases have been updated. Anticipated Completion Date July 31, 2024 Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Erin Emerson, MDHHS

Finding 2022-057 Low-Income Home Energy Assistance, ALN 93.568 - Eligibility Determinations Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS will continue to communicate with BSCs and local offices regarding the requirements to obtain adequate verification and maintain sufficient documentation to support State Emergency Relief (SER) processing. MDHHS will also continue to provide direct SER guidance and clarification through the SER mailbox. Beginning in fiscal year 2023, MDHHS implemented quarterly case reads and during April 2023, MDHHS began monthly meetings with BSCs to discuss the results of quarterly SER case reads. In addition, MDHHS will update SER policy to include additional verification sources. Anticipated Completion Date MDHHS will update policy by September 30, 2023. All other corrective action is ongoing. Responsible Individual(s) Nicole Denson-Sogbaka, MDHHS Kent Schulze, MDHHS

Finding 2022-054 Temporary Assistance for Needy Families, ALN 93.558 - Non-Financial Eligibility Documentation Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS?s ESA will continue to emphasize the importance of maintaining eligibility documentation through ongoing staff training and a memorandum sent out to the local offices. ESA leadership will reach out to the managers of the individual specialists regarding the issues identified and provide additional guidance. Anticipated Completion Date Training will be ongoing. ESA will issue the memorandum and address the specific issues with local office management and specialists by August 31, 2023. Responsible Individual(s) Kenton Schulze, MDHHS Lana Karadsheh, MDHHS Brian Sanborn, MDHHS

Finding 2022-049 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Home Help Payment Oversight Management Views MDHHS agrees with the finding. Planned Corrective Action Beginning in April 2022, MDHHS automated the payment methodology for ESV to ensure that payments to individual providers using ESV are based on tasks authorized and completed, and compared to approved authorizations before payment is issued. Also, individual caregiver verifications currently in ESV and Paper Service Verification (PSV) will be replaced with Electronic Visit Verification (EVV), which will help ensure payments are reflective of the services provided. MDHHS will continue to manually review PSVs until EVV is implemented. Anticipated Completion Date December 2024 Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

Finding 2022-048 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Ineligible HHP Payments Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS made improvements to the monthly hospitalization reports to help capture all facility stays for Home Help Clients. MDHHS is now pulling reports by billing date instead of hospitalization dates to capture inpatient stays that are billed late. MDHHS also implemented a new policy on February 1, 2023, that allows payment for Home Help Program (HHP) services on the day an individual is admitted to the hospital. MDHHS changed the HHP payment process to an automated process during April 2022, tying payments to services on the Electronic Service Verification (ESV) prior to payment being made. In addition, MDHHS modified policy to begin recoupment by task instead of by daily rate for services provided on overlapping days. MDHHS provided a recoupment calculator and training for HHP staff to ensure the correct amount is recouped using the revised policy and procedure. Anticipated Completion Date Completed Responsible Individual(s) Elaina Brown-Mingo, MDHHS Michelle Martin, MDHHS

Finding 2022-047 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 - Payments on Behalf of Ineligible Beneficiaries Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS implemented a system solution to identify out of sync records between CHAMPS and Bridges and retrigger updates to CHAMPS. MDHHS is also developing a prior report review process to ensure impacted records that do not get corrected with the CHAMPS retrigger are addressed. Anticipated Completion Date The system solution was implemented as of August 31, 2022. The prior report review process will be implemented by September 30, 2023, and reviews will be ongoing. Responsible Individual(s) Jamy Hengesbach, MDHHS

Finding 2022-019 Medicaid Cluster, ALN 93.775, 93.777, and 93.778 and Children's Health Insurance Program, ALN 93.767 - Beneficiary Eligibility Management Views MDHHS agrees with the finding. Planned Corrective Action MDHHS continues to pursue other data sources for income verification and other system enhancements so that all case data is available to all reviewers. MDHHS conducts mandated training for local office caseworkers. In addition, MDHHS will continue to determine where additional training or enhancements to training are needed to ensure eligibility is accurately determined and documentation is properly maintained and loaded to the electronic case file. Lastly, MDHHS has been working since 2018 to ensure correct eligibility classifications in Bridges at the time of payment and a system change was implemented in April 2021 to correct the issue. All new cases are being correctly routed. MDHHS expects that all existing cases will be updated during the 14-month period following the May 11, 2023 end of the PHE, as allowed by the Centers for Medicare and Medicaid Services. Anticipated Completion Date MDHHS continues to pursue other data sources for income verification and other system enhancements, in addition to determining where training is needed, on an ongoing basis. MDHHS expects to have all existing cases updated by June 2024. Responsible Individual(s) Logan Dreasky, MDHHS Brant Cole, MDHHS Mariah Schaefer, MDHHS

Finding 2022-046 CCDF Cluster, ALN 93.575 and 93.596 - Provider Health and Safety Requirements Management Views MDE and the Department of Licensing and Regulatory Affairs (LARA) agree with the finding. Planned Corrective Action For part a., the Child Care Licensing Bureau (CCLB) within LARA has updated its internal policies to clarify how it manages workflow operations, while ensuring CCLB meets federal compliance requirements. In June 2022, the Child Care Organizations Act was amended and the language in Michigan Compiled Law 722.113h was changed to allow for inspections to be conducted in accordance with the State plan. The State plan specifies the annual licensing inspection requirement, at 45 CFR 98.42(b)(2)(i)(B) for unannounced inspections, must be performed ?not less than annually.? According to guidance from the Federal Office of Child Care Region V, this does not mean that inspections must be performed at exact 12-month intervals; therefore, the lead agency has flexibility to schedule the inspections within each calendar year. CCLB has subsequently completed the annually required renewal and/or interim inspections for the licenses identified in the audit sample. The applicable health and safety requirements were reviewed during the inspections conducted. For part b., CCLB is currently creating a new licensing system that will automate letters being sent to licensed child care providers. The new system will generate and store inspection reports directly in the system instead of creating the report in a separate location and then manually moving it to other locations (network drive, SharePoint). This allows the inspection reports to be maintained digitally and be accessible at a later date, while ensuring proper documentation to support renewal inspections is maintained. For part c., in June 2022, CCLB implemented a new process to save all extension letters mailed in PDF format and stored in the current system to be accessed and available upon request. In addition, CCLB will incorporate refresher trainings regarding documentation and storage of inspection reports at its biannual all-staff trainings. The current process of documentation creation and storage will be phased out after the new licensing system is implemented and processes are no longer manually done by CCLB staff. Anticipated Completion Date a. Completed b. October 1, 2023 c. October 1, 2023 Responsible Individual(s) Emily Laidlaw, LARA Lisa Brewer-Walraven, MDE

Finding 2022-044 CCDF Cluster, ALN 93.575 and 93.596 - Client Eligibility Management Views MDHHS and MDE agree with the finding. Planned Corrective Action MDHHS Public Assistance Operations (PAO), within the ESA, will continue assisting the local office and BSC staff by providing guidance on MDE policies and processes. ESA will inform the local office and BSC staff of policy changes or noted trends during PAO?s Bridges Bits and Bytes communications sessions. ESA?s Payment Accuracy Unit completed case reads in December 2022 and, as a result, ESA and MDE finalized a checklist on May 9, 2023, for use by local office staff to help ensure required documentation that supports eligibility is obtained. Also, MDE launched a Child Development and Care case review SharePoint site on May 1, 2023, to share information with MDE and MDHHS staff, reduce errors and promote integrity efforts for the program. Anticipated Completion Date MDHHS assistance and guidance for local office and BSC staff is ongoing. Responsible Individual(s) Mariah Schaefer, MDHHS Gayle Vail, MDHHS Lisa Brewer-Walraven, MDE

Finding 2022-041 Homeowner Assistance Fund, ALN 21.026 - Eligibility Determinations Management Views MSHDA agrees with the finding. Planned Corrective Action For parts a. and b., MSHDA will implement further training of both Case Managers and Case Manager Assistants to address the cited items. This will include additional training on documentation of the homeowner?s hardship and detailing calculations in the case notes. For part c., MSHDA will provide additional training to staff making sure that all fields on the checklist are answered correctly. The checklist now has a system failsafe that all fields must have an answer prior to allowing the file to be conditionally approved in the online application portal. Anticipated Completion Date Completed Responsible Individual(s) Dawn Hengesbach, MSHDA Glenn Ross, MSHDA Raul Escobedo, MSHDA Krysta Smith, MSHDA

Finding 2022-031 Pandemic EBT Food Benefits, ALN 10.542 - Overpayment of Benefits Management Views MDHHS agrees with the finding. Planned Corrective Action During the school year, the two students in the identified case were enrolled in GSRP and issued benefits on January 28, 2022, based on the school file. These students enrolled in early childhood before the end of the school year, so they were also identified in the childcare group and were subsequently issued duplicate benefits as part of the Summer Pandemic EBT issuance on August 24, 2022. A technical solution is currently being evaluated to identify additional steps that may be implemented that cross references students across eligibility groups to ensure that duplicate payments are not issued. Anticipated Completion Date MDHHS expects to determine additional steps for a technical solution by September 30, 2023. Responsible Individual(s) Kathy Cornell, MDHHS

UNITED STATES DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Lincoln School Senior Apartments respectfully submits the following corrective action plan for the year ended March 31, 2022. Name and Address of Independent Public Accounting Firm: Squires Maddux & Company, PLLC 100 Second Avenue South, Ste 270 Edmonds, Washington 98020 Audit Period: March 31, 2022 Prepared by: Name: Steve Armatage Position: Controller Telephone Number: (206) 441-8866 Extension 105 Email Address: sarmatage@panpacificproperties.com The findings from the March 31, 2022 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. Section A of the schedule, Summary of Audit Results, does not include findings and is not addressed. FINDINGS ? FINANCIAL STATEMENTS AUDIT NONE. FINDINGS ? FEDERAL AWARDS PROGRAMS AUDITS DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2022-001: Section 202, CFDA 14-157 Supportive Housing for the Elderly S3800-030 Statement of Condition ? All of the deposits were made at year end, but due to availability of funds, three of the twelve deposits were made late. FINDINGS ? FEDERAL AWARDS PROGRAMS AUDITS (Continued) DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT FINDING 2022-001: Section 202, CFDA 14-157 Supportive Housing for the Elderly (Continued) S3800-045 Reporting Views of Responsible Officials - Management applied for and received a significant rent increase from HUD that should help improve liquidity so that sufficient funds are available to make the required reserve deposit when due. Property(s) and associated questioned costs this finding applies to: S3800-037 FHA/Contract Number - 127EE034 S3800-038 Questioned Costs - $0 S3800-080 Recommendation - Management has taken steps to improve liquidity so that sufficient funds should be available for monthly deposits. Management should ensure those deposits are made monthly. S3800-140 Completion Date ? June 20, 2022 S3800-150 Response - Management has taken corrective action and concurs with the auditor?s recommendation. If the Department of Housing and Urban Development has questions regarding this plan, please call Steve Armatage at (206) 441-8866 Extension 105. Sincerely yours, ______________________________________________ Steve Armatage, Pan Pacific Properties Inc. Controller

FINDING 2022-002 Federal Awards MANAGEMENT RESPONSE: The Berwick Area School District agrees with the finding. As stated with the first finding The District went through a change in Business Managers and additional guidance was needed. The Business Office continues to enhance year-end closing procedures with the intent of accurately capturing the District?s financial position and activity for the fiscal year end prior to the audit engagement. The district will enhance the procedures with the preparation of the Schedule of Expenditures of Federal Awards to ensure completion in a timely manner. The District will continue to utilize its resources throughout the fiscal year to minimize audit adjustments required. INDIVIDUAL RESPONSIBLE: Superintendent, Business Manager ANTICIPATED COMPLETION DATE: June 30, 2022

Finding: Washington State University did not ensure that returns of Title IV funds were accurate for the Student Financial Assistance programs. Questioned Costs: Assistance Listing # 84.007 84.033 84.038 84.063 84.268 84.379 Amount $2,582 Status: Corrective action complete Corrective Action: The University has improved processes for the return of Title IV funds. The University: ? Included a standard calculation in workbooks to quickly identify whether amounts to be returned for withdrawn students will exceed the amounts disbursed. ? Implemented a quality check to review these exceptions, and to investigate and correct as necessary. The University has returned all questioned costs to the sponsors. Completion Date: May 2023 Agency Contact: Heather Lopez Chief Audit Executive PO Box 641221 Pullman, WA 99164-1221 (509) 335-2001 hlopez@wsu.edu