Corrective Action Plans

Finding 1204926 (2025-001)

Material Weakness 2025

PA

Student Financial Aid Subrecipient Monitoring Internal Control / Segregation of Duties

Finding 2025-001 Condition During our audit, 1 out of 3 employees selected for testing received a bonus payment for achieving first year enrollment goals. The College then determined 2 employees received such bonuses and additional testing confirmed a total of 2 out of 27 employees who were involved...

Finding 2025-001 Condition During our audit, 1 out of 3 employees selected for testing received a bonus payment for achieving first year enrollment goals. The College then determined 2 employees received such bonuses and additional testing confirmed a total of 2 out of 27 employees who were involved in the College's admissions/recruiting, financial aid and registrar offices received bonuses based on their contributions towards enrollment performance. These bonuses were paid from internal College funds and not from Title IV funds. Corrective Action Plan Corrective Action Planned: The college implemented a policy on incentive pay citing the restrictions and banning incentive pay for specific job duties. The policy and a standard form for awarding additional compensation have been reviewed and approved by senior leadership and posted to the college’s human resources website. Name(s) of Contact Person(s) Responsible for Corrective Action: Amanda Stahl, Vice President for Finance and Ann Eckert, Assistant Vice President for Human Resources will be responsible for ensuring adherence to the policy and review of any awarding of additional compensation. Anticipated Completion Date: The policy and forms were approved and completed September 30, 2025.

View Audit 396527

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 1204920 (2025-001)

Material Weakness 2025

Morenci Unified School District No. 18

AZ

School Nutrition Programs Cash Management Eligibility

2025-001 ELIGIBILITY Program: Child Nutrition Cluster CFDA Number: 10.533, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Type of Finding: Noncompliance, significant deficiency in internal control Compl...

2025-001 ELIGIBILITY Program: Child Nutrition Cluster CFDA Number: 10.533, 10.555, 10.559 Federal Agency: U.S. Department of Agriculture Pass-Through Agency: Arizona Department of Education Grantor Number: ADE ED09-0001 Type of Finding: Noncompliance, significant deficiency in internal control Compliance Requirement: E. Eligibility Criteria: Federal regulations require participating districts to determine student eligibility for free, reduced price, and paid meals based on household income and household size thresholds established annually by the U.S. Department of Agriculture. Applications must be reviewed and approved using the current income eligibility guidelines and appropriate calculation methods to ensure correct benefit levels. Condition: During testing of 25 student meal applications, we noted 1 instance where the District incorrectly calculated household income relative to household size when determining eligibility status. In these cases, students were approved for free price meals when the income calculations supported reduced meal status. Cause: The District did not have sufficient review controls in place to ensure that eligibility determinations were recalculated or independently verified prior to approval. Effect: As a result of the errors, certain students received free meal benefits for which they were not eligible. This may have resulted in improper program reimbursement claims and indicates that the District’s controls over eligibility determinations were not operating effectively. Questioned Costs: The projected questioned costs related to these errors are not expected to be material; however, the District may have received reimbursement at the free price rate rather than the reduced rate for affected meals. Corrective Action: The District will review their meal application process and implement a more stringent review to ensure eligibility criteria are met based on household income. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Erika Aguallo, Business Manager

View Audit 396523

Finding 1204917 (2025-001)

Material Weakness 2025

City of Madera

CA

Subrecipient Monitoring HUD Housing Programs Period of Performance

Finding 2025-001 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet cri...

Finding 2025-001 Special Tests and Provision – Internal Control and Compliance over Environmental Reviews (Significant Deficiency) Criteria: Title 24 U.S. Code of Federal Regulations sections 58.1, 58.22, 58.34, 58.35, and 570.604 require projects to have an environmental review unless they meet criteria specified in the regulations that would exempt or exclude them from environmental certification requirements. For projects where the environmental review was not performed, a written documentation that the review was not required must be prepared. Condition and Context: The City could not provide support that there was pre-award or post-award review of grant projects to determine if a project requires an environmental review or is categorically excluded from the environmental review requirements. The City did not have adequate internal controls to ensure compliance with the special test – environmental review requirements. Testing was performed over each requirement for the City. Out of a total population of twelve (12) projects, we selected a sample of four (4) projects to test for environmental reviews. Four (4) out of the four (4) projects tested did not have an exemption report prepared in a timely manner. The sample was not intended to be, and was not, a statistically valid sample. City’s Corrective Action Plan: The City will reinforce its standard operating procedure concerning Environmental Reviews (ER) and will reinsure that environmental reviews are properly completed for every awarded grant project. Corrective Action Plan (Continued) Contact person responsible for corrective action: Michael Lima, Finance Director Anticipated completion date: June 30, 2026

View Audit 396513

Finding 1204912 (2025-002)

Material Weakness 2025

Kildahl Park Pointe Cooperative

MN

Reporting Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperativ...

Recommendation: We recommend that the Cooperative continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Action Taken: The Cooperative will continue to review the auditor prepared adjusting journal entries and financial statements with the intention of understanding and acceptance of responsibility for reporting under generally accepted accounting principles. Planned Completion Date: Not Applicable.

View Audit 396512

Finding 1204911 (2025-001)

Material Weakness 2025

Kildahl Park Pointe Cooperative

MN

Internal Control / Segregation of Duties

Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempts...

Recommendation: We recommend that the Cooperative continue to segregate incompatible duties as best it can within the limits of what the Cooperative considers to be cost beneficial. Action Taken: The Cooperative reviews and makes improvements to its internal controls on an ongoing basis and attempts to maximize the segregation of duties in all areas within the limits of the staff available. Planned Completion Date: Not Applicable.

View Audit 396512

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 1204907 (2025-001)

Material Weakness 2025

Town of Westport, Massachusetts

MA

Subrecipient Monitoring Reporting Significant Deficiency § 200.1

Finding 2025-001 Condition: Expenditures were not reconciled to the general ledger for reporting submitted to the U.S. Department of the Treasury and Bristol County, Massachusetts. Corrective Action Planned: To ensure the accuracy of ARPA reporting, and all Federal Grants, a reconciliation process w...

Finding 2025-001 Condition: Expenditures were not reconciled to the general ledger for reporting submitted to the U.S. Department of the Treasury and Bristol County, Massachusetts. Corrective Action Planned: To ensure the accuracy of ARPA reporting, and all Federal Grants, a reconciliation process will be implemented and followed by all involved. Anticipated Completion Date: April 30, 2026 Contact: Nicole Pearsall, Town Accountant

View Audit 396509

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 1204877 (2025-002)

Material Weakness 2025

Catholic Charities of the Diocese of Albany, INC

NY

Cash Management Material Weakness

The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete tim...

The Administration agrees with this finding. The delays in completion of financial transactions into the software had a negative impact on the vouchering process. The training and monthly review of accounts noted in the response to Finding 2025-001, will ensure the information needed to complete timely vouchers will occur. This new process will enable the fiscal employees responsible for vouchering to complete their functions in a timely manner.

View Audit 396496

Finding 1204868 (2025-001)

Material Weakness 2025

Kedren Community Health Center, Inc.

CA

KEDREN'S PRIMARY CARE CLINICAL MANAGEMENT HAS IMPLEMENTED SEVERAL STEPS TO ENSURE THAT THE PATIENTS ARE BILLED PROPERLY IN ACCORDANCE WITH THE SLIDING FEE SCHEDULE. THESE CHANGES WILL BE IMPLEMENTED AND MONITORED

View Audit 396494

Finding 1204867 (2025-003)

Material Weakness 2025

Ohio Christian University

OH

Eligibility Matching / Level of Effort / Earmarking

Need Analysis Planned Corrective Action: The institution is moving to automated loan packaging by the Power FAIDS financial aid management system, which packages the loan based on grade level and remaining unmet financial need. Therefore, if a student’s remaining need is less than the available subs...

Need Analysis Planned Corrective Action: The institution is moving to automated loan packaging by the Power FAIDS financial aid management system, which packages the loan based on grade level and remaining unmet financial need. Therefore, if a student’s remaining need is less than the available subsidized eligibility, the system will only package up to the remaining need. Furthermore, as a second quality assurance check, a rule has been written in the PowerFAIDS financial aid management system that will flag any student that has been awarded sub over need. Person Responsible for Corrective Action Plan: Justin Pichey, Director of Financial Aid Anticipated Date of Completion: This has already been implemented for fiscal year 2026-2027.

View Audit 396488

Finding 1204866 (2025-002)

Material Weakness 2025

Ohio Christian University

OH

Student Financial Aid Cash Management Significant Deficiency

Credit Balances Held Beyond Payment Period Planned Corrective Action: Ohio Christian University has implemented procedures to ensure that all Title IV credit balances are identified and released to students within 14 days of the credit balance occurring, in compliance with federal regulations. The F...

Credit Balances Held Beyond Payment Period Planned Corrective Action: Ohio Christian University has implemented procedures to ensure that all Title IV credit balances are identified and released to students within 14 days of the credit balance occurring, in compliance with federal regulations. The Financial Aid Office will run weekly credit balance reports following each disbursement to identify any student accounts with a Title IV credit balance. These reports will be reviewed jointly by the Financial Aid and Student Accounts offices to confirm eligibility and authorize timely refunds. As an ongoing quality assurance measure, supervisory review will be conducted monthly to verify compliance with the 14-day requirement, and any exceptions will be documented and addressed immediately. Staff training has been enhanced to reinforce regulatory requirements and internal timelines related to credit balance processing. Person Responsible for Corrective Action Plan: Justin Pichey, Director of Financial Aid & Chelsie Hedrick, Senior Accountant Anticipated Date of Completion: This was implemented starting with the Spring 2026 semester.

View Audit 396488

Finding 1204864 (2025-004)

Material Weakness 2025

Gila Crossing Community School

AZ

Allowable Costs / Cost Principles Procurement, Suspension & Debarment Reporting

Finding Number: 2025‐004 Program Name/Assistance Listing Title: Indian School Equalization Program, Special Education Cluster (IDEA) Assistance Listing Number: 84.425, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The Schoo...

Finding Number: 2025‐004 Program Name/Assistance Listing Title: Indian School Equalization Program, Special Education Cluster (IDEA) Assistance Listing Number: 84.425, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School lacked adequate internal controls over disbursements, journal entries, and payroll. - Efforts to maintain proper supporting documentation for various transactions must improve.Staff training to highlight the importance of following procedures and maintaining supporting documentation for all transactions has already occurred and will be held multiple times in the future. - Two current employees have unusual employment status that makes recalculating their pay difficult; they are part‐time, but on salary.

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Finding 1204861 (2025-003)

Material Weakness 2025

Gila Crossing Community School

AZ

Equipment & Real Property Management

Finding Numbers: 2025‐003, 2024‐003, 2023‐003 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Numbers: 84.425 Contact Person: Holena Lebron, Superintendent An􀆟cipated Completion Date: June 30, 2026 Planned Corrective Action: The School has not been abl...

Finding Numbers: 2025‐003, 2024‐003, 2023‐003 Program Name/Assistance Listing Title: COVID‐19 Education Stabilization Fund Assistance Listing Numbers: 84.425 Contact Person: Holena Lebron, Superintendent An􀆟cipated Completion Date: June 30, 2026 Planned Corrective Action: The School has not been able to devote proper resources and training to ensure capital assets are accurate and up to date. - The staff member assigned to make improvements in this area since the fiscal year 2023‐24 audit is no longer employed by the School. Additional staff and training are needed. - The School will seek to replace needed staff and reassign duties regarding the tracking of capital assets, including the assigning of identification numbers and inventory procedures.

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Finding 1204859 (2025-002)

Material Weakness 2025

Gila Crossing Community School

AZ

Procurement, Suspension & Debarment § 200.320

Finding Numbers: 2025‐002, 2024‐002 Program Name/Assistance Listing Titles: Indian School Equalization; Administrative Cost Grants for Indian Schools, Special Education Cluster (IDEA) Assistance Listing Numbers: 15.042; 15.046, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Complet...

Finding Numbers: 2025‐002, 2024‐002 Program Name/Assistance Listing Titles: Indian School Equalization; Administrative Cost Grants for Indian Schools, Special Education Cluster (IDEA) Assistance Listing Numbers: 15.042; 15.046, 84.027 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School’s internal controls over procurement of goods and services were not adequate. - A change in office staff just before the audit visit made finding documentation related to procurement difficult. Efforts to improve in this area have been made and will continue to be a focus of the administration. Procurement procedures are in place and are being followed, but record keeping remains a challenge. A new hire in this area with training emphasis is needed.

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Finding 1204856 (2025-001)

Material Weakness 2025

Gila Crossing Community School

AZ

Special Tests & Provisions Significant Deficiency

Finding Numbers: 2025‐001, 2024‐001, 2023‐001 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School did not complete character ...

Finding Numbers: 2025‐001, 2024‐001, 2023‐001 Program Name/Assistance Listing Title: Indian School Equalization Assistance Listing Number: 15.042 Contact Person: Holena Lebron, Superintendent Anticipated Completion Date: June 30, 2026 Planned Corrective Action: The School did not complete character reinvestigations timely for all employees. - An internal review identified that employee suitability determinations and five‐year reinvestigations were not consistently tracked. - To address this, the administration will review all personnel files to identify employees who are due or overdue for reinvestigation. Any overdue determinations will be completed immediately. A tracking system will be implemented to monitor the five‐year requirement and ensure reinvestigations are completed on time moving forward. Periodic file reviews will also be conducted to maintain compliance.

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Corrective Action Plans

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