Corrective Action Plans

Finding 1168449 (2025-001)

Material Weakness 2025

CA

Procurement, Suspension & Debarment § 200.320

FINDING 2025-001: PROCUREMENT (50000) Federal Agency: U.S. Department of Education Passthrough Entity: California Department of Education Program Names: Individuals with Disabilities Education Act (IDEA) (AL No. 84.027, 84.173) Response to finding: During the 2025-26 fiscal year, the District implem...

FINDING 2025-001: PROCUREMENT (50000) Federal Agency: U.S. Department of Education Passthrough Entity: California Department of Education Program Names: Individuals with Disabilities Education Act (IDEA) (AL No. 84.027, 84.173) Response to finding: During the 2025-26 fiscal year, the District implemented changes to reclassify certain contracts from federal funding sources to state funding. The District utilized the SELPA Master Contract for applicable vendors to ensure proper contracting and compliance. Federal funds will continue to be used to support Instructional Aides (IAs). These actions were taken to improve alignment with funding requirements and strengthen fiscal compliance. The Assistant Superintendent of Educational Services is responsible for monitoring and implementing federal procurement procedures to ensure compliance. This procedure was implemented beginning the 2025–26 School Year.

View Audit 380234

Finding 1168392 (2025-003)

Material Weakness 2025

The Conservation Innovation Fund

DC

Procurement, Suspension & Debarment § 200.214 § 200.318 § 200.320

CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented a corrective action involving updates to the CIF Procurement Policies & Procedures. This polic...

CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented a corrective action involving updates to the CIF Procurement Policies & Procedures. This policy, which includes a Conflict of Interest section, was updated to reflect a decrease of the micro-purchase threshold from $50,000 to $10,000, clarifies that the SAM.gov check for suspension and debarment will occur prior to contract execution with the contractor, and the SAM.gov check will be documented with the date it was conducted. The updated CIF Procurement Policies & Procedures will be approved by the Board of Directors.

View Audit 380212

Finding 1168391 (2025-002)

Material Weakness 2025

The Conservation Innovation Fund

DC

Subrecipient Monitoring § 200.332

CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented multiple corrective actions to address this finding: 1. CIF created a new template for Subawar...

CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented multiple corrective actions to address this finding: 1. CIF created a new template for Subaward Agreements that includes all elements required under 2 CFR 200.332(b). This template will be used for any future Subaward Agreements into which CIF enters. 2. CIF created an Amendment template for each active Federal award Subaward/Subrecipient Agreement that includes all elements required under 2 CFR 200.332(b), a requirement to submit period financial reports to CIF, and a section on compliance with audit requirements according to 2 CFR 200.332(g) / 2 CFR 200.501. 3. For each Subrecipient of CIF’s grant NR233A750004G045 under ALN #10.937, formerly known as the Partnerships for Climate Smart Commodities grant but now known as the Advancing Markets for Producers (AMP) program, CIF will use that template to execute an Amendment to the Subaward/Subrecipient Agreement following the execution of the Amendment to the Grant Agreement between CIF and the United States Department of Agriculture (USDA). 4. CIF implemented a schedule for reviewing current subrecipients’ FY 25 Audit Reports after they are published in the Federal Audit Clearinghouse in mid-2026, document the impact of any audit findings on the federally funded program, and implement a corrective action plan. 5. CIF made revisions in the FY 26 update to the CIF Subaward Management & Subrecipient Monitoring Policy and Procedures which will apply to any new subawards. The pre-award risk assessment procedures now include dating and ensure that results are documented prior to subaward execution. The monitoring procedures are now explicitly linked to risk assessment results, with greater oversight required for subrecipients without experience managing Federal funds.

View Audit 380212

Finding 1168390 (2025-001)

Material Weakness 2025

The Conservation Innovation Fund

DC

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

CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented a system for documenting time and effort in a manner that complies with Federal requirements w...

CIF grew substantially in FY 24 following execution of the Federal award. This finding reflects the learning phase as CIF came into compliance with the Uniform Guidance. Beginning in FY 26, CIF implemented a system for documenting time and effort in a manner that complies with Federal requirements which involves timesheets that record actual time spent on a funding source and are accompanied by supervisory approvals. This system has been formally documented in the FY 26 update to the CIF Financial Policy and includes annual training for staff responsible for managing payroll allocations and Federal reporting. Charges to Federal awards for salaries and wages are now based on records that accurately reflect the work performed. The records are supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. The records support the distribution of the employee's salary or wages among specific activities or cost objectives if the employee works on more than one Federal award; a Federal award and non-Federal award; an indirect cost activity and a direct cost activity; two or more indirect activities allocated using different allocation bases; or an unallowable activity and a direct or indirect cost activity.

View Audit 380212

Finding 1168377 (2025-002)

Material Weakness 2025

Peter & Paul Community Services Inc.

MO

Reporting Material Weakness

FINDING: FINANCIAL REPORTING – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Finding Type: Material Weakness in Compliance and Internal Control over Compliance Finding No. 2025-002 Recommendation: Management should implement procedures to ensure an accurate schedule of expenditures of federal awards wi...

FINDING: FINANCIAL REPORTING – SCHEDULE OF EXPENDITURES OF FEDERAL AWARDS Finding Type: Material Weakness in Compliance and Internal Control over Compliance Finding No. 2025-002 Recommendation: Management should implement procedures to ensure an accurate schedule of expenditures of federal awards with a corresponding reconciliation to the accrual basis trial balance. It is recommended that management establish and enforce review and approval procedures related to the schedule of expenditures of federal awards and the accrual basis trial balance. Responsible Official: Anthony D’Agostino, CEO Corrective Action Plan: The Organization acknowledges the importance regarding the accuracy of the schedule of expenditures of federal awards and corresponding reconciliation to the accrual basis trial balance. The Organization is taking steps to ensure the accuracy and completeness of the schedule of expenditures of federal awards. The Organization will also consider the employment of additional personnel with suitable knowledge, skills, and experience to contribute to the functions of the finance department. Planned completion date for corrective action plan: Fiscal year 2026

View Audit 380191

Finding 1168371 (2025-007)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Cash Management Allowable Costs / Cost Principles Significant Deficiency § 200.302

Significant Deficiency Item 2025-007 - Cash Management - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we...

Significant Deficiency Item 2025-007 - Cash Management - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that there is no evidence of review and approval of drawdowns from the Health Center Program Cluster and the supporting records. Recommendation: We recommend that LBUCC implement a policy that requires all drawdowns and supporting documents to be reviewed and that such review and approval be documented. Action Taken: LBUCC revised the drawdown policy which now includes a review and approval from the CFO and the process is documented. Effectivity Date: Implemented 12/3/2025.

View Audit 380161

Finding 1168368 (2025-006)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Special Tests & Provisions Subrecipient Monitoring HUD Housing Programs § 200.303

Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During ...

Significant Deficiency Item 2025-006 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC conducted quarterly internal audit reviews of fifty (50) samples self-pay patients to review for sliding fee discount determination. However, we noted that the findings or exceptions identified in the quarterly internal audit review remained uncorrected. Recommendation: We recommend that LBUCC establish a process for communicating, investigating and correcting all internal audit findings or exceptions on a timely manner. Additionally, we recommend that management identify the potential cause of such findings or exceptions and that necessary corrective actions be taken to address such cause. For example, LBUCC may conduct periodic training of all employees involved in the patient intake and screening process. Action Taken: The internal audit process has been redesigned and expanded to include weekly reviews and all exceptions/errors will be corrected and the cause determined. Additional training will be provided with the expectation that the exceptions/errors will reduce going forward. Effectivity Date: This will be fully implemented by 1/31/2026

View Audit 380161

Finding 1168365 (2025-005)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Allowable Costs / Cost Principles Material Weakness Reporting § 200.430

Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 Dur...

Material Weakness Item 2025-005 -Activities Allowed and Una/lowed Costs - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 During our audit, we noted that LBUCC charged salaries to the Section 330 grant based on pre-determined allocations or budget rather than actual hours worked. LBUCC utilized timesheets that reflect the allocations as its time and effort documentation. Recommendation: We recommend that LBUCC implement a time and effort reporting system that tracks actual hours worked on each program or grant. We recommend that they require supervisors to review and approve the actual time spent on grant activities and that such review and approval be documented. Action Taken: LBUCC will implement a time and effort reporting system to include a semi-annual certification for all employees funded by the HRSA 330 grant and a time card reporting system for those funded by multiple grants. Effectivity Date: Time and effort reporting will be implemented in January 2026 and fully in place by 1/31/2026

View Audit 380161

Finding 1168362 (2025-004)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Reporting § 200.327

Significant Deficiency Item 2025-004 - Reporting - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 LBUCC did not maintain doc...

Significant Deficiency Item 2025-004 - Reporting - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 HBLCS50772-01-00 and 6 HBHCS46163-03-01 LBUCC did not maintain documentation evidencing management's review of the Federal Financial Report (SF-425) prior to submission. Although the reports were submitted timely, there were no indication of formal review procedures to validate the accuracy, completeness, or consistency of reported financial data with the accounting records. Recommendation: We recommend that LBUCC establish and implement a formal review process over the Federal Financial Report (SF-425); we also recommend that evidence of the review be documented and approval be kept on file. Action Taken: Process in place where Director of Accounting will prepare the Federal Financial Report (SF-425) and the Chief Financial Officer will review and document approval which will be kept on file. Effectivity Date: Process was implemented 12/1/2025

View Audit 380161

Finding 1168359 (2025-003)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Allowable Costs / Cost Principles Cash Management Material Weakness § 200.309 § 200.77

Material Weakness Item 2025-003 - Period of Performance - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8/-ICS46163-03-01 During our audit,...

Material Weakness Item 2025-003 - Period of Performance - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8/-ICS46163-03-01 During our audit, we noted that LBUCC drew down $190,688 of federal grant funds under the Section 330 program for the budget period beginning June 1, 2024 to reimburse salary expenses incurred in May 2024. Recommendation: We recommend that LBUCC implement procedures to ensure that all drawdowns are supported by expenses incurred strictly within the grant's approved period of performance and train staff on grant compliance requirements. Action Taken: A change in the process to draw down funds has been implemented to determine that the funds were incurred in the proper funding period rather than the period it was paid. Effectivity Date: Process change was implemented 12/1/2025.

View Audit 380161

Finding 1168356 (2025-002)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Special Tests & Provisions Cash Management Eligibility

Material Weakness Item 2025-002 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our a...

Material Weakness Item 2025-002 - Special Tests and Provisions - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 H80CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our audit, we noted that LBUCC did not properly determine the sliding fee discount provided to certain eligible patients based on information provided during the patient registration process. Additionally, we could not ascertain if the sliding fee discount provided to certain eligible patients were correct as LBUCC did not maintain documentation of the proof of income of those eligible patients. Recommendation: We recommend that LBUCC conduct training of all of its personnel who are involved in determining and applying the sliding fee scale of patients. We also recommend LBUCC to maintain complete and auditable documentation supporting each patient's eligibility for sliding fee discount. Action Taken: Eligibility was provided additional training which included training on a tool to assist them in determining the proper sliding fee discount. Effectivity Date: Training was held on October 28, 2025, and the tool to assist them was reviewed and provided at that time and implemented immediately thereafter.

View Audit 380161

Finding 1168353 (2025-001)

Material Weakness 2025

Los Barrios Unidos Community Clinic, Inc.

TX

Procurement, Suspension & Debarment Subrecipient Monitoring

Material Weakness Item 2025-001 - Procurement, Suspension and Debarment - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 Dur...

Material Weakness Item 2025-001 - Procurement, Suspension and Debarment - U.S. Department of Health and Human Services, Health Center Program Cluster (Assistance Listing Number 93.224/93.527) Notice of Award Number 6 HB0CS00505-23-04, 6 H2ECS45602-02-04, 1 H8LCS50772-01-00 and 6 H8HCS46163-03-01 During our audit, we noted that there is no evidence that any exclusion search was conducted in 2025 for all sample employees tested. Recommendation: We recommend that LBUCC develop and implement a formal exclusion search policy for employees whose salaries are charged to HHS grants to ensure compliance with federal and state regulations. The policy should include documentation procedures and procedures for investigating and resolving any exceptions found during the search. Action Taken: LBU has subscribed to the software platform Verify Comply which will allow us to upload a list of all employees and vendors in bulk for exclusion monitoring in OIG, SAM and other federal and state exclusion lists. Ongoing monitoring will occur to include all new hires and new vendors. A report will be available to support and validate monitoring. Effectivity Date: Software implementation and training is scheduled for 1/7/2026 with the expectation that all vendors and employees will be monitored by 1/30/2026.

View Audit 380161

Finding 1168350 (2025-001)

Material Weakness 2025

Riverside Episcopal Housing Development Fund Company, Inc.

NY

Special Tests & Provisions HUD Housing Programs

Name of auditee: Riverside Episcopal Housing Development Fund Company, Inc. TIN: 014-EH261 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: June 30, 2025 CAP prepared by: James Juliano CFO/Vice President Episcopal Community Housing, Inc. (716) 929-5817 Current Findings on the Sche...

Name of auditee: Riverside Episcopal Housing Development Fund Company, Inc. TIN: 014-EH261 Name of Audit Firm: EFPR Group, CPAs, PLLC Period covered by audit: June 30, 2025 CAP prepared by: James Juliano CFO/Vice President Episcopal Community Housing, Inc. (716) 929-5817 Current Findings on the Schedule of Findings and Questioned Costs and Recommendations 1) Finding 2025-001 (a) Comments on the finding and recommendation: Management agrees with the finding. Management also agrees with the recommendation, please see below for action taken. (b) Action taken: Management informed us that the amount will be deposited as soon as cash flow and operational circumstances permit.

View Audit 380158

Finding 1168335 (2025-001)

Material Weakness 2025

Bishop (csi) Non-Profit Housing Corporation

MI

HUD Housing Programs Procurement, Suspension & Debarment Subrecipient Monitoring

Name of auditee: Bishop (CSI) Non-Profit Housing Corporation HUD auditee identification number: 044-11134 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Anne Sackrison Position: Chief Executive Officer Telephone number: 5...

Name of auditee: Bishop (CSI) Non-Profit Housing Corporation HUD auditee identification number: 044-11134 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended June 30, 2025 CAP prepared by Name: Anne Sackrison Position: Chief Executive Officer Telephone number: 586-753-9052 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding #2025-001: Effective May 1, 2025, the required monthly deposit to the reserve for replacements increased from $12,539 to $63,106 based on the capital needs assessment and replacement reserve analysis. The Corporation did not increase the monthly deposits and as of June 30, 2025, the reserve for replacements account is underfunded by $99,135. Comments on the Finding and Each Recommendation: Management should transfer $99,135 from the operating account in order to bring the reserve for replacements account current. Action(s) taken or planned on the finding: Agreed. On July 1, 2025, management transferred $99,135 to the reserve for replacements account.

View Audit 380148

Finding 1168334 (2025-002)

Material Weakness 2025

Phoenix Houses of Texas, Inc.

TX

Reporting Subrecipient Monitoring Cash Management

Finding #2025-002 – Significant Deficiency and Other Noncompliance – Reporting. Applicable federal program: U. S. Department of Health and Human Services, Assistance Listing #93.959, Passed through Texas Health and Human Services Commission, All contracts, Contract years: 09/01/23 – 08/31/24 and 09/...

Finding #2025-002 – Significant Deficiency and Other Noncompliance – Reporting. Applicable federal program: U. S. Department of Health and Human Services, Assistance Listing #93.959, Passed through Texas Health and Human Services Commission, All contracts, Contract years: 09/01/23 – 08/31/24 and 09/01/24 – 08/31/25. Condition and context: In our testing of a sample of monthly billings and quarterly reports from throughout the fiscal year, we noted that reports were not being submitted within the required timelines for several reporting periods. Management communicated their delays to Texas Health and Human Services Commission (THHS), and their plan to rectify the delays. Phoenix Houses of Texas were able to file all delayed quarterly reports and monthly billings prior to June 30, 2025. THHS has approved all the delayed monthly billings and quarterly reports. Recommendation: Re-emphasize internal controls over timely grant billing and reporting to comply with grant contracts. Planned corrective action: All outstanding billings were subsequently submitted and billings are now current and submitted in accordance with required timelines. Corrective actions implemented include updates to Finance Department policies and procedures to formalize month-end closing and billing timelines and to strengthen oversight and monitoring controls. These changes ensure that billing and reporting are performed on a timely and ongoing basis. Responsible officer: Drew Dutton, CEO and Anunoy Mou, Finance Director. Estimated completion date: Completed September 2025.

View Audit 380132

Finding 1168333 (2025-002)

Material Weakness 2025

Independent School District 701

MN

Internal Control / Segregation of Duties

Inadequate Segregation of Duties Actions Planned - The school district has implemented a process for federal programs by distributing duties, and adding additional oversight. Program managers are assigned to monitor and give oversight approval for federal fund expenses and budgets. Program managers ...

Inadequate Segregation of Duties Actions Planned - The school district has implemented a process for federal programs by distributing duties, and adding additional oversight. Program managers are assigned to monitor and give oversight approval for federal fund expenses and budgets. Program managers sign off on all receipts and disbursements. Monthly reports given to program managers to assist in the oversight. The Special Education Director acts as a program manager for special ed funds, a Principal acts as a program manager for Title funds, and the Superintendent acts as program manager for all other federal funds. Request for reimbursement and receipting is completed by the Administrative Assistant with oversight by the Business Manager and Superintendent. The key action to eliminate inadequate segregation of duties is developing strong controls over the review and approval of adjusting journal entires. This involves detailed review by the program manager and the Superintendent. Adjusting journal entries are discussed and signed off on each month to timely detect misstatements. Official Responsible - Business Manager and Superintendent of Schools Planned Completion Date - December 31, 2025 Disagreement with Finding - None - ISD #701 - Hibbing concurs with the finding. Plan to monitor - The District is aware of the situation and will monitor, as it deems appropriate. Monitoring will include educating program managers to provide additional oversight fo the interim and year end reportin. This finding will like be ongoing due to limited resources.

View Audit 380131

Finding 1168327 (2025-007)

Material Weakness 2025

Independent School District 701

MN

Allowable Costs / Cost Principles

Inadequate documentation over time and effort Actions Planned - The District has met with the administrative team and expressed the necessity to follow all documentation requirements. Administrative duties changed during the fiscal year and the position overseeing the federal program was unaware of ...

Inadequate documentation over time and effort Actions Planned - The District has met with the administrative team and expressed the necessity to follow all documentation requirements. Administrative duties changed during the fiscal year and the position overseeing the federal program was unaware of the requirement to document the time spent between state and federal activity. Official Responsible - Business Manager and Superintendent of Schools Planned Completion Date - December 31st, 2025 Disagreement with Finding - None - ISD #701-Hibbing concurs with the findng. Plan to Monitor - Further training and updates will be shared with the adminsitrative team as well as paryoll personel to ensure approriate documentaiton is provided.

View Audit 380131

Finding 1168323 (2025-001)

Material Weakness 2025

Navarro College District

TX

Internal Control / Segregation of Duties Special Tests & Provisions Student Financial Aid

Corrective Action Plan 1. Implement Automated Notifications (New and Long-Term Solutions) The institution will establish a two-phase approach to ensure timely and compliant Title IV disbursement notifications. New Process: A weekly report will be generated for Title IV loan disbursements with the co...

Corrective Action Plan 1. Implement Automated Notifications (New and Long-Term Solutions) The institution will establish a two-phase approach to ensure timely and compliant Title IV disbursement notifications. New Process: A weekly report will be generated for Title IV loan disbursements with the corresponding notifications sent to students. Financial aid staff will review the report to confirm that each required notification was issued within the regulatory timeframe. Any missing notifications will be immediately sent and documented. This interim process will remain in effect until full automation is implemented. Long-Term Automated Solution: The student information system will be configured to automatically generate and send Title IV disbursement notifications to students. Each notification will be sent no earlier than 30 days before, and no later than 30 days after, the crediting of Title IV loan funds to the student’s ledger account, as required by 34 CFR §668.165(a)(2). The system will also store a timestamped record of each notification in the student’s electronic file for audit and compliance verification. 2. Develop Written Procedures A formal institutional policy and procedural guide will be developed to define the timing, content, and method of Title IV disbursement notifications. This documentation will explicitly address regulatory requirements under 34 CFR §668.165(a) and outline staff responsibilities for monitoring and documentation. 3. Staff Training Financial Aid staff will receive training on the new automated notification process, including policy updates, system functionality, and documentation requirements. Completion of training will be tracked to ensure all relevant personnel are fully informed and able to implement the new procedures consistently. 4. Periodic Compliance Reviews Quarterly internal audits will be conducted to confirm that required notifications are being issued as scheduled and properly documented in each student’s record. Any discrepancies identified will result in immediate corrective measures and additional staff coaching as needed. Responsible Party Director of Financial Aid Timeline for Completion - New System Implementation: Immediate - Long-Term Solution: Work with software provider and IT for options to implement this process - Policy Documentation & Staff Training: Within 90 days - First Compliance Review: Within 90 days

View Audit 380118

Finding 1168316 (2025-001)

Material Weakness 2025

Episcopal Community Services of San Francisco

CA

Subrecipient Monitoring Eligibility Reporting

Significant Deficiency Finding: 2025-001 Certification of Tenants Criteria and Condition The grant agreement requires ECS to (1) maintain complete tenant files in the San Francisco HMIS ONE System with hard-copy eligibility documents; (2) apply changes to tenant rent portions based on City and Count...

Significant Deficiency Finding: 2025-001 Certification of Tenants Criteria and Condition The grant agreement requires ECS to (1) maintain complete tenant files in the San Francisco HMIS ONE System with hard-copy eligibility documents; (2) apply changes to tenant rent portions based on City and County of San Francisco Department of Homelessness and Supporting Housing (HSH) notifications; and (3) perform required initial, annual, and interim recertifications under the Housing First program model. We noted instances where tenant files did not contain complete eligibility documentation and/or where required recertifications or updates to tenant rent portions were not performed or documented in accordance with the grant requirements. Context ECS provides rental assistance under the program described in Appendix A-2, which requires full documentation of tenant eligibility and strict adherence to rent-portion updates and recertification timelines. Of our 31 selections, we noted 6 instances where homelessness verification was missing, 6 instances where the rent portions based on HSH notifications were incorrect and 10 instances where the recertifications were not completed for the grant period under audit. Questioned Cost There are no questioned costs regarding this finding. Cause The exceptions result from inconsistent file maintenance and monitoring procedures, including insufficient review over documentation completeness and timeliness of recertifications. The issues were centered on tenant files managed by a third-party service provider. Effect Incomplete tenant files and untimely recertifications increase the risk of noncompliance with grant requirements and may result in incorrect tenant rent portions being charged or insufficient support for program eligibility. Repeat Finding This finding is not a repeat finding. Recommendation We recommend that ECS enhance its documentation and monitoring processes with its third-party property managers by implementing a standardized tenant file checklist, conducting periodic supervisory reviews to confirm that all eligibility documents and recertifications are completed and retained, and establishing a tracking process to ensure tenant rent portions are updated promptly based on HSH notifications. View of responsible officials Management agrees with the recommendation. Corrective Action Planned ECS has taken and will continue to take the following steps in the 2026 fiscal year to correct this deficiency. Step 1: Resources ECS began addressing Certificate of Tenancy errors with the hiring an Associate Chief of Real Estate and Asset Management in August, a Director of Property Management in October and a Property Management Compliance Manager in September. Step 2: Best Practices ECS has hired a consulting firm to correct Certificate of Tenancy errors at its one of its sites and will apply the best practices learned to all the affiliate and master lease sites. In addition, ECS has put together policies and procedures and has offered training to both ECS and subcontracted staff on Certificate of Tenancy. ECS will continue to offer compliance training as it takes over property management across all Master Lease sites and the affiliate portfolio. Step 3: Take control of property management Replace outsourced property management with ECS staff to better control Tenant documentation at all master lease and affiliate sites. Step 4: Quality and Compliance ECS has started in a few sites to review Tenant documentation and will expand this review to all sites across its entire portfolio. Implementation Date ECS will fully correct Certificate of Tenancy errors by June 30, 2026. Responsible Personnel The Chief Operating Officer and the Associate Chief of Real Estate and Asset Management.

View Audit 380063

Finding 1168306 (2025-001)

Material Weakness 2025

Lake County School District #7

OR

Cash Management Reporting School Nutrition Programs § 200.302 § 200.328

2025-001 Reporting US Department of Education – AL #s10.553, 10.555, 10.559 and 10.582 Child Nutrition Cluster Condition: The District submitted monthly child nutrition reimbursement claims that contained inaccurate meal counts for multiple months during the fiscal year. Specifically, the District o...

2025-001 Reporting US Department of Education – AL #s10.553, 10.555, 10.559 and 10.582 Child Nutrition Cluster Condition: The District submitted monthly child nutrition reimbursement claims that contained inaccurate meal counts for multiple months during the fiscal year. Specifically, the District overstated reimbursable meal counts due to errors in including non-reimbursable meals served. Additionally, the claims were not subject to an independent review prior to submission to ensure accuracy and completeness. Name of Contact Person: Ann Berman, Business Manager Plan of Action: The District will revisit the internal control processes surrounding the grant reporting and reimbursement process to ensure meal count information submitted is within program requirements of Child Nutrition Cluster programs. In the event there are questions surrounding meal count and other information subject to reporting, the District will continue to rely on timely guidance from external governmental accounting consultants, the Oregon Department of Revenue, and the Oregon Department of Education.

View Audit 380053

Finding 1168300 (2025-001)

Material Weakness 2025

Interfaith Ministries for Greater Houston

TX

Procurement, Suspension & Debarment HUD Housing Programs Significant Deficiency

Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Housing and Urban Development, Assistance Listing #14.218, Passed through Harris County, Community Development Block Grants/Entitlement Grants – CDBG – Entitlement/Special Purpose Gra...

Finding #2025-001 – Significant Deficiency and Other Noncompliance. Applicable federal programs: U. S. Department of Housing and Urban Development, Assistance Listing #14.218, Passed through Harris County, Community Development Block Grants/Entitlement Grants – CDBG – Entitlement/Special Purpose Grants Cluster, Contract #’s: C2023-006G, C2024-006H, and C2020-050G, Contract years: 10/23-09/24, 10/24-09/25, and 03/24-09/24. Assistance Listing #14.218, Passed through City of Houston, Community Development Block Grants/Entitlement Grants – CDBG – Entitlement/Special Purpose Grants Cluster, Contract #: 4600016648, Contract year: 05/25-06/25. U. S. Department of Health and Human Services, Assistance Listing #93.576, Passed through Episcopal Migration Ministries, Refugee and Entrant Assistance Discretionary Grants, Contract #’s: 90RP0117‐01-00, 90RP0117-02-00, 90RP0117-03-00, and 90RP0117-04-00, Contract years: 10/23-09/24 and 10/24-09/25. Applicable state program: Texas Department of Agriculture, Home-Delivered Meal Grant Program, Contract #’s: HDM2024029-070-071 and HDM2025052-053, Contract years: 02/24-01/25 and 02/25-01/26. Condition and context: During our testing of 24 expenditures requiring procurement, we identified one instance of expenditures in Home-Delivered Meal Grant Program greater than the simplified acquisition threshold of $10,000 where simplified acquisition procedures in accordance with Interfaith Ministries’ policy were not followed. Recommendation: Emphasize adherence to established policies and procedures to ensure procurement is performed according to the procurement policy, and that proper procurement documentation is maintained. Planned corrective action: Our organization implemented a robust procurement policy effective July 1, 2018 that complies with the guidelines of 2 CFR 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, Subpart D – Post Federal Award Requirements, Procurement Standards 200.317-326 and the Texas Grants Management Standards. Under the established procurement method for small purchases between $10,000 and $100,000, Interfaith Ministries is required to obtain price or rate quotations from a minimum of three sources. The management team will re-emphasize the established policy and procedures for procurement with Interfaith Ministries staff. Responsible officer: Sheroo Mukhtiar, Chief Executive Officer and Stephanie Alvarez, Chief Financial Officer. Estimated completion date: December 1, 2025

View Audit 380050

Finding 1168299 (2025-002)

Material Weakness 2025

Interfaith Ministries for Greater Houston

TX

Allowable Costs / Cost Principles HUD Housing Programs Significant Deficiency

Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Assistance Listing #93.566, Passed through Texas Office for Refugees, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Contra...

Finding #2025-002 – Significant Deficiency and Other Noncompliance. Applicable federal program: U. S. Department of Health and Human Services, Assistance Listing #93.566, Passed through Texas Office for Refugees, Refugee and Entrant Assistance State/Replacement Designee Administered Programs, Contract #’s: FFY2024-27947V-CMA and FFY2025-27947V-CMA, Contract years: 10/23-09/24 and 10/24-09/25. Condition and context: Interfaith Ministries’ policies and procedures for verifying the completeness of documentation includes ensuring the acknowledgement of receipt of a debit card by the client is maintained in the client file. In a sample of 33 client files tested for refugee cash assistance program, we noted one client who received a debit card in February 2025 did not have the acknowledgement receipt in the client file. Recommendation: Emphasize adherence to established policies and procedures to ensure acknowledgement of receipt of a debit card by the client is maintained in the client file. Planned corrective action: With the implementation of the Refugee Cash Assistance (RCA) Debit Card program by TXOR, our organization established the policy that client case files must contain a copy of the Debit Card Activation Page with the client’s signature and the date the card was delivered to the client as required by TXOR. Our program team will re-emphasize these policies through additional staff training to ensure compliance with the established policy and procedures for the RCA Debit Card program. Additionally, our compliance department will establish procedures to perform periodic reviews to ensure that the client files are complete. Responsible officer: Ali Al Sudani, Chief Program Officer and Terry Merriett, VP of Quality Assurance & Compliance. Estimated completion date: December 1, 2025.

View Audit 380050

Finding 1168294 (2025-001)

Material Weakness 2025

Beacon Interfaith Housing Collaborative

MN

Procurement, Suspension & Debarment

Responsible party for corrective action: Chris LaTondresse, President and CEO Corrective action: Beacon Interfaith Housing Collaborative agrees with the finding. Management is currently updating its policies to require retaining documentation from checks that verify whether individuals or entities s...

Responsible party for corrective action: Chris LaTondresse, President and CEO Corrective action: Beacon Interfaith Housing Collaborative agrees with the finding. Management is currently updating its policies to require retaining documentation from checks that verify whether individuals or entities serving as vendors are debarred or suspended. Proposed completion date: Management has begun the corrective action and is expected to have new policies in place by June 30, 2026.

View Audit 380040

Finding 1168293 (2025-004)

Material Weakness 2025

Catholic Charities of Los Angeles, Inc.

CA

Subrecipient Monitoring Reporting Significant Deficiency

This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.

View Audit 380037

Finding 1168284 (2025-003)

Material Weakness 2025

Catholic Charities of Los Angeles, Inc.

CA

Subrecipient Monitoring Reporting Significant Deficiency

This was the result of being understaffed during this period. Priorities were determined and unfortunately these reports were delayed. Sufficient staff have been hired since this occurred and I don't see this as a problem going forward.

View Audit 380037

Corrective Action Plans

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