Corrective Action Plans

Finding 1172613 (2025-001)

Material Weakness 2025

CA

Subrecipient Monitoring

Finding 2025-001: Subrecipient Monitoring Information on the Federal Programs: Department of Treasury, Assistance Listing Number 21.023 Criteria: Compliance requires a debarment search to be completed for subrecipients and to verify with the subrecipients if they are expected to obtain a financial a...

Finding 2025-001: Subrecipient Monitoring Information on the Federal Programs: Department of Treasury, Assistance Listing Number 21.023 Criteria: Compliance requires a debarment search to be completed for subrecipients and to verify with the subrecipients if they are expected to obtain a financial audit. Condition: Centro Legal de la Raza, Inc. has indicated a debarment search was completed for each subrecipient awarded during the current period, however there was no retention of the search or a review of the search results. In addition, staff did not verify with subrecipients if they were expected to obtain a financial and/or compliance audit. Cause: Centro Legal de la Raza, Inc. staff were not aware that retention of the search or the review of its results was required or that as part of their compliance they should be verifying the subrecipient’s expectation for a financial and/or compliance audit. Context: Without retention, there is no support for the completion of the search or the review of its results. Failure to be aware and following through to obtain (if expected) financial or compliance audits does not allow the Organization to ensure their subawards comply with federal rules. Effect: Centro Legal de la Raza, Inc. may have missed completing a search on a subrecipient or missed reviewing a financial or compliance audit of a subrecipient to ensure compliance of the subaward. Questioned Costs: None noted. Identification as a Repeat Finding: n/a Recommendation: We recommend Centro Legal de la Raza, Inc. staff retain the debarment searches and they develop a procedure in which the searches are reviewed before accepting subrecipients. In addition, Centro Legal de la Raza, Inc. staff should inquire and document of subrecipients their expectation of a financial and/or compliance audit and follow through if one is expected to ensure subawards are complying with federal rules. Management Views and Corrective Action Plan: Management agrees with the finding and recommendation. All relevant staff have also undergone training to ensure compliance at all stages of the debarment process. Name and Title of Responsible Official: Brenda Orellana, Grants Director Planned Completion Date: March 31, 2026.

View Audit 385888

Finding 1172612 (2025-001)

Material Weakness 2025

Arbor Vista, Inc.

CA

HUD Housing Programs

Management at Satellite Affordable Housing Associates Property Management (“SAHA PM”) will implement a review process to ensure that all required EIV reports are run timely and maintained in the tenant lease file as required by HUD Handbook 4350.3, Chapter 9, Section 1, 9-5B.

View Audit 385882

Finding 1172611 (2025-001)

Material Weakness 2025

Satellite St. Andrew's Manor, LLC

CA

HUD Housing Programs Significant Deficiency Internal Control / Segregation of Duties

Finding 2025-001: Reportable finding considered a significant deficiency – Activities Allowed and Unallowed Management at Satellite Affordable Housing Associates Property Management (“SAHA PM”) is in agreement with the finding and intends to follow the requirements of the HUD Regulatory Agreement in...

Finding 2025-001: Reportable finding considered a significant deficiency – Activities Allowed and Unallowed Management at Satellite Affordable Housing Associates Property Management (“SAHA PM”) is in agreement with the finding and intends to follow the requirements of the HUD Regulatory Agreement in the future. Management has reimbursed the property $28,539, an amount equal to HCD’s net cash flow payment from FY 2024. Management will reimburse the property the $12,600 for FY 2025 and FY 2024 annual monitoring fees paid to HCD. Management will seek to obtain HUD approval on form HUD-9250 for payment of these fees from residual receipts.

View Audit 385881

Finding 1172610 (2025-001)

Material Weakness 2025

Satellite Senior Homes Newark Gardens Ii, Inc.

CA

Allowable Costs / Cost Principles § 200.403

Management at SAHA PM notes its responsibility to establish and maintain effective internal control over financial reporting to provide reasonable assurance that transactions are properly recorded, processed, and summarized to permit the preparation of reliable financial statements in accordance wit...

Management at SAHA PM notes its responsibility to establish and maintain effective internal control over financial reporting to provide reasonable assurance that transactions are properly recorded, processed, and summarized to permit the preparation of reliable financial statements in accordance with generally accepted accounting principles (“GAAP”). We plan to establish a checklist for the property accounting team that includes a comparison of gross rent potential to the HUD approved rent schedule.

View Audit 385880

Finding 1172609 (2025-001)

Material Weakness 2025

Satellite Senior Homes, Inc.

CA

HUD Housing Programs

Management at Satellite Affordable Housing Associates Property Management (“SAHA PM”) will implement a review process to verify billed subsidy amounts against the approved contract rent schedule, train staff on entering the correct approved contract rent amounts in Yardi, and reimburse the Federal p...

Management at Satellite Affordable Housing Associates Property Management (“SAHA PM”) will implement a review process to verify billed subsidy amounts against the approved contract rent schedule, train staff on entering the correct approved contract rent amounts in Yardi, and reimburse the Federal program for identified overcharges.

View Audit 385879

Finding 1172608 (2025-003)

Material Weakness 2025

Neighborhood Properties, Inc.

OH

Allowable Costs / Cost Principles Reporting Significant Deficiency

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should implement a strategy of using time and effort documentation in determining payroll costs charged to grants, including use of backward-looking reconciliations when necessary. Explanation of disagreement with a...

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should implement a strategy of using time and effort documentation in determining payroll costs charged to grants, including use of backward-looking reconciliations when necessary. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management of the Organization is in the process of implementing a policy to track time and effort of all employees based on actual time spent by grant. Some employees work directly with tenants on a HUD funded grant on a regular basis, but all employees may work directly with a tenant on a HUD funded grant or may perform administrative work specifically on a HUD funded grant from time to time. Therefore, all employees will track time spent with tenants or specifically with a grant in the Yardi Tenant Contact system. • Housing Support Staff and Management will document grant allocations as required. • Backoffice employees, such as those working in HR or Accounting, will be allocated to Admin and Support within the HUD funded grant, based on time spent. • Maintenance employees can be allocated to tenants based on units and work orders. • Formal review of payroll and grant allocations, based on time sheets, will take place by March 30th 2026, and on a monthly basis going forward. Potential true-up to take place after each review. Name(s) of the contact person(s) responsible for corrective action: Susan Keshen, Fractional CFO Planned completion date for corrective action plan: March 31, 2026

View Audit 385864

Finding 1172591 (2025-002)

Material Weakness 2025

Neighborhood Properties, Inc.

OH

Procurement, Suspension & Debarment Subrecipient Monitoring Eligibility

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should establish and implement written procedures to verify suspension and debarment status prior to executing vendor contracts. The SAM.gov verification procedure should be documented and retained in the procuremen...

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should establish and implement written procedures to verify suspension and debarment status prior to executing vendor contracts. The SAM.gov verification procedure should be documented and retained in the procurement file. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management of the Organization has developed and implemented a formal suspension and debarment policy. • New vendor report will be reviewed by Compliance Officer and Director of Finance. • Compliance Officer will verify vendor legitimacy based on new vendor report. • New vendor creation is now separated from invoice creation and under different staff members. Vendor creation will be forwarded to the Compliance Officer to check vendor on Sam.gov • New, formal suspension and department policy has been created. Name(s) of the contact person(s) responsible for corrective action: Susan Keshen, Fractional CFO Planned completion date for corrective action plan: February 28, 2026

View Audit 385864

Finding 1172574 (2025-001)

Material Weakness 2025

Neighborhood Properties, Inc.

OH

HUD Housing Programs Subrecipient Monitoring Significant Deficiency

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should strengthen internal controls to ensure timely updates of tenant subsidy amounts based on the contract terms and implement a review process to verify that HAP payments align with the most recent annual contrac...

Continuum of Care Program – Assistance Listing No. 14.267 Recommendation: Management should strengthen internal controls to ensure timely updates of tenant subsidy amounts based on the contract terms and implement a review process to verify that HAP payments align with the most recent annual contract documentation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management of the Organization has established a system of internal control monitoring and review to ensure HAP payments align with the most recent annual contract documentation. Compliance Officer reviews annual reports for all clients every month. Spreadsheet is reviewed for variance and adjustments made as needed. Name(s) of the contact person(s) responsible for corrective action: Susan Keshen, Fractional CFO Planned completion date for corrective action plan: August 31, 2025.

View Audit 385864

Finding 1172557 (2025-002)

Material Weakness 2025

City of Yerington

NV

Subrecipient Monitoring Reporting

The City Agrees with the recommendation and the finance department will implement a formal review and approval process over recognition and recording of certain revenues. This process will include:Accounting staff with received additional training on accounting software accounting program regarding ...

The City Agrees with the recommendation and the finance department will implement a formal review and approval process over recognition and recording of certain revenues. This process will include:Accounting staff with received additional training on accounting software accounting program regarding generated internal billing over non-typical billed revenues;Accounting staff will receive one-on-one training with accounting software training consultants over accounts receivable subsidiary ledger maintenance;Accounting staff with perform monthly review of subsidiary ledger balances.Planned Completion Date:

View Audit 385855

Finding 1172557 (2025-002)

Material Weakness 2025

City of Yerington

NV

Subrecipient Monitoring Reporting

2026-02-28 00:00:00

View Audit 385855

Finding 1172555 (2025-002)

Material Weakness 2025

YWCA Pierce County

WA

Internal Control / Segregation of Duties § 200.303

Monthly/quarterly reimbursement invoices will be prepared by the Finance Coordinator. Before submission, the Finance Director will review the invoices comparing them with general ledger supporting documents and then will initial the organization’s copy of the invoice. The CEO, or other designee will...

Monthly/quarterly reimbursement invoices will be prepared by the Finance Coordinator. Before submission, the Finance Director will review the invoices comparing them with general ledger supporting documents and then will initial the organization’s copy of the invoice. The CEO, or other designee will then review and sign the original invoice being sent to the grantor.

View Audit 385850

Finding 1172554 (2025-005)

Material Weakness 2025

Sheridan County

WY

Procurement, Suspension & Debarment Eligibility § 200.213

2025-005 – Procurement, Suspension and Debarment Corrective Actions – Sheridan County Issue: The Weed & Pest District does not have formal, written policies or procedures governing procurement activities, including required methods of procurement, documentation standards, and approval thresholds. Ad...

2025-005 – Procurement, Suspension and Debarment Corrective Actions – Sheridan County Issue: The Weed & Pest District does not have formal, written policies or procedures governing procurement activities, including required methods of procurement, documentation standards, and approval thresholds. Additionally, the Weed & Pest District lacks documented procedures to verify and document that vendors are not suspended or debarred prior to entering into contracts or making payments using federal funds. Corrective Action: Management agrees with the finding and plans to develop and formally adopt procurement and suspension and debarment policies. Implementation is expected to occur during the next fiscal year. Implementation of Corrective Action: All Weed & Pest federal award grants will be sent to the County Administrative Director for review. Suspension and debarment language, including required lower tier transaction verification requirements shall be added to all Weed & Pest contracts which are funded through Federal Awards as follows: • Suspension and Debarment, Voluntary Exclusion. By signing this Contract, ______________ certifies that it is not suspended, debarred, or voluntarily excluded from Federal financial or non-financial assistance, nor are any of the participants involved in the execution of this Contract suspended, debarred, or voluntarily excluded. Further, _____________ agrees to notify Sheridan County Weed & Pest by certified mail should _____________ or any of its agents or subcontractors working on this project become debarred, suspended or voluntarily excluded during the term of this Contract. Weed & Pest will conduct a search of the System for Award Management (SAM.GOV) to determine if the bidding entity has been suspended or debarred from participating in Federal award contracts. A copy of the SAM.GOV certification will be required from contractors prior to final Weed & Pest award of contract.

View Audit 385845

Finding 1172552 (2025-001)

Material Weakness 2025

Darlington Community School District

WI

Internal Control / Segregation of Duties

Finding #2025-001 – Limited Segregation of Duties (Prior Year Finding #2024-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detecte...

Finding #2025-001 – Limited Segregation of Duties (Prior Year Finding #2024-001) Condition: The available office staff precludes a proper segregation of duties in the control areas reviewed. Effect: Because of the lack of segregation of duties, errors or irregularities could occur and not be detected on a timely basis. Cause: Controls Over Accounts Payable/Disbursements Person processing accounts payable is not always separate from those who print the checks. Controls Over Payroll Person preparing the payroll is not independent of other personnel duties such as custody of the checks and reconciling the bank statements. Criteria: Internal controls should be in place that provide adequate segregation of duties. Recommendation: Procedures should be implemented segregating duties among different employees. Management should continue to maintain a working knowledge of matters relating to the District’s operations. Response: We agree with this finding but due to the size of our District and financial constraints we do not believe it is cost effective to increase the office staff in an attempt to bring about a more effective segregation of duties. The Principal at the High School or Elementary/Middle School approves monthly accounts payable checks and the Department Head or Principal approves payroll timesheets prior to processing payroll. The Principals and Department Heads will continue to monitor transactions of the District. Contact Person: Cale Jackson Anticipated Completion: Not Applicable

View Audit 385843

Finding 1172549 (2025-001)

Material Weakness 2025

Visiting Nurse Services of Iowa

IA

Procurement, Suspension & Debarment § 200.320

Healthy Start Communities – Assistance Listing No. 93.926 Recommendation: We recommend the organization follow its newly established procurement policy related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying m...

Healthy Start Communities – Assistance Listing No. 93.926 Recommendation: We recommend the organization follow its newly established procurement policy related to the maintaining of necessary documentation to support the method of procurement utilized. The Organization may also consider qualifying multiple vendors for particular goods/service and then utilizing an approved vendors list. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The organization put a procurement policy in place effective November 30, 2024. Since then, the policy has been followed and will continue to be as new vendors are brought on. Name(s) of the contact person(s) responsible for corrective action: Danielle Martin, Vice President & Chief Financial Officer Planned completion date for corrective action plan: November 30, 2024

View Audit 385840

Finding 1172548 (2025-001)

Material Weakness 2025

City of Lapeer

MI

Procurement, Suspension & Debarment

2025-001 – Procurement, Suspension, and Debarment Auditor Recommendation: We recommend that the City complete a search on sam.gov and document the results of that search in the vendor file or require the vendor to sign a certification that they are neither suspended nor debarred as part of new contr...

2025-001 – Procurement, Suspension, and Debarment Auditor Recommendation: We recommend that the City complete a search on sam.gov and document the results of that search in the vendor file or require the vendor to sign a certification that they are neither suspended nor debarred as part of new contracts for covered transactions to determine if a particular vendor has any active exclusions from participating in federal award programs during the initial bidding process, as required of the Uniform Guidance, and again on an annual basis for best practice. Corrective Action: The City will create a federal grant checklist and train department directors to ensure that all vendors are screened for suspension and debarment through the appropriate system prior to entering into any contract and on an annual basis thereafter for the duration of the contract. Documentation of each search will be retained to provide evidence of compliance with the Uniform Guidance. Staff responsible for vendor onboarding and contract management will receive training on the annual screening requirement, and a tracking mechanism will be established to ensure ongoing monitoring of vendor eligibility. Responsible Person: Kelly Hanna, Director of Finance Anticipated Completion Date: 03/01/2026

View Audit 385832

Finding 1172547 (2025-004)

Material Weakness 2025

Saguache County Community Council, Inc.

CO

Special Tests & Provisions Material Weakness Internal Control / Segregation of Duties

Corrective action Plan: Due to the termination of activities as mentioned in Note 8 of the financial statements, the Organization is unable to develop and implement a corrective action plan.

View Audit 385826

Finding 1172546 (2025-003)

Material Weakness 2025

Saguache County Community Council, Inc.

CO

Procurement, Suspension & Debarment Allowable Costs / Cost Principles Material Weakness

Corrective action Plan: Due to the termination of activities as mentioned in Note 8 of the financial statements, the Organization is unable to develop and implement a corrective action plan.

View Audit 385826

Finding 1172545 (2025-002)

Material Weakness 2025

Saguache County Community Council, Inc.

CO

Reporting

Corrective action Plan: Due to the termination of activities as mentioned in Note 8 of the financial statements, the Organization is unable to develop and implement a corrective action plan.

View Audit 385826

Finding 1172540 (2025-001)

Material Weakness 2025

Connected Lane County

OR

Reporting Significant Deficiency Internal Control / Segregation of Duties § 200.212 § 200.512

Finding 2025-001: Significant deficiency in internal controls over compliance and immaterial noncompliance Corrective Action Planned: Connected Lane County updated internal control processes, approved by the board on 05.21.25, which significantly reduced year end processing delays and the number of ...

Finding 2025-001: Significant deficiency in internal controls over compliance and immaterial noncompliance Corrective Action Planned: Connected Lane County updated internal control processes, approved by the board on 05.21.25, which significantly reduced year end processing delays and the number of corrections needed to complete the audit. The audit for fiscal year 2025 ending on June 30, 2025 was completed within seven months of the end of the fiscal year. Person(s) Responsible: Jesse Nelson, Executive Director and Mary Bell, Finance Manager Anticipated Completion Date: 09.01.2025

View Audit 385818

Finding 1172539 (2025-002)

Material Weakness 2025

Zepf Center

OH

Allowable Costs / Cost Principles Significant Deficiency Internal Control / Segregation of Duties

Fatherhood Connection (FIRE) – Assistance Listing No. 93.086 Recommendation: The Center should implement controls for review of payment limits prior to distributing funds to program participants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action ...

Fatherhood Connection (FIRE) – Assistance Listing No. 93.086 Recommendation: The Center should implement controls for review of payment limits prior to distributing funds to program participants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is implementing a tool to monitor and track the incentive payments. Name(s) of the contact person(s) responsible for corrective action: David Oppenlander, CFO Planned completion date for corrective action plan: January 31, 2026

View Audit 385809

Finding 1172537 (2025-001)

Material Weakness 2025

Zepf Center

OH

Reporting Significant Deficiency Internal Control / Segregation of Duties

Fatherhood Connection (FIRE) – Assistance Listing No. 93.086 Recommendation: The Center should implement a strategy of using time and effort documentation in determining payroll costs charged to grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. ...

Fatherhood Connection (FIRE) – Assistance Listing No. 93.086 Recommendation: The Center should implement a strategy of using time and effort documentation in determining payroll costs charged to grants. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management is in the process of implementing a policy to track time and effort of salaried employees. Name(s) of the contact person(s) responsible for corrective action: David Oppenlander, CFO Planned completion date for corrective action plan: January 31, 2026

View Audit 385809

Finding 1172535 (2025-003)

Material Weakness 2025

Mill Creek Community School Corporation

IN

Matching / Level of Effort / Earmarking Internal Control / Segregation of Duties Subrecipient Monitoring § 200.303

FINDING 2025-003 Finding Subject: Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Lori Bennett Contact Phone Number and Email Address: 317-539-9200, LBennett@mccsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Correct...

FINDING 2025-003 Finding Subject: Education Stabilization Fund - Earmarking Contact Person Responsible for Corrective Action: Lori Bennett Contact Phone Number and Email Address: 317-539-9200, LBennett@mccsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: While the school corporation no longer has any active funds with the COVID-19 Education Stabilization Fund the school corporation will ensure that the designed or implemented a system of internal controls, which would include segregation of duties, that would likely be effective in preventing, or detecting and correcting, noncompliance for any future federal program. Anticipated Completion Date: January 1, 2026 INDIANA STATE

View Audit 385771

Finding 1172533 (2025-002)

Material Weakness 2025

Mill Creek Community School Corporation

IN

Procurement, Suspension & Debarment Subrecipient Monitoring School Nutrition Programs § 200.303

FINDING 2025-002 Finding Subject: Child Nutrition Cluster - Suspension and Debarment Contact Person Responsible for Corrective Action: Lori Bennett Contact Phone Number and Email Address: 317-539-9200, LBennett@mccsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description o...

FINDING 2025-002 Finding Subject: Child Nutrition Cluster - Suspension and Debarment Contact Person Responsible for Corrective Action: Lori Bennett Contact Phone Number and Email Address: 317-539-9200, LBennett@mccsc.k12.in.us Views of Responsible Officials: We concur with the finding. Description of Corrective Action Plan: The School Corporation will require that suspension and debarment verification be done for all appropriate vendors prior entering into and paying an invoice at the start of each year. The verification is to be done by checking the SAM exclusions, collecting a certification from that person, or adding a clause or condition to the covered transaction with that person. Documentation will be included with the first voucher each year for that qualifying vendor. Anticipated Completion Date: January 2026

View Audit 385771

Finding 1172529 (2025-001)

Material Weakness 2025

University of Kentucky

KY

Allowable Costs / Cost Principles Subrecipient Monitoring

Contact Person(s) Responsible: Cara Nelson, Director Accounts Payable Services Corrective Action Planned for Reference 2025-001 – Duplicate accrual posting: Management acknowledges an invoice identified during the Single Audit was accrued twice for fiscal year 2025. This occurred when an invoice ret...

Contact Person(s) Responsible: Cara Nelson, Director Accounts Payable Services Corrective Action Planned for Reference 2025-001 – Duplicate accrual posting: Management acknowledges an invoice identified during the Single Audit was accrued twice for fiscal year 2025. This occurred when an invoice returned to the vendor for correction was resubmitted and not flagged as a duplicate accrual. To reduce the risk of future errors, management is implementing an automated report that detects potential duplicate accruals by matching key attributes such as purchase order number, document number, invoice amount, and cost object. All flagged items will be investigated and resolved or documented. Given the minimal rate of occurrence, this automated process is expected to efficiently and effectively reduce the risk of undetected duplicate accruals. Anticipated Completion Date: January 31, 2026

View Audit 385756

Finding 1172525 (2025-013)

Material Weakness 2025

Delaware Academy Central School District

NY

Reporting

Finding 2025-013: Schedule of Expenditures of Federal Awards (SEFA) Reporting Corrective Action: The District will implement formal procedures to ensure that the Schedule of Expenditures of Federal Awards (SEFA) is complete, accurate, and fully reconciled to the general ledger for all federal funds ...

Finding 2025-013: Schedule of Expenditures of Federal Awards (SEFA) Reporting Corrective Action: The District will implement formal procedures to ensure that the Schedule of Expenditures of Federal Awards (SEFA) is complete, accurate, and fully reconciled to the general ledger for all federal funds expended. Specific Actions: • Develop a written procedure to track federal grant expenditures, including ARP ESSER, Title programs, and other federal awards, throughout the fiscal year. • Reconcile all federal expenditures to the general ledger prior to preparing the SEFA. • Require supervisory review and approval of the SEFA to confirm completeness, accuracy, and proper reporting of all federal award expenditures. • Provide training to accounting staff on federal reporting requirements, including SEFA preparation and reconciliation procedures. • Maintain documentation of reconciliations and supporting records for audit purposes. Responsible Party: School Business Manager Anticipated Completion Date: Procedures implemented by March 31, 2026, with ongoing monitoring for each fiscal year thereafter.

View Audit 385749

Corrective Action Plans

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