Corrective Action Plans

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Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. ...
Segregation of Duties Recommendation: We recommend the University implement additional internal controls to ensure proper segregation of duties. This includes hiring additional staff or redistributing responsibilities to separate the functions of authorizing, processing, and reviewing transactions. Additionally, ongoing training should be provided to financial aid staff on the importance of internal controls and compliance with Title IV regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review its staffing and the need for separation of duties as part of an effective internal control system and take appropriate actions.. Name(s) of the contact person(s) responsible for corrective action: Vice President for Enrollment Management Damon Wade, Director of Financial Aid Deniesha Newby, and Controller Will Gibbons Planned completion date for corrective action plan: June 30, 2026
Credit Balance Recommendation: We recommend the University evaluate its procedures and policies around credit balances to ensure that students are refunded within the fourteen day requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action tak...
Credit Balance Recommendation: We recommend the University evaluate its procedures and policies around credit balances to ensure that students are refunded within the fourteen day requirement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management understands this federal requirement and will ensure that it is met. Name(s) of the contact person(s) responsible for corrective action: Controller Will Gibbons Planned completion date for corrective action plan: June 30, 2026
Direct Loan Reconciliations Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a process to maintain all reconciliations as su...
Direct Loan Reconciliations Recommendation: The University should ensure all necessary employees receive proper training, support, and time to follow the University’s policies and federal requirements related to monthly reconciliations. There should be a process to maintain all reconciliations as support of performance monthly. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will take action to ensure compliance with this recommendation.. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby Planned completion date for corrective action plan: June 30, 2026
Common Origination and Disbursement (COD) Reporting Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreem...
Common Origination and Disbursement (COD) Reporting Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely and accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will ensure that its policies and procedures are reviewed and updated to ensure compliance with this recommendation. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby Planned completion date for corrective action plan: June 30, 2026
Direct Loan Overaward Recommendation: We recommend the University establish additional policies to ensure all students meet the financial need criteria before awarding Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in res...
Direct Loan Overaward Recommendation: We recommend the University establish additional policies to ensure all students meet the financial need criteria before awarding Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review existing procedures and modify as needed to ensure compliance with this recommendation.. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby Planned completion date for corrective action plan: June 30, 2026
National Student Loan Database System (NSLDS) Reporting Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with au...
National Student Loan Database System (NSLDS) Reporting Recommendation: We recommend the University evaluate its procedures and review regulations to ensure the University understands the definitions for enrollment information required to be reported to the NSLDS. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will review regulations to ensure that staff understands reporting requirements of the NSLDS. Name(s) of the contact person(s) responsible for corrective action: Financial Aid Director Deniesha Newby Planned completion date for corrective action plan: June 30, 2026
Return of Title IV (R2T4) Funds Recommendation: We recommend the University review the R2T4 requirements and ensure their process incorporates a review of students to ensure no calculations are missed that should be performed. Explanation of disagreement with audit finding: There is no disagreement ...
Return of Title IV (R2T4) Funds Recommendation: We recommend the University review the R2T4 requirements and ensure their process incorporates a review of students to ensure no calculations are missed that should be performed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will take action to comply with this recommendation. Name(s) of the contact person(s) responsible for corrective action: Director of Financial Aid Deniesha Newby
U.S. Department of Education Maranatha Baptist University (the University) respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 01, 2024 to June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The...
U.S. Department of Education Maranatha Baptist University (the University) respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 01, 2024 to June 30, 2025 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS—FINANCIAL STATEMENT AUDIT Our audit did not disclose any matters required to be reported in accordance with Government Auditing Standards. FINDINGS—FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2025-001 Student Financial Assistance Cluster – Assistance Listing No. 84.007, 84.063 & 84.268 Recommendation: We recommend that the University maintain documentation of both formal and informal award notifications in their financial aid software to ensure all necessary communications are made. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University Financial Aid Office will add a step in the awarding process to verify that award emails are sent and are documented in the system. Name of the contact person responsible for corrective action: Donald Donovan, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2026 *** If the U.S Department of Education has questions regarding this plan, please call Donald Donovan, Chief Financial Officer, at 920-206-2314.
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended Se...
Corrective Action Plan Corrective Action Plan – Uniform Guidance Audit Finding Organization: Scripps Health and Affiliates Federal Agency: U.S. Department of Homeland Security Pass-Through Agency: California Governor’s Office of Emergency Services UEI Number: JJRCL53EXL36 Audit Period: Year Ended September 30, 2025 Finding Reference Number: 2025-001 Federal Program: COVID-19 – Disaster Grants – Public Assistance (Presidentially Declared Disasters) Assistance Listing Number: 97.036 Finding Summary: The organization did not employ an adequate internal control review of payroll expenditures to support activities allowed or unallowed and allowable costs/cost principles related to payroll expenditures reimbursed for the project worksheet. Corrective Action Plan: Additional internal controls to ensure payroll expenditures are reviewed were implemented in late fiscal year 2022 by adopting a new approach to ensure compliant timekeeping. The new approach includes the following steps: revised the timekeeping policy to clarify employee and manager responsibilities, modified “failure to comply” provisions, deployed educational programs for both management and staff, reviewed/improved Kronos and UKG Pro Time and Attendance system automated notifications, and training resources have been available to management and staff via our Scripps intranet site. Leadership monitors policy compliance by individual employee and managers via systemwide reporting on a biweekly basis. Responsible Officials & Contact Person: Brett Tande, Executive Vice President & Chief Financial Officer Scripps Health and Affiliates Expected Completion Date: Completed in fiscal year 2022. As the expenditures in the project worksheet were incurred from the beginning of the COVID-19 pandemic, the corrective action plan put in place during 2022 could not previously remediate the project; however, all payroll expenditures incurred after the end of fiscal year 2022 have these corrective actions in place.
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Section III – Federal Award Findings and Questioned Costs All identified cases are being reviewed and corrected to ensure compliance. Supervisors will conduc...
CORRECTIVE ACTION PLAN FOR THE YEAR ENDED JUNE 30, 2025 Finding: 2025-001 Name of contact person: Corrective Action: Proposed Completion Date: Section III – Federal Award Findings and Questioned Costs All identified cases are being reviewed and corrected to ensure compliance. Supervisors will conduct targeted refresher training on income and resource calculation, SSI termination procedures, and redetermination timeliness and procedures. Regular quality assurance reviews and staff support will continue to ensure sustained compliance and improved accuracy in case processing. Training will be completed by December 15, 2025. Corrective actions for finding 2025-001 also apply to the State Awards findings. Section IV – State Award Findings and Questioned Costs Lisa Chaney, Nicole Victory and Debbie McGuire - Medicaid Supervisors; Mandy Edwards - Medicaid Manager 189
Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Name of contact person: Corrective Action: The County acknowledges the material weakness identified in the Medicaid eligibility determination process and agrees with the audit finding. To address the deficiencies noted, the Cou...
Corrective Action Plan For the Year Ended June 30, 2025 Finding 2025-003 Name of contact person: Corrective Action: The County acknowledges the material weakness identified in the Medicaid eligibility determination process and agrees with the audit finding. To address the deficiencies noted, the County will strengthen internal controls related to eligibility determinations by implementing a comprehensive, county-wide corrective action strategy focused on staff competency, supervisory oversight, and process standardization. First, the County will enhance training for all staff involved in Medicaid eligibility determinations. This training will reinforce program requirements and applicable State Medicaid manuals, with specific emphasis on income and resource verification, household composition, timely requests for information, redetermination timeframes, and proper handling of SSI terminations. Refresher trainings will be conducted regularly, and training materials will be updated to reflect current policy and procedural changes. Second, the County will formalize and strengthen its internal case review and quality assurance processes. Supervisory reviews will be conducted routinely to ensure eligibility determinations are accurate, complete, and compliant with federal and state guidelines. Identified errors will be documented, corrected timely, and used as coaching opportunities to prevent recurrence. Management will monitor trends in errors to assess effectiveness of corrective actions and adjust oversight efforts as needed. Anetre Vaughan, Adult Medicaid Supervisor and Jacqueline Boyd, Family and Children's Medicaid Supervisor Section III - Federal Award Findings and Question Costs BUILD YOUR FUTURE ON OUR FOUNDATION 115 Justice Drive  Suite 1  Winton, North Carolina 27986 Office 252.358.7805  Facsimile 252.358.0198  www.HerfordCountyNC.gov 116
Recommendation: The design of the current internal controls should be reviewed to ensure tenant files are complete and accurate. The information in the files should support the data used in preparing the Form 50059, and procedures for calculating income using HUD guidelines should be reviewed. The i...
Recommendation: The design of the current internal controls should be reviewed to ensure tenant files are complete and accurate. The information in the files should support the data used in preparing the Form 50059, and procedures for calculating income using HUD guidelines should be reviewed. The information in the files should also support that proper eligibility screening procedures have been completed, and updated lease agreements should be obtained for any tenant whose lease is not the correct model lease document. A corrected Form 50059 should be prepared to correct the tenant income discrepancy noted in the audit, and the required adjustment processed through the HUD voucher. In addition, management should review all files and report any additional discrepancies to HUD in a timely manner. Action Taken: Day Spring Baxter Avenue, Inc. will review all tenant files and report any discrepancies in calculated tenant rent and rental subsidy to HUD and make the necessary adjustments on the 50059 forms as soon as possible. Tenant files will be reviewed to ensure proper documentation is maintained and the proper model lease is being used.
Condition: We selected a sample of 25 students that had a change in status. One of the students information was not reported to NSLDS timely, however the College’s controls did detect the error outside the required timeframe, and the error was corrected. We expanded our sample to 50 students. We fou...
Condition: We selected a sample of 25 students that had a change in status. One of the students information was not reported to NSLDS timely, however the College’s controls did detect the error outside the required timeframe, and the error was corrected. We expanded our sample to 50 students. We found another instance of a student’s information not reported timely, however management did eventually detect and correct the error outside the required timeframe. Corrective Action planned: Management agrees and has implemented necessary procedures/controls to ensure the College is in compliance with enrollment requirements. Management has corrected the student’s change status not previously reported. Name(s) of Contact Person(s) Responsible for Corrective Action: {Jennifer Young, Director of Financial Aid and Edgewood Central, and Katelyn Peters, Student Service Specialist.} Anticipated Completion Date: Has already began as of the audit. Staff turnover occurred, have replaced the Student Service Specialist position - now have second point on NSC reporting.
Finding No. 2025-001 – Special Tests and Provisions – NSLDS Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The School agrees with the finding. The Registrar will work with Ellucian to update reporting process to National Student Clearinghouse to include ...
Finding No. 2025-001 – Special Tests and Provisions – NSLDS Reporting – Compliance and Internal Control (Significant Deficiency) Corrective Action Plan: The School agrees with the finding. The Registrar will work with Ellucian to update reporting process to National Student Clearinghouse to include the two program lengths for same CIP code. Anticipated Completion Date: Our expected remediation date is June 15, 2026. If we are unable to remediate by June 15, 2026, we will correct enrollment reporting to reflect accurate program length by September 1, 2026. Person(s) Responsible for Corrective Action: Michelle T. Weller Registrar 212-431-2300
Finding 1201454 (2025-002)
Material Weakness 2025
Finding: The change in student status for 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) timely when the student withdrew or changed status during the fiscal year. The change in student status for an additional 2 of 25 students tested was not reported to th...
Finding: The change in student status for 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) timely when the student withdrew or changed status during the fiscal year. The change in student status for an additional 2 of 25 students tested was not reported to the National Student Loan Data System (NSLDS) accurately when the student graduated during the fiscal year. Explanation for Finding: The Registrar's data collection was not reviewed after submission to National Student Clearinghouse (NSC) by another responsible individual to ascertain the accuracy of graduate, withdrawal and status change dates of students being reported. The College received a response from NSC of no errors, therefore the withdrawn student in question was not reported in a timely manner. Corrective Actions Taken or Planned: The Registrar will run a report on the 15th of the month to verify any students that have exited the institution from the prior two submission periods (last two months) have valid exit dates in the National Student Loan Clearinghouse. The Assistant Registrar will review the work of the Registrar and verify any discrepancies between Coe’s records and those stored in the National Student Clearinghouse for correction. The Registrar will then ensure timely and accurate submission of student records from the Clearinghouse to NSLDS after all the data has been reviewed. When there are staffing changes in the future that impact a person on the staff in the Office of the Registrar who has been responsible for the verification and reporting of valid exit dates in the National Student Loan Clearinghouse, it is the responsibility of the Registrar, unless the Registrar has left, in which case it shall be the responsibility of the Assistant Registrar, to appoint another specific staff member in the Office of the Registrar to take the actions required by the written policy for the verification and reporting of this data. Persons Responsible and Completion Date: Registrar, Assistant Registrar. The actions outlined above has been added to the Withdrawal & Exit Procedure (NSC-NSLDS) as of 10/28/2025
2025-002 Procurement Supporting Documentation Planned Corrective Action Plan: Heartwood will review federal grant requirements then will ensure that policies and procedures are in compliance with those requirements. Finally, documentation obtained during required procedures, will be centrally locate...
2025-002 Procurement Supporting Documentation Planned Corrective Action Plan: Heartwood will review federal grant requirements then will ensure that policies and procedures are in compliance with those requirements. Finally, documentation obtained during required procedures, will be centrally located to demonstrate compliance. Anticipated Completion Date: June 30, 2026 Responsible Contact Person: Sherri Sampson, Executive Director
2025-001 Unallowable Costs Planned Corrective Action Plan: Heartwood agrees with the finding and acknowledges that two expenditures charged to the Preschool Development Grants (PDG) program were determined to be unallowable under Federal cost principles. To address this issue and prevent similar occ...
2025-001 Unallowable Costs Planned Corrective Action Plan: Heartwood agrees with the finding and acknowledges that two expenditures charged to the Preschool Development Grants (PDG) program were determined to be unallowable under Federal cost principles. To address this issue and prevent similar occurrences in the future, Heartwood will implement the following corrective actions: 1. Enhanced Review Procedures Heartwood will implement additional review procedures for expenditures charged to Federal programs to ensure that all costs are evaluated for allowability under Uniform Guidance (2 CFR §200.403) and the specific terms and conditions of the PDG grant prior to being charged to the grant. 2. Training for Program and Fiscal Staff Program administrators and fiscal staff responsible for processing or approving grant expenditures will receive training on Federal cost principles and allowable expenditures under Uniform Guidance and the PDG program requirements. 3. Monitoring and Oversight Heartwood will require periodic supervisory review of grant expenditures to confirm that costs charged to the program are properly supported, reasonable, and allowable. 4. Review of Current-Year Expenditures Heartwood will review other expenditures charged to the PDG program during the fiscal year to determine whether additional unallowable costs were incurred and will take appropriate corrective action if necessary. 5. Disposition of Questioned Costs Heartwood will work with the pass-through entity or Federal awarding agency to determine the appropriate disposition of the questioned costs totaling $1,467.53, which may include reimbursement to the grant if required. Anticipated Completion Date: December 31, 2026 Responsible Contact Person: Sherri Sampson, Executive Director
Condition: The subsidiary ledger for loans funded by the Federal award programs maintained by the Department did not agree to the City’s general ledger. Corrective Action Planned: The City is actively evaluating a Loan Servicing software package to replace the current offline subledger and anticipat...
Condition: The subsidiary ledger for loans funded by the Federal award programs maintained by the Department did not agree to the City’s general ledger. Corrective Action Planned: The City is actively evaluating a Loan Servicing software package to replace the current offline subledger and anticipate on implementing it in fiscal year 2027. Going forward, Office of Strategic Planning and Community Development (OSPCD) Finance in conjunction with the Auditing Department will train the OSPCD program director and staff on the agreed standard methodology and criteria for recording and reporting new loans and payments in both the subledger and MUNIS. Loan activity will be reconciled to the general ledger to ensure compliance each fiscal year. The City will continue to research discrepancies for CDBG and HOME, make necessary adjustments and plans on resolving the remaining variances in these two program accounts. Anticipated Completion Date: September of 2026 Contact: Alan Inacio, OSPCD Director of Finance and Administration
2025-001 Eligibility – Tenant Files Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 – Housing Choice Vouchers 14.879 Mainstream Vouchers Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Statement of Condition: Out of a total tenant...
2025-001 Eligibility – Tenant Files Section 8 Housing Voucher Cluster (Section 8): 14.871 Section 8 – Housing Choice Vouchers 14.879 Mainstream Vouchers Significant Deficiency in Internal Control and Other Matter to be Reported Under the Uniform Guidance Statement of Condition: Out of a total tenant population of approximately 2,025 tenants, a sample of 25 files was selected for testing. Exceptions were noted in 9 of the 25 files, categorized as follows: • 3 tenant file errors where the Authority did not generate the required EIV form. • 1 tenant file had the following errors: o The Authority did not generate the required EIV form. o The child support income was miscalculated and SNAP benefits were included in the income calculation. Correcting the income errors increased the HAP rent from $774 to $869. • 1 tenant file error where the child support income was miscalculated. Correcting the error would decrease the HAP rent from $1,500 to $1,476. • 1 tenant file error where the tenant’s income was miscalculated. Correcting the error would decrease HAP rent from $552 to $279. • 1 tenant file where the tenant’s income was miscalculated. Correcting the issue would increase the HAP rent from $501 to $517. • 1 tenant file error where medical expenses were erroneously reported on the HUD-50058 form. Correcting the error would decrease the HAP rent from $524 to $500. • 1 tenant file error where the utility allowance was miscalculated. Correcting this error would increase the HAP rent from $1,027 to $1,145. Recommendation: The Authority should correct the deficiencies noted in the tested files and utilize an ongoing, secondary quality control review process for a sample of the entire tenant population to ensure proper compliance with eligibility requirements. Furthermore, management should provide ongoing staff training, conduct timely reviews of tenant files, and evaluate current staffing levels, skill sets and caseloads to ensure staff have the capacity to execute their duties accurately. Action Taken: The Authority concurs with this finding and has implemented a robust file review process, enhanced quality control procedures, and provided training on errors noted along with annual program training for all staff. The cited files were corrected.
Name of Contact Person: Amanda John, Executive Director. Corrective Action: We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Proposed Completion Date: Immediately.
Name of Contact Person: Amanda John, Executive Director. Corrective Action: We will implement proper internal control procedures for the Housing Choice Voucher program eligibility requirements. Proposed Completion Date: Immediately.
Program: Congressionally Recommended Awards / HOME Investment Partnerships Program / Homeland Security Grant Program / Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 16.753 / 14.239 / 97.067 / 93.323 Federal Grantor: U.S. Department of Justic...
Program: Congressionally Recommended Awards / HOME Investment Partnerships Program / Homeland Security Grant Program / Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 16.753 / 14.239 / 97.067 / 93.323 Federal Grantor: U.S. Department of Justice / U.S. Department of Housing and Urban Development / U.S. Department of Homeland Security / U.S. Department of Health and Human Services Award No. and Year: Multiple Compliance Requirements: 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 Criteria: 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) states that the auditee (the County) must prepare a Schedule of Expenditures of Federal Awards (SEFA) for the period covered by the auditee’s financial statements, which must include the total federal awards expended as determined in accordance with §200.502. §200.331 of the Uniform Guidance states the County is responsible for making case-by-case determinations to determine whether the entity receiving the Federal funds is a subrecipient. In addition, §200.303 of the Uniform Guidance states that the County must establish and maintain effective internal control over the federal awards, including controls over the accuracy of program information and expenditure amounts. Condition: During our audit procedures performed over the SEFA we noted the following: • The Sheriff-Coroner Department did not properly identify the amount expended for the Congressionally Recommended Awards, AL No. 16.753. The expenditures reported by the Department were overstated by $2,638,516. • The Orange County Community Resources Department did not properly identify the amount of Federal funding passed through to subrecipients for the HOME Investment Partnerships Program, AL No. 14.239. The amount passed through to subrecipients reported by the Department was overstated by $4,500,624. • The Sheriff-Coroner Department did not properly identify the amounts expended for the Homeland Security Grant Program, AL No. 97.067. The expenditures reported by the Department were overstated by $715,489. • The Orange County Health Care Agency (HCA) did not properly identify the amount expended for the Epidemiology and Laboratory Capacity for Infectious Disease program, AL No. 93.323. The expenditures reported by the Agency were overstated by $486,000. Cause: As a result, the County lacked adequate internal controls to ensure the SEFA is completely and accurately stated. Specifically, the County’s processes for recording and tracking expenditures of Federal awards are not designed so that expenditures are identified when incurred. In addition, the County’s processes for identifying and reporting subrecipients are not designed to ensure appropriate reporting on the SEFA. Effect: Adjustments to the SEFA were required. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. Program expenditures and amounts passed through to subrecipients were reconciled to the supporting records. Repeat Finding from Prior Years: No. Recommendation: The County, including all its reporting departments, should follow existing policies, procedures and internal controls to ensure all expenditures and amounts passed through to subrecipients are accurately tracked and reported on the SEFA. Personnel knowledgeable of federal expenditures should review amounts coded to federal programs for completeness and accuracy. The SEFA should be prepared and reviewed in a timely manner and reconciled to underlying records as well as the basic financial statements. Management Response and Corrective Action Plan: Health Care Agency: 1. Person Responsible: David Santalahti, HCA Claims & Financial Reporting Manager 2. Corrective action plan: HCA Accounting will review and enhance its procedures and training for analysis and tracking federal award expenditures to ensure expenditures are reported in the appropriate fiscal year period. 3. Anticipated Implementation date: June 30, 2026 Orange County Community Resources: 1. Person Responsible: Bill Malohn, OCCR Accounting Manager 2. Corrective action plan: Concur. OCCR has established policies and internal controls to ensure all expenditures and amounts passed through to subrecipients are accurately tracked and reported on the SEFA. Appropriate personnel review amounts coded to federal programs for completeness and accuracy. We prepare and review the SEFA in a timely manner and reconcile to underlying records as well as the basic financial statements. In this particular situation, we miscategorized one provider as a subrecipient and reported the related funding as such on the SEFA. This oversight had no impact on the total amount we reported on the SEFA. We will be sure to follow our policies and procedures to ensure accurate SEFA reporting. 3. Anticipated Implementation date: February 2, 2026 Sheriff-Coroner: 1. Person Responsible: Monique Vansuch, Fiscal Administrator 2. Corrective action plan: The Sheriff-Coroner Department acknowledges the finding and recognized federal grant expenditure incurred is defined as when expenditures are delivered and/or services are performed rather than when the expenditures are paid. We will strengthen the internal controls to ensure grant expenditures are reported per the Uniform Guidance. 3. Anticipated Implementation date: June 30, 2026
Program: Housing Voucher Cluster Federal Financial Assistance Listing Number: 14.871 / 14.879 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: Multiple Compliance Requirements: Special Tests and Provisions – HQS Enforcement Type of Finding: Significant Deficiency...
Program: Housing Voucher Cluster Federal Financial Assistance Listing Number: 14.871 / 14.879 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: Multiple Compliance Requirements: Special Tests and Provisions – HQS Enforcement Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: The 2025 OMB Compliance Supplement requires that for dwellings under Housing Assistance Payment (HAP) contracts that fail a Housing Quality Standards (HQS) inspection, the County must enforce HQS requirements. Specifically, upon notification that a unit has failed HQS, the County must inspect the unit within 15 days to confirm the deficiency and notify the owner if the deficiency is confirmed. Once notified, the owner is required to make the necessary repairs within the prescribed time frame. If the owner does not correct the cited HQS deficiencies within the specified correction period, the County must stop (abate) HAPs beginning no later than the first of the month following the specified correction period or must terminate the HAP contract. Condition: For one sample selected for testing, the County did not timely enforce HQS requirements. Cause: The cause of the finding was an administrative oversight that resulted in delays in issuing the final inspection notice following a missed inspection appointment. The County’s existing procedures did not adequately ensure timely follow-up and escalation when an inspection resulted in a noshow. Effect: Because the required inspection and notification were not completed timely, the County did not fully comply with the HQS enforcement requirements. This delay increased the risk that housing assistance payments could continue for a unit that did not meet HUD’s minimum housing quality standards, potentially affecting program compliance and participant health and safety. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of sixty (60) out of a total population of 1,029 instances of failed HQS were selected. The condition noted above was identified during our procedures related to special tests and provisions – HQS enforcement. Repeat Finding from Prior Years: No. Recommendation: We recommend the County strengthen its HQS enforcement procedures by implementing controls to ensure timely follow-up on failed inspections, including missed appointments. Such controls may include automated tracking of inspection deadlines, supervisory review of no-show appointments, and escalation procedures to ensure owners are notified within required time frames. Management Response and Corrective Action Plan: 1. Person Responsible: Linda Tarzjani, Leasing Manager 2. Corrective action plan: Concur. We will strengthen our HQS enforcement procedures by implementing controls to ensure timely follow-up on failed inspections, including missed appointments. In doing so we will consider automated tracking of inspection deadlines, supervisory review of noshow appointments, and escalation procedures to ensure owners are notified within required time frames. 3. Anticipated Implementation date: February 1, 2026
Program: Community Development Block Grant Federal Financial Assistance Listing Number: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: B-24-UC-06-0504 and 2025; B-20-UW-06-0504 and 2021 Compliance Requirements: Reporting Type of Finding: Material Weaknes...
Program: Community Development Block Grant Federal Financial Assistance Listing Number: 14.218 Federal Grantor: U.S. Department of Housing and Urban Development Award No. and Year: B-24-UC-06-0504 and 2025; B-20-UW-06-0504 and 2021 Compliance Requirements: Reporting Type of Finding: Material Weakness in Internal Control over Compliance and Material Instance of Noncompliance Criteria: CFR Appendix A to Part 170I(a)(2), Reporting Requirements, states the recipient must report each subaward to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS) no later than the end of the month following the month in which the subaward was issued. Condition: During our testing of the County’s compliance with reporting requirements, we noted the County did not submit the required subaward data to FSRS. Cause: The department was unaware of this compliance requirement. Effect: Reports were not submitted to FSRS in accordance with the reporting requirements per Appendix A to Part 170I(a)(2). Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling : We identified that the FFATA reporting was not completed as required by 2 CFR Part 170 for the following instances: (Refer to Chart/Table to Finding 2025-003) Repeat Finding from Prior Years: No. Recommendation: We recommend that the County adhere to their policies and procedures in accordance with 2 CFR Appendix A to Part 170I(a)(2). Management Response and Corrective Action Plan: 1. Person Responsible: Francisco Padilla, Community Development Analyst 2. Corrective action plan: Concur. We will adhere to our policies and procedures to ensure reports are submitted to FSRS in accordance with 2 CFR Appendix A to Part 170I(a)(2). 3. Anticipated Implementation date: April 30, 2026
Program: Homeland Security Grant Program Federal Financial Assistance Listing Number: 97.067 Federal Grantor: U.S. Department of Homeland Security Pass-Through Entity: California Governor’s Office of Emergency Services Award No. and Year: Multiple Compliance Requirements: Subrecipient Monitoring Typ...
Program: Homeland Security Grant Program Federal Financial Assistance Listing Number: 97.067 Federal Grantor: U.S. Department of Homeland Security Pass-Through Entity: California Governor’s Office of Emergency Services Award No. and Year: Multiple Compliance Requirements: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance and Material Noncompliance Criteria: Title 2 of the U.S. Code of Federal Regulations (CFR), Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance), Section 200.332, requires that pass-through entities: • Evaluate the risk of noncompliance with a subaward to determine the appropriate monitoring. • Verify every subrecipient is audited as required by Uniform Guidance, issue management decisions for audit findings, as applicable, and ensure the subrecipient take timely corrective action on all audit findings, as applicable. • Verify whether the subrecipient is suspended, debarred, or otherwise excluded before entering into a covered transaction. Condition: For two (2) out of two (2) subrecipients selected for testing, the subrecipient risk assessments were not performed by the department and the subrecipient was not checked for suspension or debarment prior to entering into the agreement. For one (1) out of two (2) subrecipients selected for testing, evidence could not be provided to verify the County reviewed the subrecipient’s single audit report to ensure timely corrective action was taken on audit findings, as applicable. Cause: Internal controls were not in place to ensure compliance with subrecipient monitoring requirements. Effect: Ineffective controls over this area of compliance could result in noncompliance occurring for a subrecipient and not being detected. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sample of two (2) subrecipients out of a population of two (2) was selected for testing. Repeat Finding from Prior Years: No. Recommendation: We recommend the department enhance internal controls to ensure compliance with subrecipient monitoring requirements. Management Response and Corrective Action Plan: 1. Person Responsible: Monique Vansuch, Fiscal Administrator 2. Corrective action plan: The Sheriff-Coroner Department will complete and document risk assessments, suspension/debarment status and verify subrecipient’s single audit report is reviewed and corrective actions are implemented prior to subaward issuance. 3. Anticipated Implementation date: June 30, 2026
Program: Block Grants for Community Mental Health Services Federal Financial Assistance Listing Number: 93.958 Federal Grantor: U.S. Department of Health and Human Services Pass Through: California Department of Health Care Services Award No. and Year: 68-0317191 and 2024 Compliance Requirements: Su...
Program: Block Grants for Community Mental Health Services Federal Financial Assistance Listing Number: 93.958 Federal Grantor: U.S. Department of Health and Human Services Pass Through: California Department of Health Care Services Award No. and Year: 68-0317191 and 2024 Compliance Requirements: Subrecipient Monitoring Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: In accordance with Title 2 U.S. Code of Federal Regulations (CFR) 200.332, pass-through entities must comply with the following: • 2 CFR Part 200.332(a), Requirements for Pass-Through Entities, states that all passthrough entities must ensure that every subaward is clearly identified to the subrecipient as a subaward and includes certain information as well as all the requirements imposed by the pass-through entity on the subrecipient so that the Federal award is used in accordance with Federal statutes, regulations, and the terms and conditions of the award. Condition: The following information was not provided at the time of the subaward for three (3) out of five (5) subawards selected for testing from the HCA’s Block Grants for Community Mental Health Services program • Federal Award Identification Number (FAIN) • Federal award date of award to recipient by the Federal Agency • Identification of whether or not the award is R&D • Indirect cost rate for the Federal award (including if the de-minimus rate is charged) Cause: The HCA’s procedures did not consistently ensure that the required award information and applicable requirements were communicated to the subrecipients at the time of subaward. Effect: The County’s control policies were not consistently followed which require compliance with the Subrecipient Monitoring requirements as found in 2 CFR 200.332. Questioned Costs: No questioned costs were identified as a result of our audit procedures. Context/Sampling: A nonstatistical sample of three (3) of five (5) subrecipients were sampled. The condition noted above was identified during our procedures related to subrecipient monitoring. Repeat Finding from Prior Years: No. Recommendation: We recommend that the County adhere to their policies and procedures in accordance with 2 CFR 200.332 to ensure compliance with subrecipient monitoring requirements. Management Response and Corrective Action Plan: 1. Person Responsible: Brittany Davis, HCA Procurement & Contract Services Division Manager 2. Corrective action plan: HCA will coordinate with internal stakeholders on the review of all subrecipient contracts and applicable funding source requirements to ensure that subaward criteria and subrecipient responsibilities are included. Amendments or subrecipient notification letters will be issued, as needed, to notify contractors of subrecipient responsibilities. 3. Anticipated Implementation date: June 30, 2026
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