Corrective Action Plans

Finding 551130 (2024-006)

Material Weakness 2024

County of Solano

CA

Eligibility Material Weakness

Federal Agency: U.S. Department of Agriculture Program/Cluster: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number: 10.557 Pass‐through: California Department of Public Health Award No. and Year: 22-10294 Compliance Requirement: Eligibility Type...

Federal Agency: U.S. Department of Agriculture Program/Cluster: Special Supplemental Nutrition Program for Women, Infants, and Children Federal Assistance Listing Number: 10.557 Pass‐through: California Department of Public Health Award No. and Year: 22-10294 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Condition #1. Five (5) instances out of 60 cases were missing all eligibility documentation. This included the documentation of the determination of eligibility and redetermination in the period under audit. The missing documentation included the records to evidence compliance with the eligibility criteria. Condition #2. Two (2) instances out of 60 cases were missing the Self Declaration Statement form when the applicant was unable to provide acceptable documentation for proof of income, proof of address, or proof of identification. Response to Condition #1 Per California Department of Public Health, Women, Infant, Children division (CDPH/WIC), the categories of non-breastfeeding, breastfeeding, and partially breastfeeding women files remain accessible to the local agency. For children five years of age, the files are purged six months after the fifth birthday. The WIC WISE records for the 5 files were not available due to the file purge by CDPH/WIC, therefore the auditor was unable to determine compliance to eligibility requirements for each of the five files. The auditor suggests the local agency retain eligibility documents. According to the California WIC Policy and Procedure Manual, WIC WISE Forms JOB AID section, eligibility documents provided by an applicant or a re-certifying client are not required to be retained by the local agency. The County has communicated this finding to CDPH/WIC and the risk it presents. At this time, the County is working with CDPH/WIC to address this finding. Specific Corrective Plan Procedures addressing Condition #1 Staff participate in a robust Quality Assurance (QA) plan which involves periodic file reviews and observations as documented in Solano County’s Continuous Quality Improvement (CQI) Monitoring Plan. Additionally, CDPH/WIC conducts a Program Monitoring Visit (PMV) every two years which includes a random record review of the agency’s compliance to eligibility policies. Solano County WIC program will continue to conduct the QA plan, and participate with the CDPH/WIC PMVs. Response to Condition #2 Solano County agrees with the finding. This use of the Self Declaration Statement (SDS) is a specific consideration in the QA plan. The WIC Supervisor was aware of the matter as it was discovered that both SDSs were missing from the family file as part of a regular QA review. The error was addressed with the employee shortly after the mistake occurred. Specific Corrective Plan Procedures addressing Condition #2 Staff participate in a Quality Assurance (QA) plan which involves periodic file reviews and observations as documented in Solano County’s Continuous Quality Improvement (CQI) Monitoring Plan. Additionally, CDPH/WIC conducts a Program Monitoring Visit (PMV) every two years which includes a random record review of the agency’s compliance to eligibility policies. Solano County WIC program will continue to conduct the QA plan, and participate with the CDPH/WIC PMVs. Responsible Individual(s): Christopher Husing, Senior Health Services Manager, Solano Public Health Anticipated Completion Date: April 1, 2025

View Audit 352056

Finding 551129 (2024-005)

Material Weakness 2024

County of Solano

CA

Eligibility Material Weakness

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Health Care Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Eligibility Type of Finding: Mater...

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Medicaid Cluster Federal Assistance Listing Number: 93.778 Pass‐through: California Department of Health Care Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Eligibility Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Solano County agrees that eligibility determinations and redeterminations including obtaining documentation and verifications should be performed annually to determine if individuals are eligible in accordance with the compliance requirements of the program. There are overdue redeterminations in our system due to the Medi-Cal expansion and increasing need for IHSS services in our communities without a substantial increase in staffing to support this service need. This year, we continue to have uncovered caseloads related to Social Worker job transition or leave, fair hearing and the growing complexity of our client population requiring more case management throughout the year. In FY 2024-25, we were granted seven additional social workers. We are anticipating these additional social workers will reduce the number of overdue redeterminations. We also have hired two Extra Help Social Workers who will focus on overdue redeterminations. We participate in State level discussions related to advocacy and increased IHSS administrative funding to support the growing number of IHSS clients. Responsible Individual(s): Gwendolyn Gill, Health Services Administrator Bela Matyas, Chief Deputy Director Anticipated Completion Date: July 1, 2025

View Audit 352056

Finding 551128 (2024-004)

Material Weakness 2024

County of Solano

CA

Eligibility Special Tests & Provisions Material Weakness

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Eligibility and ...

Federal Agency: U.S. Department of Health and Human Services Program/Cluster: Temporary Assistance for Needy Families Federal Assistance Listing Number: 93.558 Pass‐through: California Department of Social Services Award No. and Year: 1946001347 A7, 2023/2024 Compliance Requirement: Eligibility and Special Tests and Provisions Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: CW 2.1: Solano County has policies and procedures as well as systematic processes set up to ensure the required collection and documentation of the applicant’s intent to cooperate with child support. It is Solano County’s policy that the Child Support Questionnaire (CW 2.1Q) and Notice and Agreement (CW2.1NA) be processed in accordance with regulations, which require workers to: • Conduct an interview either via telephone, or in-person with the applicant, print the forms, and document the County Use Section which requires worker’s signature and date. • Mail the forms to the applicant for a wet signature or collect the signature via electronic means. • Ensure the CW2.1 forms are received and complete. • Initiate the required case action(s) based upon information provided on the forms. Solano County has a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent this error in the future: • A post-Audit meeting will be held with all stakeholders to discuss the specific audit findings and action steps needed. • The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the applicable eligibility handbook with verbiage to emphasize the following: o The requirement to review and collect the information needed to complete the notice and agreement (form CW2.1) for child, spousal, and medical support from the applicant. o That the case be authorized according to program rules only after required forms are received by the county, reviewed to ensure that the case is updated with the correct information, documented in the case journal, and the form(s) scanned into the document imaging system. o Highlight these requirements when training this topic. • The CalWORKs Program Specialist will address the findings and requirements as follows: o Present at the Monthly Program Support Forum conducted with managers, supervisors, and lead workers. o Written guidance and reminder will be published in the Monthly Program Support Newsletter to all staff. o Present and discuss this requirement with lead workers at the Lead Worker Coordination Meeting, and with supervisors at the Division Coordination Meeting. • In addition to regular case reviews, focused case reviews will be added to review for completion of the Notice and Agreement for Child, Spousal, and Medical Support (form CW 2.1). SAWS 2A SAR: Solano County has policies and procedures as well as systematic processes set up to ensure the worker has reviewed the Rights and Responsibilities (SAWS 2A SAR) with the applicant/recipient and obtain their signature. It is Solano County’s policy that the SAWS 2A SAR be processed at application and redetermination which require workers to: • Conduct an interview either via telephone, or in-person with the applicant, print the form, and document the worker’s signature and date. • Mail the form to the applicant for a wet signature or collect the signature via electronic means. • Ensure the completed form is on file prior to authorizing benefits. Solano County has a Quality Assurance Unit of lead workers to conduct 2-3 case reviews per month for all workers. Case reviews are a valuable tool in assessing case accuracy and recognizing quality casework. The case reviews are used to develop and strengthen worker and supervisory skills, provide structure for measuring results, identify, correct and prevent errors, and strengthen accountability to the programs and services we delivery as an agency. Specific corrective actions are outlined below to prevent this error in the future: • A post-Audit meeting will be held with all stakeholders to discuss the specific audit findings and action steps needed. • The CalWORKs Program Specialist will work with Hiring and Staff Development to strengthen the applicable eligibility handbook with verbiage to emphasize the following: o That the case be authorized according to program rules only after the signed SAWS 2A SAR form is received by the county, documented in the case journal, and the form(s) scanned into the document imaging system. o Highlight these requirements when training this topic. • The CalWORKs Program Specialist will address the finding and requirement in the following ways: o Present at the Monthly Program Support Forum conducted with managers, supervisors, and lead workers. o Written guidance and reminder will be published in the Monthly Program Support Newsletter to all staff. o Present and discuss this requirement with lead workers at the Lead Worker Coordination Meeting, and with supervisors at the Division Coordination Meeting. • In addition to regular case reviews, focused case reviews will be added to review for completion of the Rights and Responsibilities (SAWS 2A SAR). Responsible Individual(s): Daniel Horel, Employment and Eligibility Services Administrator Thomas West, Employment and Eligibility Services Manager Diana Hernandez, Employment and Eligibility Services Manager Jennifer Stephenson, Employment and Eligibility Services Manager Anticipated Completion Date: May 31, 2025

View Audit 352056

Finding 551125 (2024-003)

Material Weakness 2024

County of Solano

CA

Subrecipient Monitoring Reporting Material Weakness § 200.303

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Reporting Type of Finding: Material Weakness in In...

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Reporting Type of Finding: Material Weakness in Internal Control over Compliance, Material Noncompliance Views of Responsible Officials and Corrective Action Plan: Since May 2022, the County has contacted multiple agencies trying to report through the FSRS system on the multiple Housing Voucher awards, with no success. The County’s assigned Housing and Urban Development (HUD) office is the San Francisco regional office. Per their director, “These are systems that we don’t work with in HUD PIH so I won’t be able to be of assistance relative to this.” The County is unable to complete FFATA reporting for reasons outside of the County’s control. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: Because the corrective action is outside of the County’s control, we cannot determine an anticipated completion date.

View Audit 352056

Finding 551124 (2024-002)

Material Weakness 2024

County of Solano

CA

Subrecipient Monitoring § 200.331 § 200.521

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material ...

Federal Agency: U.S. Department of Housing and Urban Development Program/Cluster: Housing Voucher Cluster Federal Assistance Listing Number: 14.871, 14.879 Pass‐through: n/a – direct award Award No. and Year: CA131, 2023/2024 Compliance Requirement: Subrecipient Monitoring Type of Finding: Material Weakness in Internal Control over Compliance, Instance of Noncompliance Views of Responsible Officials and Corrective Action Plan: Due to the subrecipient’s low-risk status, another site visit is not due until FY2025/26. When that visit takes place, the County will formally document and communicate the results of the site visit. The department has created a subrecipient monitoring checklist to be completed quarterly which includes review of quarterly reports and will serve as documentation. Additionally, the department has a standing quarterly meeting with the subrecipient and will add an agenda item for quarterly report review discussion. The department will begin taking meeting minutes for documentation. Responsible Individual(s): James Bezek, Director of Resources Management Anticipated Completion Date: June 30, 2025

View Audit 352056

Finding 551122 (2024-001)

Significant Deficiency 2024

Molloy College

NY

Student Financial Aid Special Tests & Provisions Reporting

Name of contact person responsible for corrective action: Marguerite Lane, Associate Vice President Enrollment Management Mlane@molloy.edu 516-323-4014 Corrective action: Molloy University understands the finding and has devised a process to ensure that the correct withdrawal dat...

Name of contact person responsible for corrective action: Marguerite Lane, Associate Vice President Enrollment Management Mlane@molloy.edu 516-323-4014 Corrective action: Molloy University understands the finding and has devised a process to ensure that the correct withdrawal date is recorded National Student Loan Data System (NSLDS) with the 60-day window from the date of determination. In the finding, the withdrawals were reported within the window, but the effective dates reported were incorrect. We identified the issue and made the corrections, but the corrections were made outside the 60-day window. To address this, we will utilize our current practice of relying on error reports to address such errors, but we will run these reports at an increased frequency (bi-weekly) and have an additional staff member review the information. We will keep a file for each student withdrawal to show that our dates align in our system, the National Student Clearinghouse, and NSLDS within the required timeframe. Proposed Completion Date: March 31, 2025

View Audit 352050

Finding 551121 (2024-002)

Significant Deficiency 2024

Calaveras County Water District

CA

Reporting Significant Deficiency § 200.502

Finding 2024-002 – Significant Deficiency Award No.: 97.036, Disaster Grants-Public Assistance (Presidentially Declared Disasters) Federal Grantor: U.S. Department of Homeland Security, Federal Emergency Management Agency, Passed-through California Governor’s Office of Emergency Services, FEMA-...

Finding 2024-002 – Significant Deficiency Award No.: 97.036, Disaster Grants-Public Assistance (Presidentially Declared Disasters) Federal Grantor: U.S. Department of Homeland Security, Federal Emergency Management Agency, Passed-through California Governor’s Office of Emergency Services, FEMA-4683-DR-CA Compliance Requirement: Other compliance requirements. Condition: The schedule of Expenditures of Federal Awards (SEFA) was not complete, and expenditures reported on the SEFA were revised during the single audit. Criteria: 2 CFR Part 200, Subpart F (Uniform Guidance) Section 200.502 states, “The auditee should prepare a Schedule of Expenditures of Federal Awards for the period covered by the auditee’s financial statements.” Internal controls over the SEFA should be in place ensure accrual basis expenses incurred under the federal program are properly reported as expenses on the SEFA and are properly reported as revenue in the financial statements prior to the start of the single audit. Cause: SEFA was not fully reconciled and finalized until after the single audit began. Effect: The expenses included on the SEFA for program 97.036, Disaster Grants-Public Assistance (Presidentially Declared Disasters), program FEMA-4683-DR-CA, were revised during the single audit and questioned costs in the amount of $131,195 were identified, which could have resulted in the auditor not selecting the correct major program or expenses for testing and could have resulted in the single audit not satisfying the requirements of the Uniform Guidance. Context: The District provided cost estimates to the California Governor’s Office of Emergency Services (CalOES) for the amount of flood damage expenses incurred for FEMA Project 725590 and 710830 that were used by CalOES to reimburse the District. The District did not adequately reconcile the expenses incurred at year-end to expense reports available in the accounting system and did not revise the expense estimates provided to CalOES to the actual amounts incurred during the year, resulting in CalOES overpaying the District and the District using the estimated costs on the SEFA for the single audit. Recommendation: We recommend additional review procedures be implemented to ensure the SEFA is complete and accurate when the single audit begins, which includes reconciling all expenses incurred under each federal award down to the invoice, payroll check and lowest level of other costs claimed, cutting-off each expense at year-end and claiming the reconciled qualifying expenses within 45 days after each quarter end. At year-end, programs should be reviewed for cost adjustments, extensions, and other changes that should be reflected on the SEFA when reconciling expenses for the SEFA. Separate program codes should be used for each grant on the SEFA that summarizes expenses down to the individual invoice level that should be provided to the auditor for the single audit. If overclaimed amounts are identified, the grantor and/or pass-though agency should be contacted to determine whether to return the funds or apply the overclaimed amounts to future claims. Views of Responsible Officials and Planned Corrective Actions: The District will implement a formal reconciliation process to ensure all expenditures incurred under each federal award are accurately recorded before the start of the single audit. A quarterly reconciliation process will be conducted after each quarter-end to review and adjust expenses as necessary. The District will contact FEMA to determine whether the questioned costs may be applied to a future claim or whether the amount needs to be returned to FEMA. Estimated Completion Date of Corrective Action: October 1, 2025

View Audit 352048

Finding 551120 (2024-001)

Significant Deficiency 2024

Supporters of Abuse Free Environments Inc.

MT

Procurement, Suspension & Debarment Significant Deficiency

Finding: SECTION III – Federal Awards Findings: 2024-001 Expense Approval Documentation – Significant Deficiency During the audit performed by Carver, Florek and James, CPA’s, there was a finding related to expense approval documentation. A total of 20 transactions related to SAFE’s building constru...

Finding: SECTION III – Federal Awards Findings: 2024-001 Expense Approval Documentation – Significant Deficiency During the audit performed by Carver, Florek and James, CPA’s, there was a finding related to expense approval documentation. A total of 20 transactions related to SAFE’s building construction project were tested and 16 did not contain certain documentation of approval. Cause: During the pre-construction phase, SAFE’s Board of Directors accepted a construction bid from Quality Construction for the purposes of expanding SAFE’s emergency shelter facility. The Board of Directors authorized the total amount of the contract for construction and for architectural services, to include project management. Architectural services and project management were provided by MMW Architects. The Board further authorized Stacey Umhey and Heidi Pederson to approve all invoices related to the project. In their role as project managers, Architects from MMW Architects approved all construction invoices for costs incurred prior to forwarding those invoices to SAFE. Ms. Umhey and Ms. Pederson relied on this approval for costs of the project and considered this approval by the architects to be in compliance with SAFE’s policy. Corrective Action: All future invoices will be approved by the authorized SAFE staff person, even in instances where there is project manager approval. This corrective action will be put in place immediately and will continue into the future.

View Audit 352043

Finding 551117 (2024-001)

Material Weakness 2024

Trinity College of Florida, Inc.

FL

Student Financial Aid Special Tests & Provisions Matching / Level of Effort / Earmarking

Trinity College of Florida will develop, implement and maintain a written information security program in accordance with GLBA compliance

View Audit 352041

Finding 551114 (2024-003)

Material Weakness 2024

Community Health Centers of Arkansas, Inc.

AR

Procurement, Suspension & Debarment Subrecipient Monitoring § 200.318

Views of Responsible Officials and Planned Corrective Actions – Management acknowledges the audit finding related to procurement and suspension and debarment compliance under Federal Programs: Technical and Non-Financial Assistance to Health Centers, Grants for New and Expanded Services under the He...

Views of Responsible Officials and Planned Corrective Actions – Management acknowledges the audit finding related to procurement and suspension and debarment compliance under Federal Programs: Technical and Non-Financial Assistance to Health Centers, Grants for New and Expanded Services under the Health Center Program (Federal Assistance Listing Numbers 93.129, 93.527; Federal Award Year 2023-2024). We are committed to implementing corrective measures to address the identified deficiencies and ensure full compliance with 2 CFR 200.318 and 2 CFR 180 regulations. Corrective Actions Taken: 1. Established & Implemented Detailed Record-Keeping for Procurement Transactions: - A new accounting system with a centralized procurement tracking system has been implemented and is currently being used. Bill.com is used to record vendor invoices and procurement transactions in real time and syncs with Sage Intacct, the new accounting software implemented in January 2024. - Detailed records of all federal grant expenditures are maintained in Bill.com and monthly reconciliations are conducted in the general ledger to ensure all procurement transactions are properly classified to their specific grant by their grant ID. 2. Established & Implemented Suspension & Debarment Verification Procedures: - A new accounting system with a centralized procurement tracking system has been implemented and is currently being used. Bill.com is used to record vendor information including Sam.gov vendor eligibility documentation. - All vendors are verified using Sam.gov. and documentation is kept in the electronic vendor file in Bill.com. This process was implemented in March 2024 and is ongoing. 3. Monitoring - The Finance team conducts annual self-assessments to ensure vendor eligibility documentation is current and up to date. Any vendors that are suspended, debarred, or otherwise excluded from federal assistance programs are reported to the Executive team to ensure compliance. We believe that these actions will significantly mitigate the risks associated with the identified conditions and strengthen our internal control environment and align our procurement practices with federal regulations.

View Audit 352037

Finding 551113 (2024-002)

Material Weakness 2024

City of Rancho Cordova

CA

Reporting Internal Control / Segregation of Duties § 200.303

Program/Cluster: Disaster Grants – Public Assistance Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Federal Emergency Management Agency Pass-through: California Governor’s Office of Emergency Services Award Year: 2024 Grant Award Number: FEMA-4683-DR-CA Comp...

Program/Cluster: Disaster Grants – Public Assistance Federal Financial Assistance Listing Number: 97.036 Federal Grantor: U.S. Department of Federal Emergency Management Agency Pass-through: California Governor’s Office of Emergency Services Award Year: 2024 Grant Award Number: FEMA-4683-DR-CA Compliance Requirement: P – Other Information Management’s Response: We concur. Views of Responsible Officials and Corrective Action: The noncompliance resulted from staff managing these records not being fully aware of the FEMA program compliance supplement that states expenditures are to be reported on the SEFA once they are approved and obligated. The City of Rancho Cordova will implement the following corrective actions: • Ensure all relevant personnel within the city are aware of FEMA’s specific documentation requirements. • Review and revise internal procedures to strengthen controls over grant expenditures to include documentation that supports the status of FEMA’s review of the eligible project cost • Implement a tracking system to ensure all future expenditures have been both approved and obligated by FEMA prior to being included on the SEFA, regardless of the year in which the expenditure was incurred. These measures will ensure that all future costs claimed are allowable, approvals properly supported, and in full compliance with FEMA regulations. Name of Responsible Person: Kim Juran, Administrative Services Director Projected Implementation Date: January 1, 2025

View Audit 352034

Finding 551112 (2024-001)

None 2024

Conservatorio De Musica De Puerto Rico

PR

Reporting Subrecipient Monitoring Internal Control / Segregation of Duties § 200.510

Management is implementing enhanced controls and formal procedures to ensure that all funding sources, particularly those received through intermediary or passthroughentities, are correctly identified and appropriately classified for reporting. These measures include: - Expanding documentation reque...

Management is implementing enhanced controls and formal procedures to ensure that all funding sources, particularly those received through intermediary or passthroughentities, are correctly identified and appropriately classified for reporting. These measures include: - Expanding documentation requests to verify funding sources. - Maintaining ongoing dialogue with pass-through entities to confirm federal assistance classifications.

View Audit 352031

Finding 551110 (2024-002)

Significant Deficiency 2024

Southeast, Inc. and Affiliates

OH

Special Tests & Provisions

Finding Number: 2024-002 Planned Corrective Action: The sliding fee adjustment errors resulted from manual errors. Going forward, we will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Further, we will correct the EHR system error which resulted...

Finding Number: 2024-002 Planned Corrective Action: The sliding fee adjustment errors resulted from manual errors. Going forward, we will implement a process to periodically review sliding fee adjustments throughout the year for accuracy. Further, we will correct the EHR system error which resulted in write-off adjustments being incorrectly coded to sliding fee adjustments. Anticipated Completion Date: 6/30/2025 Responsible Contact Person: Jared Close, Controller

View Audit 352030

Finding 551106 (2024-014)

Material Weakness 2024

William Peace Universirty

NC

Student Financial Aid Internal Control / Segregation of Duties Matching / Level of Effort / Earmarking § 200.303

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007, 84.033 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...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007, 84.033 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: The Financial Aid Office has expanded staffing and continues to provide ongoing training through NASFAA, NCASFAA, CFNC, and Ellucian. Roles and responsibilities are now clearly defined to ensure proper segregation of duties, and cross-training is underway to provide continuity during vacancies. These efforts support the implementation of enhanced internal controls and Title IV compliance. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: June 2025

View Audit 352022

Finding 551105 (2024-013)

Significant Deficiency 2024

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Student Financial Assistance Cluster - Assistance Listing No. 84.268 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 proc...

Student Financial Assistance Cluster - Assistance Listing No. 84.268 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: The Business Office will complete monthly reconciliations in addition to the reconciliation at the time of draw of federal funds to comply with federal requirements. Name(s) of the contact person(s) responsible for corrective action: Belinda Burke, VP for Finance and Administration, CFO Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551103 (2024-012)

Significant Deficiency 2024

William Peace Universirty

NC

Student Financial Aid Reporting Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the University evaluate its procedures and policies around reporting to the COD to ensure that student information is reported timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Department will evaluate its policies and procedures around reporting to the COD to ensure that student information is reported timely. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551099 (2024-011)

Significant Deficiency 2024

William Peace Universirty

NC

Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007,84.033 Recommendation: The University should review the procedures surrounding the verification process to ensure all necessary support and documentation is obtained as well as maintained in student files. Explanati...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007,84.033 Recommendation: The University should review the procedures surrounding the verification process to ensure all necessary support and documentation is obtained as well as maintained in student files. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has added personnel and implemented an electronic document management system. All verification documentation is now scanned and maintained within each student’s electronic file to ensure accuracy, completeness, and audit readiness. Staff continue to receive regular training on verification protocols. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551098 (2024-010)

Material Weakness 2024

William Peace Universirty

NC

Student Financial Aid Eligibility Material Weakness

Student Financial Assistance Cluster - Assistance Listing No. No. 84.268 Recommendation: We recommend the University review its process around sending exit counseling information to students to ensure this information is received and the University is performing required procedures. Explanation of d...

Student Financial Assistance Cluster - Assistance Listing No. No. 84.268 Recommendation: We recommend the University review its process around sending exit counseling information to students to ensure this information is received and the University is performing required procedures. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Financial Aid Office has hired additional staff, enhanced training efforts, and established a standard procedure to send loan exit counseling notifications to students at the end of each term, ensuring regulatory compliance. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: June 2025

View Audit 352022

Finding 551097 (2024-009)

Significant Deficiency 2024

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Internal Control / Segregation of Duties

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063 Recommendation: We recommend the University implement a review process to ensure calculations of Pell awards are using the correct information. Explanation of disagreement with audit finding: There is no disagreement with the a...

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063 Recommendation: We recommend the University implement a review process to ensure calculations of Pell awards are using the correct information. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: To reduce calculation errors in Pell Grant awards, the Financial Aid Office has hired additional staff, increased training, and implemented an automated packaging system. This system ensures Pell award amounts are calculated using accurate and verified student information. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: August 2025

View Audit 352022

Finding 551094 (2024-008)

Significant Deficiency 2024

William Peace Universirty

NC

Subrecipient Monitoring Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit fin...

Student Financial Assistance Cluster - Assistance Listing No. No. 84.063, 84.268, 84.007, 84.033 Recommendation: We recommend the University ensure its written information security program addresses the required minimum elements as outlined in 16 CFR 314.4. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Information Technology Department will ensure its written information security program addresses the required minimum elements outlined in 16 CFR 314.4. Name(s) of the contact person(s) responsible for corrective action: Belinda Burke, VP for Finance and Administration, CFO Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551093 (2024-007)

Significant Deficiency 2024

William Peace Universirty

NC

Questioned Costs Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. 84.268 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 disagree...

Student Financial Assistance Cluster - Assistance Listing No. 84.268 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: The Financial Aid Office has hired additional personnel to enhance oversight and processing capacity. Staff will continue to receive training and will review all late and supplemental awards to verify that students meet financial need criteria before Title IV funds are disbursed. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: June 2025

View Audit 352022 Questioned Costs: $1

Finding 551091 (2024-006)

Significant Deficiency 2024

William Peace Universirty

NC

Reporting Student Financial Aid Significant Deficiency

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 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...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268 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: Given the findings related to enrollment reporting, the University will review policies and procedures to ensure information is reported in a timely and accurate manner. The University will review the NSLDS regulations and ensure understanding and compliance of the NSLDS definitions related to required reporting of enrollment changes. The University will verify program lengths for all active programs reported to NSLDS. The Registrar is the responsible party for enrollment reporting via NSC to NSLDS. Name(s) of the contact person(s) responsible for corrective action: Lynda Szymanski, VP for Academic Affairs Planned completion date for corrective action plan: April 2025

View Audit 352022

Finding 551087 (2024-005)

Significant Deficiency 2024

William Peace Universirty

NC

Student Financial Aid Significant Deficiency Matching / Level of Effort / Earmarking

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007, 84.033 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 ...

Student Financial Assistance Cluster - Assistance Listing No. 84.063, 84.268, 84.007, 84.033 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: At the conclusion of each academic term, the Director of Financial Aid will review enrollment data with the Registrar’s Office to identify students who may require Return of Title IV (R2T4) calculations. Completion of all required R2T4 calculations will be documented and verified by the Director to ensure full compliance with federal guidelines. Name(s) of the contact person(s) responsible for corrective action: Damon Wade, VP for Enrollment Management and Marketing Planned completion date for corrective action plan: May 2025

View Audit 352022

Finding 551086 (2024-006)

Material Weakness 2024

City of South El Monte

CA

Reporting

City response: Management agrees and is currently recruiting few vacant positions that fulfill those roles.

View Audit 352020

Finding 551085 (2024-001)

Significant Deficiency 2024

Centro Margarita,inc

PR

Reporting § 200.328

Centro Margarita, Inc. acknowledges the finding identified during the single audit regarding reporting requirements. Therefore, CMI will identify additional personnel including finance and accounting staff members and program coordinators that should be involved in financial reporting processes. A...

Centro Margarita, Inc. acknowledges the finding identified during the single audit regarding reporting requirements. Therefore, CMI will identify additional personnel including finance and accounting staff members and program coordinators that should be involved in financial reporting processes. Also, Centro Margarita, Inc. will conduct a comprehensive assessment of the technical training needs of the identified personnel. Evaluate their current knowledge and skill levels related to reporting requirements, accounting principles, and compliance regulations. Finally, Centro Margarita, Inc. will determine the most effective delivery method for the training program, taking into account the learning preferences and availability of personnel. Options may include: • In-person workshops or seminars led by subject matter experts. • Online courses or virtual training sessions accessible remotely. • Self-paced learning modules supplemented with instructional materials and resources. Implementing this corrective action plan focused on technical training for personnel responsible for reporting requirements, Centro Margarita, Inc. can enhance reporting accuracy, compliance, and overall effectiveness.

View Audit 352019

Corrective Action Plans

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