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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 The College received a response from NSC of no errors, therefore the withdrawn student in question was not reported in a timely manner.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
Program: HIV Emergency Relief Project Grants (Ryan White) Federal Financial Assistance Listing Number: 93.914 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: 6H89HA00019-32-04; 2024 Compliance Requirements: Activities Allowable or Unallowed and Allowable Costs/Cost ...
Program: HIV Emergency Relief Project Grants (Ryan White) Federal Financial Assistance Listing Number: 93.914 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: 6H89HA00019-32-04; 2024 Compliance Requirements: Activities Allowable or Unallowed and Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.430, Compensation – Personal Services, states that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: During our testing, for one (1) out of sixty (60) payroll expenditures, we noted the timecard did not contain documented evidence of supervisory approval. Cause: The County’s internal control procedures were not consistently followed to ensure that the review and approval of timecards was documented. Effect: Lack of documented review for personnel hours could lead to an increased risk that unallowable or inaccurate activities and costs to be charged to the Federal program. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sampling of sixty (60) timecards were selected for testing out of a population of 5,994. The condition noted above was identified during our procedures related to activities allowed or unallowed and allowable costs/cost principles. Repeat Finding from Prior Years: No. Recommendation: We recommend that the County strengthen its policies and procedures to ensure that timecards consistently include documented evidence of supervisor approval prior to payroll processing. The County should also establish compensating controls for circumstances where timely supervisory approvals is not possible, and ensure such controls are consistently documented. Management Response and Corrective Action Plan: 1. Person Responsible: Barbara Harano, HCA Disbursements Manager 2. Corrective action plan: HCA Payroll will continue to review the Unapproved Timesheets Report in OC Time and send reminder emails to all supervisors with pending approvals. If supervisory approvals cannot be obtained by the OC Time timesheet upload deadlines, HCA Payroll will ensure documented timesheet approvals are appended through the OC Time amendment process and archived in the Unit’s shared drive. 3. Anticipated Implementation date: January 22, 2026
Program: Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.566 Federal Grantor: U.S. Department of Health and Human Services Pass Through: California Department of Social Services Award No. and Year: Various Compliance Req...
Program: Refugee and Entrant Assistance State/Replacement Designee Administered Programs Federal Financial Assistance Listing Number: 93.566 Federal Grantor: U.S. Department of Health and Human Services Pass Through: California Department of Social Services Award No. and Year: Various Compliance Requirements: Activities Allowed or Unallowed, Allowable Costs/Cost Principles, and Eligibility Type of Finding: Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 45 CFR Part 400, prescribes the eligibility conditions refugees must meet to receive RCA including the following: • RCA recipients must meet the general eligibility requirements for immigration status and refugee identification in accordance with 45 CFR §400.40 - §400.44. • RCA is limited to refugees who are ineligible for TANF, SSI, OAA, AB, APTD, and AABD in accordance with 45 CFR §400.53. • Mandatory work registrants must comply with work requirements and may not voluntarily quit or refuse suitable employment within 30 days prior to application; benefits must be terminated when requirements are not met (45 CFR §§400.75(a), 400.77, and 400.82(a)). • RCA payments may not exceed ORR-authorized rates and may not be less than the State TANF payment rate (45 CFR §§400.60(b) and 400.60(d); ORR PL 22-01). Condition: During our testing of the Social Services Agency’s (SSA) compliance with eligibility and allowable cost/cost principles, we noted the following: • One (1) instance of payment issued to a participant who did not meet eligible immigration status requirements. • One (1) instance of payment issued to a participant who was eligible for another federally funded cash assistance program. • One (1) instance of payment issued to a participant who failed to meet the mandatory work registrant requirements within the required time frame. • One (1) instance of payment issued to a participant using an incorrect benefit rate. Cause: Controls over eligibility determination and benefit rate calculation were not consistently applied, including insufficient verification and supervisory review of eligibility criteria and payment amounts. Effect: Program funds were expended for ineligible participants and an incorrect benefit rate was used, increasing the risk of noncompliance with federal requirements. Questioned Costs: Questioned costs for cases tested in which we determined to be ineligible to receive cash assistance was $1,814. Context/Sampling: A nonstatistical sample of sixty (60) out of all active program participants were sampled. For ineligible cases, we have projected questioned costs against the remaining population for a total of $24,276. The underpayment related to an incorrect benefit rate used was not projected as questioned costs as this did not result in an over-expenditure of federal funds The condition above was identified during our procedures over eligibility, activities allowed or unallowed, and allowable costs/cost principles testing. Repeat Finding from Prior Years: Yes. Recommendation: We recommend that the SSA department strengthen its internal controls to ensure that program eligibility criteria and benefit determinations are properly supported. Management Response and Corrective Action Plan: 1. Person Responsible: Rosa Palacios, Human Services Manager 2. Corrective action plan: Staff Guidance and Eligibility Reminder: Program will issue a reminder to all eligibility staff reinforcing program eligibility requirements and the importance of thoroughly reviewing documentation when making eligibility determinations. The reminder will highlight key areas identified in the audit findings, including verification of immigration eligibility, identifying applicants who may qualify for other federally funded cash assistance programs, and ensuring accurate benefit determinations. Work Requirement Reporting Coordination: Program will also communicate with the contracted provider responsible for monitoring work participation requirements to reinforce expectations regarding timely reporting of participant non-compliance. Internal staff will be reminded to take timely action once non-compliance is reported to ensure benefits are discontinued in accordance with program requirements. System Correction: The incorrect benefit rate identified during the audit was related to a prior system configuration issue that required manual processing. The system has since been updated. Program staff will continue to monitor system updates and verify benefit calculations as needed. 3. Anticipated Implementation date: June 30, 2026
Program: Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 93.323 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Multiple Compliance Requirements: Equipment and Real Property Management Type of Finding: Materia...
Program: Epidemiology and Laboratory Capacity for Infectious Disease Federal Financial Assistance Listing Number: 93.323 Federal Grantor: U.S. Department of Health and Human Services Award No. and Year: Multiple Compliance Requirements: Equipment and Real Property Management Type of Finding: Material Weakness in Internal Control Over Compliance and Material Instance of Noncompliance Criteria: In accordance with 2 CFR section 200.313(d)(1), property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal Award Identification Number), who holds title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. Condition: Property records were not maintained in accordance with Uniform Guidance for all property and equipment purchased. As a result, we were unable to (1) test whether differences between the physical inventory and equipment records were resolved and (2) sample equipment from the property records and physically inspect the equipment and determine whether the equipment is appropriately safeguarded and maintained. Cause: The HCA department did not have adequate internal controls to ensure its property records included all the requirements under Uniform Guidance or properly identify all property and equipment purchased with federal funds. Effect: Property records were not adequately maintained. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: No sampling was used. We examined the Agency’s property records in total. Repeat Finding from Prior Years: Yes. Recommendation: We recommend the HCA department enhance internal controls to ensure its property records include all the requirements under Uniform Guidance and properly identify all property and equipment purchased with federal funds. Management Response and Corrective Action Plan: 1. Person Responsible: Anna Peters, HCA Operations & Support Assistant Deputy Director 2. Corrective action plan: The County of Orange implemented a new Asset Tracking system in 2025 and HCA migrated data from an old legacy system. A funding source field was recently added to the new system to capture job numbers. HCA will ensure all ELC funded property and equipment are properly tracked. 3. Anticipated Implementation date: June 30, 2026
Program: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Federal Financial Assistance Listing Number: 10.557 Federal Grantor: U.S. Department of Agriculture Pass-Through: California Department of Public Health Award No. and Year: 22-10270 A03 and 2022 Compliance Requireme...
Program: WIC Special Supplemental Nutrition Program for Women, Infants, and Children Federal Financial Assistance Listing Number: 10.557 Federal Grantor: U.S. Department of Agriculture Pass-Through: California Department of Public Health Award No. and Year: 22-10270 A03 and 2022 Compliance Requirements: Activities Allowed or Unallowed and Allowable Costs/Cost Principles Type of Finding: Significant Deficiency in Internal Control over Compliance Criteria: 2 CFR Section 200.303(a), Internal Controls, states that the non-Federal entity must establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. 2 CFR Section 200.430, Compensation – Personal Services, states that charges to Federal awards for salaries and wages must be based on records that accurately reflect the work performed. These records must be supported by a system of internal control that provides reasonable assurance that the charges are accurate, allowable, and properly allocated. Condition: During our testing of the HCA’s provisions for activities allowed or unallowed and allowable costs/cost principles requirements, we noted that for one (1) of sixty (60) payroll samples tested, the employee was able to review and approve their own timecard. Cause: It was determined that the control deficiency resulted from a system configuration error that permitted the employee to approve their own timecard under the supervisor/manager review role. Effect: Failure to consistently apply internal controls over payroll charges increases the risk that unallowable or unsupported payroll costs could be charged to the Federal program and not be detected in a timely manner. Questioned Costs: No questioned costs were identified as a result of our procedures. Context/Sampling: A nonstatistical sampling of sixty (60) timecards was selected for testing out of a population of 1,144. The condition noted above was identified during our procedures related to activities allowed or unallowed and allowable costs/cost principles. Repeat Finding from Prior Years: No. Recommendation: Management should ensure appropriate segregation of duties within the payroll system by restricting approval authority to independent supervisors or managers and implementing controls to prevent self-approval. In addition, management should periodically review user access roles and system configurations to confirm that approval controls are operating as designed and that payroll charges to Federal programs are allowable, properly allocated, and adequately supported. Management Response and Corrective Action Plan: 1. Person Responsible: Barbara Harano, HCA Disbursements Manager 2. Corrective action plan: An unexpected change occurred in the OC Time system that allowed an employee to both submit and approve their own timesheet. This issue had been previously reported and resolved. Auditor-Controller IT has reported the issue again to the timekeeping system vendor and is currently validating and testing the updated configuration to ensure the problem does not recur. 3. Anticipated Implementation date: June 30, 2026
The City has commenced the preparation of the FFATA report and is working toward full compliance with reporting requirements. The corrective action is expected to be fully implemented by Fiscal Year 2025/2026. The contact persons for this corrective action are Sabrina Chavez, Director of Public Serv...
The City has commenced the preparation of the FFATA report and is working toward full compliance with reporting requirements. The corrective action is expected to be fully implemented by Fiscal Year 2025/2026. The contact persons for this corrective action are Sabrina Chavez, Director of Public Services, and Martin E. Martinez, Principal Management Analyst, of the City of Perris.
Recommendation We recommend that the Department continue to monitor its monitoring activities over subrecipients, to ensure that they are being performed timely. Management Response Corrective Action The Department acknowledges the corrective action related to the completion of required WIOA monitor...
Recommendation We recommend that the Department continue to monitor its monitoring activities over subrecipients, to ensure that they are being performed timely. Management Response Corrective Action The Department acknowledges the corrective action related to the completion of required WIOA monitoring activities and has taken concrete steps to bring monitoring into compliance. NMDWS has scheduled onsite monitoring reviews and issued formal notification letters to all four subrecipients, as outlined below: • Southwestern Local Workforce Development Board: Notification letter sent January 26, 2026; onsite monitoring scheduled for March 9–13, 2026 • Northern Area Local Workforce Development Board: Notification letter sent January 26, 2026; onsite monitoring scheduled for April 20–24, 2026 • Workforce Connection of Central New Mexico: Notification letter sent January 5, 2026; onsite monitoring scheduled for May 4–11, 2026 • Eastern Area Workforce Development Board: Notification letter sent January 26, 2026; onsite monitoring scheduled for May 18–22, 2026 The Department has completed Program Years 2022, 2023 and 2024. In addition, the Department has also completed a Program Year 2024 risk assessment, which is now incorporated into the grant agreements. The WIOA Monitoring Unit will continue to utilize the Department’s Grant Risk Assessment tool for future grant agreements to ensure consistent and risk-informed monitoring. Finally, the WIOA Monitoring Unit has drafted a comprehensive subrecipient monitoring policy. This policy will establish clear monitoring standards for subrecipients and pass-through entities under WIOA Title I-B and related discretionary awards, including monitoring frequency, scope, and requirements for monitoring letters and reports. These actions are intended to address the identified deficiencies and strengthen the Department’s monitoring framework moving forward. Due Date of Completion: June 30, 2026 Responsible Party(ies): Administrative Services Division Director
Corrective actions include: 1. Enhanced Monitoring Procedures o A weekly aging report of all withdrawn students will be generated by the Financial Aid Office to track the number of days elapsed since the withdrawal determination date. o The report will clearly flag any files approaching 30 days to e...
Corrective actions include: 1. Enhanced Monitoring Procedures o A weekly aging report of all withdrawn students will be generated by the Financial Aid Office to track the number of days elapsed since the withdrawal determination date. o The report will clearly flag any files approaching 30 days to ensure timely processing. 2. Documented Supervisory Review o All R2T4 calculations will be reviewed and signed off by a supervisory-level staff member prior to submission. o Evidence of review will be retained in the student’s file. 3. Holiday and Break Coverage Planning o The Financial Aid Office will establish a written coverage plan during holiday periods and institutional breaks to ensure R2T4 calculations and returns continue to be processed within required timelines. o Cross-training of at least one additional staff member has been implemented to prevent delays due to staffing constraints. 4. Periodic Internal Reconciliation o On a quarterly basis, the CFO or designee will review a summary reconciliation of all withdrawals and related R2T4 returns to verify compliance with the 45-day requirement.
Finding: 2025-005 Name of Contact Person: Linda Higuet, Interim Finance Director Corrective Action: Management will make organizational changes as needed to ensure that each program is self-sustaining. Upper level management will obtain training for allowable costs/cost principles and activities all...
Finding: 2025-005 Name of Contact Person: Linda Higuet, Interim Finance Director Corrective Action: Management will make organizational changes as needed to ensure that each program is self-sustaining. Upper level management will obtain training for allowable costs/cost principles and activities allowed/unallowed under the Uniform Guidance and specific program regulations. Additionally, all upper level management will obtain training for financial and program specific reporting. Financial reports will be reviewed monthly by program directors, and program specific reporting will undergo monthly review by program directors. Proposed Completion Date: As soon as possible.
Finding: 2025-006 Name of Contact Person: Charshae Phillips, Section 8 Director Corrective Action: Document retention requirements will be re-emphasized to all staff, and all staff will attend training to ensure that all required documentation is obtained and maintained in accordance with program re...
Finding: 2025-006 Name of Contact Person: Charshae Phillips, Section 8 Director Corrective Action: Document retention requirements will be re-emphasized to all staff, and all staff will attend training to ensure that all required documentation is obtained and maintained in accordance with program regulations. Proposed Completion Date: As soon as possible.
Finding: 2025-004 Name of Contact Person: Linda Higuet, Interim Finance Director Corrective Action: Management will review all costs to ensure they are allowable and in accordance with the cost principles of the Uniform Guidance and specific program regulations, as applicable. Management will obtain...
Finding: 2025-004 Name of Contact Person: Linda Higuet, Interim Finance Director Corrective Action: Management will review all costs to ensure they are allowable and in accordance with the cost principles of the Uniform Guidance and specific program regulations, as applicable. Management will obtain training regarding these cost principles and regulations. Proposed Completion Date: Immediately.
CORRECTIVE ACTION PLAN U.S. Department of Education | Arizona Department of Education Tuba City Unified School District No. 15 respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 1, 2024 – June 30, 2025 The findings from the schedule of find...
CORRECTIVE ACTION PLAN U.S. Department of Education | Arizona Department of Education Tuba City Unified School District No. 15 respectfully submits the following corrective action plan for the year ended June 30, 2025. Audit period: July 1, 2024 – 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. FINANCIAL STATEMENT FINDINGS 2025-001 INFORMATION TECHNOLOGY Type of Finding: Material Weakness in Internal Control Over Financial Reporting Condition/Context: The District did not establish internal control procedures over information technology systems to ensure proper protection of District and student data. The following control deficiencies were noted regarding the District’s information technology policies and procedures: • The District did not limit access within the District’s accounting software to only those areas in each employee’s job function. Several employees had full administrative access to the accounting software, including third-party consultants, without compensating manual controls. • The District did not have a formal written policy regarding system or software changes. • Data-sharing agreements with third party provides that had access to the District’s data were not provided. • Documentation was not provided to support that the IT systems generated electronic audit trail reports or change logs were being reviewed or analyzed. This would include systemgenerated incident or error reports. • Disaster recovery and contingency plans were not provided. Recommendation: To strengthen internal controls, the District should evaluate its procedures regarding information technology security. The District should review and establish IT policies and procedures to protect the District’s data, train employees, establish backup plans, disaster recover or contingency plans, and 3rd party security and data confidentiality agreements. System general irregularity reports, including incident or error reports should be reviewed on an ongoing basis. Corrective Action: The District will evaluate its procedures regarding information technology security. The District will review and establish IT policies and procedures to protect the District’s data, disaster recovery or contingency plans, and 3rd party security and data confidentiality agreements. Additionally, the District will review system generated irregularity reports, including incident or error reports on an ongoing basis. Planned completion date for corrective action plan: For the period ending June 30, 2026. Name of the contact person responsible for corrective action: Leah Begay, Business Manager
Eligibility - Direct Loan Awarding Federal Direct Student Loans (84.268) Recommendation: We recommend that the University enhance its policies and procedures related to the packaging and awarding of financial aid, particularly in situations requiring manual calculations or professional judgment, to ...
Eligibility - Direct Loan Awarding Federal Direct Student Loans (84.268) Recommendation: We recommend that the University enhance its policies and procedures related to the packaging and awarding of financial aid, particularly in situations requiring manual calculations or professional judgment, to ensure student eligibility is accurately determined and awards are properly calculated. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective immediately, we've added a required review step for any aid package that is adjusted using professional judgment. This review focuses specifically on confirming that annual loan limits and subsidized eligibility are recalculated correctly after any change. Staff has also received refresher training on subsidized loan eligibility and amounts, and how to verify that the correct amount is awarded when appropriate. In addition, we will incorporate periodic spot checks of files involving manual adjustments to ensure calculations are accurate and consistent. Name(s) of the contact person(s) responsible for corrective action: Erica Riggs Planned completion date for corrective action plan: Spring 2026, ongoing.
Special Tests - Return to Title IV Funds (R2T4) Federal Direct Student Loans (84.268), Federal Pell Grant Program (84.063), Federal Supplemental Educational Opportunity Grants (84.007), and Teacher Education Assistance for College and Higher Education Grants (84.379) Recommendation: We recommend tha...
Special Tests - Return to Title IV Funds (R2T4) Federal Direct Student Loans (84.268), Federal Pell Grant Program (84.063), Federal Supplemental Educational Opportunity Grants (84.007), and Teacher Education Assistance for College and Higher Education Grants (84.379) Recommendation: We recommend that the University strengthen internal controls over the R2T 4 process by implementing standardized procedures, ensuring system calculations are accurate, and establishing consistent and documented review of R2T4 calculations prior to the return of Title IV funds. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Effective immediately, all R2T4 calculations will undergo a secondary review prior to funds being returned. The review will be documented via a shared document to ensure staff are consistently verifying withdrawal date, percentcompleted, return amounts per program, and timeliness. This document will be retained for audit purposes. We've also set internal deadlines to ensure funds are being returned within the 45-day requirement under Title IV. Calculations will be completed within 25 days of determining a withdrawal, and returns will be processed within 35 days. This will be tracked in a shared document that will also be retained for audit purposes. SOU is implementing a new Student Information System (SIS) beginning with the 2026-2027 academic year. Until we transition to the new SIS, known issues in the current SIS will be documented, and staff will manually review and override calculations where discrepancies are identified. As part of the new SIS implementation, we'll validate all R2T4 calculations to ensure system accuracy. All financial aid staff responsible for R2T4 processing will receive refresher training on calculation requirements, withdrawal date determination, and return timelines. We will also provide cross-training to additional staff to ensure continuity if there are additional staffing changes. Name(s) of the contact person(s) responsible for corrective action: Erica Riggs Planned completion date for corrective action plan: Fall 2026 and ongoing
Special Tests - Enrollment Reporting Federal Direct Student Loans and Federal Pell Grant Program - Assistance Listing No. 84.268 and 84.063 Recommendation: We recommend that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the thi...
Special Tests - Enrollment Reporting Federal Direct Student Loans and Federal Pell Grant Program - Assistance Listing No. 84.268 and 84.063 Recommendation: We recommend that the University enhance its policies and procedures regarding enrollment reporting including additional monitoring over the third-party service provider to ensure that reporting is completed accurately and timely. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: New registrar hired 9/2025 has enhanced policies and procedures regarding enrollment reporting by initiating regular and frequent (weekly/biweekly) contact with the National Student Clearinghouse (NSC) to ensure that reporting is completed accurately and timely. Names of the contact person responsible for corrective action: Jennifer Bratz Planned completion date for corrective action plan: Correction action plan involves ongoing regular communication with NSC and regular monitoring of reports for timeliness and accuracy, no completion date.
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