EIN: 330672915
UEI: ZS3YMNTMXVE3
Audited by: Ernst & Young LLP
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 31, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on December 21, 2023. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by June 21, 2024 (803 days ago).
What is a management decision? →FAC accepted this audit on January 3, 2023 — management decision was due July 3, 2023.
Per discussion with management, the Company has processes and internal controls over the terms and conditions of the award and transactional level internal controls in place to ensure Coronavirus related expenses reported to HHS through their reporting portal (the Portal). However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect: There is no documentation to support the performance of internal controls for the term and conditions of the award and the expenses attributable to Coronavirus calculation. Questioned Costs: None Context: During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and condition of the award and the calculation of expenses attributable to Coronavirus reported during July 1, 2021 to June 30, 2022. Identification as a repeat finding, if applicable: The finding is a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management adheres to the terms and conditions of the award and retain documentation evidencing that management reviewed the completeness and accuracy of expenses attributable to Coronavirus calculation. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal expenditures and terms and conditions.
Show full finding ▾Hide full finding ▴Finding 2022-001 ? Internal Control Deficiency over A. Activities Allowed or Unallowed Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.498 Provider Relief Funds Award Period of Performance: Period 1 ? July 1, 2021 to June 30, 2022 Criteria or Specific Requirement (including statutory, regulatory or other citation): Title 2, Subtitle A Chapter II Part 200 Subpart D 200.303 Internal controls. The non-Federal entity must: (a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The terms and conditions of the award requires the following: ? The recipient certified that the payment will only be used to prevent, prepare for, and respond to coronavirus, and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. ? The recipient certifies that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. ? The recipient shall submit reports as the secretary of Health and Human Services (HHS) determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. Condition: Per discussion with management, the Company has processes and internal controls over the terms and conditions of the award and transactional level internal controls in place to ensure Coronavirus related expenses reported to HHS through their reporting portal (the Portal). However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect: There is no documentation to support the performance of internal controls for the term and conditions of the award and the expenses attributable to Coronavirus calculation. Questioned Costs: None Context: During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and condition of the award and the calculation of expenses attributable to Coronavirus reported during July 1, 2021 to June 30, 2022. Identification as a repeat finding, if applicable: The finding is a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management adheres to the terms and conditions of the award and retain documentation evidencing that management reviewed the completeness and accuracy of expenses attributable to Coronavirus calculation. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal expenditures and terms and conditions.
Finding 2022-001 Please see management?s action plan below in response to EY?s Federal Award Finding and Questions Costs, 2022-001 ? ?During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and conditions of the award and the calculation of expenses attributable to Coronavirus reported during July 1, 2021 to June 30, 2022?. Management?s Response and Action Plan: Management has had in place internal controls to ensure that the calculation of expenses attributable to Coronavirus is correct and accurate. Management recognizes the need to document internal controls over terms and conditions and expenses attributable to Coronavirus. Management will ensure that documentation for compliance with internal controls is maintained to substantiate review of terms and conditions and expenses attributable to Coronavirus. Responsible party: Dessy Chi, Director of Finance-LLUHC, FP&S Expected Completion Date: December 31, 2022 with Period 4 portal submission
2021-001
Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect: There is no documentation to support the performance of internal controls for the lost revenue calculation. Questioned Costs: None Context: Total PRF lost revenues were $26,172,865. Management selected budget versus actual to calculate lost revenues. The amounts reported agreed to the budget and actual revenues as reported in the portal. Identification as a repeat finding, if applicable: The finding is a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management reviewed the completeness and accuracy of the lost revenue calculation. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal lost revenues.
Show full finding ▾Hide full finding ▴Finding 2022-002 ? Internal Control Deficiency over L. Reporting Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Provider Relief Funds Award Period of Performance: July 1, 2021 ? June 30, 2022 Criteria or Specific Requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect: There is no documentation to support the performance of internal controls for the lost revenue calculation. Questioned Costs: None Context: Total PRF lost revenues were $26,172,865. Management selected budget versus actual to calculate lost revenues. The amounts reported agreed to the budget and actual revenues as reported in the portal. Identification as a repeat finding, if applicable: The finding is a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management reviewed the completeness and accuracy of the lost revenue calculation. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal lost revenues.
Finding 2022-002 Please see management?s action plan below in response to EY?s Federal Award Finding and Questions Costs, 2022-002 ? ?Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls.? Management?s Response and Action Plan: Management has had in place internal controls to ensure that the calculation of lost revenues is correct and accurate. Management recognizes the need to document internal controls over lost revenue for PRF funds. Management will ensure that documentation for compliance with internal controls is maintained to substantiate lost revenue related to PRF funds. Responsible party: Jordan Urban, AVP Finance, FP&S Expected Completion Date: December 31, 2022 with Period 4 portal submission
2021-002
FAC accepted this audit on September 8, 2022 — management decision was due March 8, 2023.
During our testing of the PRF program, we noted that management did not have effective internal controls over the terms and conditions of the award or transactional level internal controls in place to ensure Coronavirus related expenses reported to HHS through their reporting portal (the Portal) were accurate and complete. This resulted in an overstatement of expenses included in the PRF submission. Effect or potential effect: Non-compliance with the term and conditions of the award and the expenses attributable to Coronavirus were reported incorrectly in the Portal. Questioned Costs: $505,471 ? Assistance Listing Number 93.498 The questioned costs were computed as the difference between the expenses attributable to Coronavirus reported in the Portal of $1,052,499 and the actual expenses attributable to Coronavirus of $547,028. Context: During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and condition of the award and that the expenses attributable to Coronavirus reported during March 2020 to December 2020 reports included expenses that were duplicated. The total overstatement of expenses was $505,471. Total expenses attributable to Coronavirus submitted in the Portal was $1,052,499 compared to actual expenses attributable to Coronavirus of $547,028. Management?s control regarding the review of the PRF reports did not identify the duplication of expenses when submitting the Period 1 submissions into the Portal. The overstatements resulted in the entity reporting expenses in excess of what was incurred. Identification as a repeat finding, if applicable:No. Recommendation: Management should develop and implement effective internal controls to ensure adherence to the terms and conditions of the award and accurate reporting in the Portal to only report actual incurred expenses. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal expenditures and terms and conditions.
Show full finding ▾Hide full finding ▴Finding 2021-001 ? Internal Control Deficiency and Noncompliance over A. Activities Allowed or Unallowed Identification of the federal program: Federal Grantor: United States Department of Health and Human Services Assistance Listing No.: 93.498 Provider Relief Funds Award Period of Performance: Period 1 ? January 1, 2020 to June 30, 2021 Criteria or Specific Requirement (including statutory, regulatory or other citation): Title 2, Subtitle A Chapter II Part 200 Subpart D 200.303 Internal controls. The non-Federal entity must: (a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). The terms and conditions of the award requires the following: ? The recipient certified that the payment will only be used to prevent, prepare for, and respond to coronavirus, and that the payment shall reimburse the recipient only for health care related expenses or lost revenues that are attributable to coronavirus. ? The recipient certifies that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse. ? The recipient shall submit reports as the secretary of Health and Human Services (HHS) determines are needed to ensure compliance with conditions that are imposed on the payment, and such reports shall be in such form, with such content, as specified by the secretary of HHS in future program instructions directed to all recipients. Condition: During our testing of the PRF program, we noted that management did not have effective internal controls over the terms and conditions of the award or transactional level internal controls in place to ensure Coronavirus related expenses reported to HHS through their reporting portal (the Portal) were accurate and complete. This resulted in an overstatement of expenses included in the PRF submission. Effect or potential effect: Non-compliance with the term and conditions of the award and the expenses attributable to Coronavirus were reported incorrectly in the Portal. Questioned Costs: $505,471 ? Assistance Listing Number 93.498 The questioned costs were computed as the difference between the expenses attributable to Coronavirus reported in the Portal of $1,052,499 and the actual expenses attributable to Coronavirus of $547,028. Context: During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and condition of the award and that the expenses attributable to Coronavirus reported during March 2020 to December 2020 reports included expenses that were duplicated. The total overstatement of expenses was $505,471. Total expenses attributable to Coronavirus submitted in the Portal was $1,052,499 compared to actual expenses attributable to Coronavirus of $547,028. Management?s control regarding the review of the PRF reports did not identify the duplication of expenses when submitting the Period 1 submissions into the Portal. The overstatements resulted in the entity reporting expenses in excess of what was incurred. Identification as a repeat finding, if applicable:No. Recommendation: Management should develop and implement effective internal controls to ensure adherence to the terms and conditions of the award and accurate reporting in the Portal to only report actual incurred expenses. View of Responsible Officials: Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal expenditures and terms and conditions.
Finding 2021-001 Please see management?s action plan below in response to EY?s Federal Award Finding and Questions Costs, 2021-001 ? ?During our testing over the PRF program, we observed that management did not retain evidence of controls surrounding the terms and condition of the award and that the expenses attributable to Coronavirus reported during March 2020 to December 2020 reports included expenses that were duplicated. The total overstatement of expenses was $505,471. Total expenses attributable to Coronavirus submitted in the Portal was $1,052,499 compared to actual expenses attributable to Coronavirus of $547,028. Management?s control regarding the review of the PRF reports did not identify the duplication of expenses when submitting the Period 1 submissions into the Portal. The overstatements resulted in the entity reporting expenses in excess of what was incurred.?. Management?s Response and Action Plan: In reviewing of payroll reports attributable to Coronavirus, certain numbers were duplicated for payroll periods from March 2020 to December 2020. Management has identified the problem to be a reporting issue when reports were produced and has since reconciled payroll reports from January 2021 to June 2022 without further issues. The overstated payroll expense of $505,471 was reported during PRF Period 1 submission. Total lost revenues and expenses reported in the PRF portal in Reporting Period 1 significantly exceeded PRF funds received through June 30, 2020. Management has reviewed and reconciled provided payroll reports and will continue the practice for the remaining of the PRF portal reporting preparation and review. Responsible party: Dessy Chi, Director of Finance-LLUHC, FP&S Expected Completion Date: December 31, 2022 with Period 4 portal submission
Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect:There is no documentation to support the performance of internal controls for the lost revenue calculation. Questioned Costs: None Context:Total PRF lost revenues were $20,554,189. Management selected budget versus actual to calculate lost revenues. The amounts reported agreed to the budget and actual revenues as reported in the Portal. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management reviewed the completeness and accuracy of the lost revenue calculation. View of Responsible Officials:Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal lost revenues.
Show full finding ▾Hide full finding ▴Finding 2021-002 ? Internal Control Deficiency over L. Reporting Identification of the federal program: Federal Grantor: United States Department of Health and Human Services, Health Resources and Services Administration (HRSA) Assistance Listing No.: 93.498 Provider Relief Funds Award Period of Performance: January 16, 2020 ? June 30, 2021 Criteria or Specific Requirement (including statutory, regulatory or other citation): Section 200.303 of the Uniform Guidance states the following regarding internal control: ?The non-Federal entity must: (a) 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. These internal controls should be in compliance with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls. Effect or potential effect:There is no documentation to support the performance of internal controls for the lost revenue calculation. Questioned Costs: None Context:Total PRF lost revenues were $20,554,189. Management selected budget versus actual to calculate lost revenues. The amounts reported agreed to the budget and actual revenues as reported in the Portal. Identification as a repeat finding, if applicable: The finding is not a repeat finding. Recommendation: Management should refine its process and retain documentation evidencing that management reviewed the completeness and accuracy of the lost revenue calculation. View of Responsible Officials:Management agrees with the finding. Management will develop internal controls to review and approve supporting documentation and calculations of the Provider Relief Fund federal lost revenues.
Finding 2021-002 Please see management?s action plan below in response to EY?s Federal Award Finding and Questions Costs, 2021-002 ? ?Per discussion with management, the Company has processes and internal controls in place to ensure the lost revenue calculation submitted for PRF was complete and accurate and complied with the terms and conditions as reported in the HRSA Portal filings. However, management did not retain documentation evidencing the performance of these controls.? .?. Management?s Response and Action Plan: Management has had in place internal controls to ensure that the calculation of lost revenues is correct and accurate. Management recognizes the need to document internal controls over lost revenue for PRF funds. Management will ensure that documentation for compliance with internal controls is maintained to substantiate lost revenue related to PRF funds. Responsible party: Jordan Urban, AVP Finance, FP&S Expected Completion Date: December 31, 2022 with Period 4 portal submission
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