EIN: 455281837
UEI: KTV2FNPR2BR7
Audited by: Price Paige & Company
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on May 14, 2025. 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 November 14, 2025 (297 days ago).
What is a management decision? →During our review of compliance over reporting, we found that the monthly reports were not timely completed. In addition, the reports included amounts inconsistent with the amounts recorded in the accounting system. Criteria: Recipients of Federal awards must submit performance and financial reports as required by the terms and conditions of the award. Reports must be accurate, complete, and submitted timely as specified by the awarding agency. Cause: Internal controls over reporting compliance requirements were not properly designed and were not placed in operation. Management is responsible for compliance with requirements over reporting and for the design, implementation, and maintenance of effective internal controls over compliance with the requirements of laws, statutes, regulations, rules, and provisions of grant agreements applicable to its federal program. Effect: Failure to submit accurate and timely reports may result in noncompliance with the Uniform Guidance and grant terms, potentially impacting continued funding or triggering additional oversight by the awarding agency. Recommendation: We recommend that management strengthen internal controls over the reporting process, including implementing a reporting calendar, assigning clear responsibilities for report preparation and review, and conducting training for personnel involved in report preparation. Management’s Response: See Corrective Action Plan.
Show full finding ▾Hide full finding ▴Condition: During our review of compliance over reporting, we found that the monthly reports were not timely completed. In addition, the reports included amounts inconsistent with the amounts recorded in the accounting system. Criteria: Recipients of Federal awards must submit performance and financial reports as required by the terms and conditions of the award. Reports must be accurate, complete, and submitted timely as specified by the awarding agency. Cause: Internal controls over reporting compliance requirements were not properly designed and were not placed in operation. Management is responsible for compliance with requirements over reporting and for the design, implementation, and maintenance of effective internal controls over compliance with the requirements of laws, statutes, regulations, rules, and provisions of grant agreements applicable to its federal program. Effect: Failure to submit accurate and timely reports may result in noncompliance with the Uniform Guidance and grant terms, potentially impacting continued funding or triggering additional oversight by the awarding agency. Recommendation: We recommend that management strengthen internal controls over the reporting process, including implementing a reporting calendar, assigning clear responsibilities for report preparation and review, and conducting training for personnel involved in report preparation. Management’s Response: See Corrective Action Plan.
Reporting Calendar and Schedule: A grant reporting calendar will be created and maintained, outlining all required reporting deadlines for each funding source, including due dates, responsible staff, and required documentation. The calendar will be reviewed weekly by the Finance Director to ensure upcoming deadlines are met. Assignment of Responsibilities: Clear responsibilities will be assigned to specific personnel for each step of the reporting process, including data preparation, report drafting, internal review, and final submission. A checklist will be used for each report to document the review proceduress and ensure all elements are completed accurately and timely. Reconciliation Procedures: All reports will be reconciled to the general ledger and supporting schedules prior to submission to ensure consistency and accuracy. Supporting documentation will be attached to each report file to provide an audit trail. Internal Review Process: A second-level review by the Controller or Finance Director will be required before reports are submitted to funding agencies. Review will include verifying accuracy, completeness, and agreement with accounting system data. Training and Internal Controls: Staff responsible for report preparation will undergo annual training on grant compliance requirements, Uniform Guidance, and reporting accuracy. Internal controls will be documented in Grants Management Policy and Procedures Manual, including reporting guidelines. Monitoring and Follow-Up: Compliance with the reporting calendar and procedures will be tracked monthly. Any missed or delayed reports will be investigated, and corrective actions taken immediately.
2022-007
During our review of compliance over reporting, we found that the monthly reports were not timely completed. In addition, the reports included amounts inconsistent with the amounts recorded in the accounting system. Criteria: Recipients of Federal awards must submit performance and financial reports as required by the terms and conditions of the award. Reports must be accurate, complete, and submitted timely as specified by the awarding agency. Cause: Internal controls over reporting compliance requirements were not properly designed and were not placed in operation. Management is responsible for compliance with requirements over reporting and for the design, implementation, and maintenance of effective internal controls over compliance with the requirements of laws, statutes, regulations, rules, and provisions of grant agreements applicable to its federal program. Effect: Failure to submit accurate and timely reports may result in noncompliance with the Uniform Guidance and grant terms, potentially impacting continued funding or triggering additional oversight by the awarding agency. Recommendation: We recommend that management strengthen internal controls over the reporting process, including implementing a reporting calendar, assigning clear responsibilities for report preparation and review, and conducting training for personnel involved in report preparation. Management’s Response: See Corrective Action Plan.
Show full finding ▾Hide full finding ▴Condition: During our review of compliance over reporting, we found that the monthly reports were not timely completed. In addition, the reports included amounts inconsistent with the amounts recorded in the accounting system. Criteria: Recipients of Federal awards must submit performance and financial reports as required by the terms and conditions of the award. Reports must be accurate, complete, and submitted timely as specified by the awarding agency. Cause: Internal controls over reporting compliance requirements were not properly designed and were not placed in operation. Management is responsible for compliance with requirements over reporting and for the design, implementation, and maintenance of effective internal controls over compliance with the requirements of laws, statutes, regulations, rules, and provisions of grant agreements applicable to its federal program. Effect: Failure to submit accurate and timely reports may result in noncompliance with the Uniform Guidance and grant terms, potentially impacting continued funding or triggering additional oversight by the awarding agency. Recommendation: We recommend that management strengthen internal controls over the reporting process, including implementing a reporting calendar, assigning clear responsibilities for report preparation and review, and conducting training for personnel involved in report preparation. Management’s Response: See Corrective Action Plan.
Establish and Maintain a Reporting Calendar: A comprehensive grant reporting calendar will be implemented to track all financial and performance reporting deadlines. Calendar will include due dates, responsible staff, and required supporting documentation. Assigned Clear Roles and Responsibilities: Each grant report will have a designated preparer and reviewer. The Controller will be responsible for ensuring that all reports reconcile to the general ledger before submission. Implemented Standardized Reporting Procedures: A written Grants Reporting and Procedure Manual will be developed outining step-by-step procedures for preparing, reviewing, and submitting reports. Reports will only be submitted after reconciliation with the accounting system and documented approval from the Finance Director or Controller. Training and Capacity Building: Staff responsible for grant reporting will receive annual training on federal compliance requirements, Uniform Guidance, and internal procedures. Training sessions will include examples of common reporting errors and reconciliation best practices. Monitoring and Internal Reviews: The Finance Director will conduct a monthly compliance check to verify timely completion and accuracy of each report. Quarterly internal audits will be conducted to assess adherence to the reporting procedures and controls.
FAC accepted this audit on May 6, 2024 — management decision was due November 6, 2024.
During our review of compliance over reporting, we found that the December 31, 2022 monthly invoices were not timely completed. In addition, the reports included indirect costs that did not have adequate support and therefore deemed unallowable in nature and excluded from the expenses reflected in the SEFA. Criteria: Federal financial report submissions are required within a specific time frame as imposed by the grantor. There are mechanisms in place to identify risks of faulty reporting caused by such items as lack of current knowledge of, inconsistent application of, or carelessness or disregard for standards and reporting requirements of Federal awards. A supervisory review of reports is performed to assure accuracy and completeness of data and information included in the reports. Cause: Internal controls over reporting compliance requirements were not properly designed and were not placed in operation. Management is responsible for compliance with requirements over Reporting and for the design, implementation, and maintenance of effective internal controls over compliance with the requirements of laws, statutes, regulations, rules, and provisions of grant agreements applicable to its federal program. Effect: As a result of this condition, the December 31, 2022 monthly invoices were not timely completed and submitted to the appropriate funding agency. Recommendation: We recommend BAIHP develop a policies and procedures manual for reporting compliance, which should include a checklist detailing all the necessary steps to ensure a proper submission of year-end invoices.
Show full finding ▾Hide full finding ▴Condition: During our review of compliance over reporting, we found that the December 31, 2022 monthly invoices were not timely completed. In addition, the reports included indirect costs that did not have adequate support and therefore deemed unallowable in nature and excluded from the expenses reflected in the SEFA. Criteria: Federal financial report submissions are required within a specific time frame as imposed by the grantor. There are mechanisms in place to identify risks of faulty reporting caused by such items as lack of current knowledge of, inconsistent application of, or carelessness or disregard for standards and reporting requirements of Federal awards. A supervisory review of reports is performed to assure accuracy and completeness of data and information included in the reports. Cause: Internal controls over reporting compliance requirements were not properly designed and were not placed in operation. Management is responsible for compliance with requirements over Reporting and for the design, implementation, and maintenance of effective internal controls over compliance with the requirements of laws, statutes, regulations, rules, and provisions of grant agreements applicable to its federal program. Effect: As a result of this condition, the December 31, 2022 monthly invoices were not timely completed and submitted to the appropriate funding agency. Recommendation: We recommend BAIHP develop a policies and procedures manual for reporting compliance, which should include a checklist detailing all the necessary steps to ensure a proper submission of year-end invoices.
Create Reporting Compliance policies and procedures manual, create checklist of reporting steps, reviewed monthly
During our review of compliance over eligibility, we identified one ineligible patient related to eligibility testing due to missing documentation to support eligibility determination. Criteria: Eligibility Control Activities including written policies to provide direction for making and documenting eligibility determinations, procedures to calculate eligibility amounts are consistent with program requirements, and a process for periodic eligibility re-determinations in accordance with program requirements are required to ensure only eligible individuals are receiving assistance using federal funding. Cause: Internal controls over eligibility compliance requirements were not properly designed and were not placed in operation. Management is responsible for compliance with requirements over Eligibility and for the design, implementation, and maintenance of effective internal controls over compliance with the requirements of laws, statutes, regulations, rules, and provisions of grant agreements applicable to its federal program. Effect: As a result of this condition, patient medical records include missing information regarding patient’s eligibility to receive medical assistance using federal funding. Recommendation: We recommend BAIHP implement a checklist detailing what documentation is required and what must be retained when determining a patient is eligible for benefits under the program and should include a secondary review of the patient file by someone other than the preparer.
Show full finding ▾Hide full finding ▴Condition: During our review of compliance over eligibility, we identified one ineligible patient related to eligibility testing due to missing documentation to support eligibility determination. Criteria: Eligibility Control Activities including written policies to provide direction for making and documenting eligibility determinations, procedures to calculate eligibility amounts are consistent with program requirements, and a process for periodic eligibility re-determinations in accordance with program requirements are required to ensure only eligible individuals are receiving assistance using federal funding. Cause: Internal controls over eligibility compliance requirements were not properly designed and were not placed in operation. Management is responsible for compliance with requirements over Eligibility and for the design, implementation, and maintenance of effective internal controls over compliance with the requirements of laws, statutes, regulations, rules, and provisions of grant agreements applicable to its federal program. Effect: As a result of this condition, patient medical records include missing information regarding patient’s eligibility to receive medical assistance using federal funding. Recommendation: We recommend BAIHP implement a checklist detailing what documentation is required and what must be retained when determining a patient is eligible for benefits under the program and should include a secondary review of the patient file by someone other than the preparer.
Create eligibility verification checklist, policy and procedures
FAC accepted this audit on September 29, 2022 — management decision was due March 29, 2023.
FAC accepted this audit on November 30, 2021 — management decision was due May 30, 2022.
FAC accepted this audit on January 3, 2021 — management decision was due July 3, 2021.
FAC accepted this audit on July 28, 2019 — management decision was due January 28, 2020.
FAC accepted this audit on June 3, 2018 — management decision was due December 3, 2018.
FAC accepted this audit on July 10, 2017 — management decision was due January 10, 2018.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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