EIN: 521694523
UEI: KRMFHP9MCKF8
Audited by: SB & Company, LLC
Oversight agency: 93 [Department of Health and Human Services]
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Data as of August 28, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on March 31, 2026. 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 October 1, 2026 (33 days from today).
What is a management decision? →During our testing and review of the Organization’s procurement policy, we were unable to obtain documentation to support the inquiries around suspension and disbarment of 2 out of 5 selected vendors.
Show full finding ▾Hide full finding ▴During our testing and review of the Organization’s procurement policy, we were unable to obtain documentation to support the inquiries around suspension and disbarment of 2 out of 5 selected vendors.
We concur with the finding, and a corrective action plan was implemented on March 15, 2026. We have modified our Accounting Policies and Procedures to include reviewing the website for vendors that are debarred from doing business using Federal Funding http://www.sam.gov/. This process will be documented as we obtain the various quotes from vendors over a certain dollar amount threshold. Documentation of such will be maintained in the vendor files. The process will be completed by the Operations Manager and will be reviewed by the CFO and the Executive Director.
FAC accepted this audit on March 31, 2025 — management decision was due October 1, 2025.
FAC accepted this audit on March 5, 2024 — management decision was due September 5, 2024.
FAC accepted this audit on March 30, 2023 — management decision was due September 30, 2023.
FAC accepted this audit on May 25, 2022 — management decision was due November 25, 2022.
During our discussion with management and review of the Organization?s procurement policy, we were unable to obtain documentation to support compliance with the procurement policy and related internal controls. Additionally, documentation was not available to support the inquiries around suspension and debarment. Criteria: The Uniform Guidance and 45 CF Part 75 require that non-Federal entities receiving Federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. The characteristics of internal controls are presented in the context of the components of internal controls discussed in the Internal Control-Integrated Framework (COSO Report), published by the Committee of Sponsoring Organizations of the Treadway Commission. The COSO Report provides a framework for organizations to design, implement, and evaluate controls that will facilitate compliance with the requirements of Federal laws, regulations, and program compliance requirements. Per 2 CFR 200.318 General procurement stands: (a) The non-Federal entity must use is own documented procurement procedures which reflect applicable State, local, and tribal laws and regulations, provided that the procurements conform to applicable Federal law and the standards identified in this part. Per Uniform Guidance, Non-Federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. ?Covered transactions? include contracts for goods and services awarded under a non-procurement transaction (e.g., grant or cooperative agreement) that are expected to equal or exceed $25,000 or meet certain other criteria as specified in 2 CFR section 180.220. All non-procurement transactions entered into by a pass-through entity (i.e., subawards to subrecipients), irrespective of award amount, are considered covered transactions, unless they are exempt as provided in 2 CFR section 180.215.Cause: The Organization did not follow the procedures in place to document and support its compliance with its written procurement policies or to the related procurement processes under Uniform Guidance guidelines and did not follow the process in place to perform and document the verifications of suspended, debarred, or otherwise excluded entities. Effect: The Organization does not have adequate documentation on whether they have entered into transactions with ineligible entities and is not in compliance with Federal guidelines. Recommendation: We recommend the Organization update and follow their controls to identify vendors that should go through the procurement process. We also recommend the Organization follow their process to verify that entities are not suspended, debarred, or otherwise excluded annually at time of award and to document these procedures. The process should apply to procurement and non-procurement awards. Views of Responsible Officials: See schedule of corrective action.
Show full finding ▾Hide full finding ▴Condition: During our discussion with management and review of the Organization?s procurement policy, we were unable to obtain documentation to support compliance with the procurement policy and related internal controls. Additionally, documentation was not available to support the inquiries around suspension and debarment. Criteria: The Uniform Guidance and 45 CF Part 75 require that non-Federal entities receiving Federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations, and program compliance requirements. The characteristics of internal controls are presented in the context of the components of internal controls discussed in the Internal Control-Integrated Framework (COSO Report), published by the Committee of Sponsoring Organizations of the Treadway Commission. The COSO Report provides a framework for organizations to design, implement, and evaluate controls that will facilitate compliance with the requirements of Federal laws, regulations, and program compliance requirements. Per 2 CFR 200.318 General procurement stands: (a) The non-Federal entity must use is own documented procurement procedures which reflect applicable State, local, and tribal laws and regulations, provided that the procurements conform to applicable Federal law and the standards identified in this part. Per Uniform Guidance, Non-Federal entities are prohibited from contracting with or making subawards under covered transactions to parties that are suspended or debarred. ?Covered transactions? include contracts for goods and services awarded under a non-procurement transaction (e.g., grant or cooperative agreement) that are expected to equal or exceed $25,000 or meet certain other criteria as specified in 2 CFR section 180.220. All non-procurement transactions entered into by a pass-through entity (i.e., subawards to subrecipients), irrespective of award amount, are considered covered transactions, unless they are exempt as provided in 2 CFR section 180.215.Cause: The Organization did not follow the procedures in place to document and support its compliance with its written procurement policies or to the related procurement processes under Uniform Guidance guidelines and did not follow the process in place to perform and document the verifications of suspended, debarred, or otherwise excluded entities. Effect: The Organization does not have adequate documentation on whether they have entered into transactions with ineligible entities and is not in compliance with Federal guidelines. Recommendation: We recommend the Organization update and follow their controls to identify vendors that should go through the procurement process. We also recommend the Organization follow their process to verify that entities are not suspended, debarred, or otherwise excluded annually at time of award and to document these procedures. The process should apply to procurement and non-procurement awards. Views of Responsible Officials: See schedule of corrective action.
Responsible Official?s Response and Corrective Action Plan We concur with the finding, and a corrective action plan was implemented on April 1, 2021. We have modified our Accounting Policies and Procedures to include reviewing the website for vendors that are debarred from doing business using Federal Funding http://www.sam.gov/. This process will be documented as we obtain the various quotes from vendors over a certain dollar amount threshold. Documentation of such will be maintained in the vendor files. The process will be completed by the Operations Manager and will be reviewed by the CFO and the Executive Director. Planned Implementation Date of Corrective Action Plan April 2022 Person Responsible for Corrective Action Plan Lashelle Stewart, Executive Director
FAC accepted this audit on March 10, 2021 — management decision was due September 10, 2021.
FAC accepted this audit on March 11, 2020 — management decision was due September 11, 2020.
Finding 2019 ? 001 US Department of Health and Human Services CFDA No. 93.926 Healthy Start Initiative Compliance and Significant Deficiency over Internal Controls. Repeat Finding: No Condition During our testing of activities allowed or unallowed and allowable costs/cost principles for payroll, we noted that an employee approved their own time sheet. Also, during the non-payroll testing, we noted an instance where an expense was incorrectly coded to the Federal program. Criteria The Uniform Guidance requires that non-Federal entities receiving Federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations and regulations and program compliance requirements. Cause The Organization did not have proper controls over approval of time sheets to ensure a person cannot approve their own time sheet. Also, there was no proper review of expenses to ensure proper coding. Effect An employee approved their time sheet and an expense was wrongly coded to a Federal Program. Questioned Costs $1,130 which is related to the instance of incorrect coding in the non-payroll testing. Responsible Official?s Response See corrective action plan. Section II - Financial Statement Findings None noted. Section III - Award Findings None noted.
Show full finding ▾Hide full finding ▴Finding 2019 ? 001 US Department of Health and Human Services CFDA No. 93.926 Healthy Start Initiative Compliance and Significant Deficiency over Internal Controls. Repeat Finding: No Condition During our testing of activities allowed or unallowed and allowable costs/cost principles for payroll, we noted that an employee approved their own time sheet. Also, during the non-payroll testing, we noted an instance where an expense was incorrectly coded to the Federal program. Criteria The Uniform Guidance requires that non-Federal entities receiving Federal awards establish and maintain internal controls designed to reasonably ensure compliance with Federal laws, regulations and regulations and program compliance requirements. Cause The Organization did not have proper controls over approval of time sheets to ensure a person cannot approve their own time sheet. Also, there was no proper review of expenses to ensure proper coding. Effect An employee approved their time sheet and an expense was wrongly coded to a Federal Program. Questioned Costs $1,130 which is related to the instance of incorrect coding in the non-payroll testing. Responsible Official?s Response See corrective action plan. Section II - Financial Statement Findings None noted. Section III - Award Findings None noted.
Finding 2019-001: Compliance and Significant Deficiency over Internal Controls Responsible Official?s Response and Corrective Action Plan We concur with the finding, and a corrective action plan was implemented on November 14, 2019. We have modified our Time and Attendance system to configure the Group Hierarchy to disallow an employee from approving their own timesheet. We also identified that the incorrectly coded expense was an isolated event that will not occur again. Accordingly, we have implemented, effective, November 14, 2019, a review of non-routine expenditures to ensure the coding is appropriate. This review will be performed by the CFO and the Executive Director. Planned Implementation Date of Corrective Action Plan November 2019 Person Responsible for Corrective Action Plan Executive Director
FAC accepted this audit on March 17, 2019 — management decision was due September 17, 2019.
FAC accepted this audit on August 30, 2018 — management decision was due March 2, 2019.
GSA_MIGRATION
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GSA_MIGRATION
2016-001
FAC accepted this audit on January 25, 2018 — management decision was due July 25, 2018.
GSA_MIGRATION
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GSA_MIGRATION
2015-002
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