EIN: 942675517
UEI: G1YBD1V47N16
Audited by: Vasquez & Company, LLP
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 March 26, 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 September 26, 2026 (22 days from today).
What is a management decision? →Criteria or Specific Requirement Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by HHS. The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines. Condition The Center determines the amount of fees to be charged to a patient based on the patient’s income, expenses and number of dependents in conjunction with the sliding fee schedule. Of the 17 patients selected for testwork, we noted that the Center charged the incorrect sliding fee amount for two (2) patients, which resulted in overcharging the two (2) patients by a total of $10. These two transactions occurred prior to March 31, 2025. In assessing the Center’s corrective action plan (CAP) for the prior year finding F2023-002, we noted that the CAP was implemented on March 31, 2025. This finding is noted as a repeat finding due to the timing of the audit process. The audit report for the prior year was issued on March 31, 2025. Therefore, the identified condition noted in the prior year finding F2023-002 existed for the majority of fiscal year 2025. Questioned Costs $10 in total overcharges for sliding fee patients sampled. Causes and Effects The potential causes for the above errors are as follows: • Errors by staff in determining the patient’s ability to pay. • Patients did not complete the required form necessary to determine the patient’s ability to pay. • Lack of sufficient documentation to support the determination of the fee amount charged to the patient. As a result, the determination supporting patients’ fees is not consistent with the sliding fee schedule. Recommendation We recommend that the Center’s procedures for the determination of sliding fees be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Center should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Center’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Show full finding ▾Hide full finding ▴Criteria or Specific Requirement Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient’s ability to pay. The patient’s ability to pay is determined based on the official poverty guidelines, as revised annually by HHS. The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines. Condition The Center determines the amount of fees to be charged to a patient based on the patient’s income, expenses and number of dependents in conjunction with the sliding fee schedule. Of the 17 patients selected for testwork, we noted that the Center charged the incorrect sliding fee amount for two (2) patients, which resulted in overcharging the two (2) patients by a total of $10. These two transactions occurred prior to March 31, 2025. In assessing the Center’s corrective action plan (CAP) for the prior year finding F2023-002, we noted that the CAP was implemented on March 31, 2025. This finding is noted as a repeat finding due to the timing of the audit process. The audit report for the prior year was issued on March 31, 2025. Therefore, the identified condition noted in the prior year finding F2023-002 existed for the majority of fiscal year 2025. Questioned Costs $10 in total overcharges for sliding fee patients sampled. Causes and Effects The potential causes for the above errors are as follows: • Errors by staff in determining the patient’s ability to pay. • Patients did not complete the required form necessary to determine the patient’s ability to pay. • Lack of sufficient documentation to support the determination of the fee amount charged to the patient. As a result, the determination supporting patients’ fees is not consistent with the sliding fee schedule. Recommendation We recommend that the Center’s procedures for the determination of sliding fees be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Center should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Center’s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
The Center’s responsible officials acknowledge the finding. The Center implemented additional training for all staff involved in the sliding fee discount application process and implemented a review of sliding fee discount applications at the management level, effective March 31, 2025. Since that time, no further errors have been identified. We are committed to maintaining accurate application of the sliding fee schedule. We will continue ongoing staff training and regular supervisory reviews going forward to ensure compliance. Furthermore, the Accounting Department will perform periodic sampling several times a year to verify that sliding fee determinations continue to be applied correctly. Responsible persons: Jim Kelly, Chief Financial Officer Rachelle Valenzuela, Clinic Manager Sehrish Khan, Director of Clinical Compliance Implementation Date: March 31, 2025
2023-002
FAC accepted this audit on March 31, 2025 — management decision was due October 1, 2025.
Criteria: Per OMB Compliance Supplement under the financial reporting requirement for SF-425, Federal Financial Report (OMB No. 4040-0014), and per Code of Federal Regulations (CFR), Title 2, Subtitle A, Chapter II, Part 200, Compliance Requirements, the annual Federal Financial Report (FFR) due dates are aligned with the Payment Management System quarterly report due dates. Condition The annual FFR for the quarter ending March 31, 2024 was submitted on November 19, 2024, which is 112 days after the required submission due date of July 30, 2024. Cause and Effect The Center had significant employee turnover during the year. As a result, the FFR was submitted late. Questioned Costs None Recommendation We recommend that the Center enhance its existing tracking process of grant report submission requirements and maintain formal documentation of reports submitted. Additionally, the Center should implement a procedure to request approval from the granting agency for federal report submission extensions in advance of the due date. Documentation of such extensions should be maintained on file. This will help ensure compliance with grant reporting requirements, as specified in the grant agreement.
Show full finding ▾Hide full finding ▴Criteria: Per OMB Compliance Supplement under the financial reporting requirement for SF-425, Federal Financial Report (OMB No. 4040-0014), and per Code of Federal Regulations (CFR), Title 2, Subtitle A, Chapter II, Part 200, Compliance Requirements, the annual Federal Financial Report (FFR) due dates are aligned with the Payment Management System quarterly report due dates. Condition The annual FFR for the quarter ending March 31, 2024 was submitted on November 19, 2024, which is 112 days after the required submission due date of July 30, 2024. Cause and Effect The Center had significant employee turnover during the year. As a result, the FFR was submitted late. Questioned Costs None Recommendation We recommend that the Center enhance its existing tracking process of grant report submission requirements and maintain formal documentation of reports submitted. Additionally, the Center should implement a procedure to request approval from the granting agency for federal report submission extensions in advance of the due date. Documentation of such extensions should be maintained on file. This will help ensure compliance with grant reporting requirements, as specified in the grant agreement.
Views of Responsible Officials and Planned Corrective Actions The FFR report was submitted late due to the Director of Finance being new to the position and balancing vacancies in the Accounting Manager and Accounts Payable Clerk positions. There were many deadlines backlogged and the FFR report is one of those items. The Center has been experiencing stability in the key positions as well as expanding the department to include a Grants Administrator who will be responsible for grants reporting. Additionally, the Center is working on a Master Calendar of due dates to monitor and stay ahead of reporting deadlines. Person Responsible: Hector Zapeta Position of Responsible Party: Accounting Manager Anticipated Completion: June 30, 2025
2023-001
FAC accepted this audit on July 22, 2024 — management decision was due January 22, 2025.
The annual FFR for the period ending December 31, 2022 was submitted on May 3, 2023, which is 3 days after the required submission due date of April 30, 2023.
Show full finding ▾Hide full finding ▴The annual FFR for the period ending December 31, 2022 was submitted on May 3, 2023, which is 3 days after the required submission due date of April 30, 2023.
The FFR report was submitted late due to the vacant position of Director of Finance. The Center electronically filed the FFR on a Friday (due date), and a glitch may have occurred which then was processed on the following Monday. Friday was the due date. Currently, the Federal Grants Manager follows up with the Director of Finance to ensure that all FFRs are filed on time. A copy of the filed FFR is sent to the Federal Grants Manager once it has been submitted.
The Center determines the amount of fees to be charged to a patient based on the patient’s income, expense and number of dependents in conjunction with the sliding fee schedule. Of the 25 patients selected for testwork, we noted the following: • 4 patients had no proof of income on file. • 10 patients were charged the incorrect sliding fee amount, which resulted in: o Overcharging 8 patients by a total of $761.07; o Undercharging 2 patients by a total of $10.
Show full finding ▾Hide full finding ▴The Center determines the amount of fees to be charged to a patient based on the patient’s income, expense and number of dependents in conjunction with the sliding fee schedule. Of the 25 patients selected for testwork, we noted the following: • 4 patients had no proof of income on file. • 10 patients were charged the incorrect sliding fee amount, which resulted in: o Overcharging 8 patients by a total of $761.07; o Undercharging 2 patients by a total of $10.
Additional training will be provide to staff in the sliding fee discount application process and implement a review of sliding fee discount applications in the future at the management level.
FAC accepted this audit on March 30, 2023 — management decision was due September 30, 2023.
FAC accepted this audit on September 1, 2022 — management decision was due March 1, 2023.
FAC accepted this audit on March 30, 2021 — management decision was due September 30, 2021.
FAC accepted this audit on February 6, 2020 — management decision was due August 6, 2020.
Criteria or Specific Requirement Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient?s ability to pay. The patient?s ability to pay is determined based on the official poverty guidelines, as revised annually by HHS. The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines. Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project. Condition The Center determines the amount of fees to be charged to a patient based on the patient?s income, expense and number of dependents in conjunction with the sliding fee schedule. Of the 25 patients selected for teswork, we noted the following: ? 2 patients that had no proof of income declaration and sliding fee application form on file ? 2 patients that were charged the incorrect sliding fee amount, which resulted in the Center overcharging 1 patient by $10, while 1 patient was undercharged by $5. Questioned Costs $5 in net overcharges for sliding fee patients sampled. Causes and Effect: The potential causes for the above errors are as follows: ? - Error by staff in determining the patient?s ability to pay. ? - Patients did not complete the required form necessary to determine patient?s ability to pay. As a result, the determination of patients fees are not consistent with the sliding fee schedule. Recommendation We recommend that the Center?s procedures for determination of sliding fees be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Center should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Center?s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Show full finding ▾Hide full finding ▴Criteria or Specific Requirement Health centers must have a schedule of fees or payments for the provision of their health services consistent with locally prevailing rates or charges and designed to cover their reasonable costs of operation. They are also required to have a corresponding schedule of discounts applied and adjusted based on the patient?s ability to pay. The patient?s ability to pay is determined based on the official poverty guidelines, as revised annually by HHS. The poverty guidelines are issued each year in the Federal Register and HHS maintains a web page that provides the poverty guidelines. Non-grant funds (State, local, and other operational funding and fees, premiums, and third-party reimbursements which the project may reasonably be expected to receive, including any such funds in excess of those originally expected), shall be used as permitted under the law and may be used for such other purposes as are not specifically prohibited under the law if such use furthers the objectives of the project. Condition The Center determines the amount of fees to be charged to a patient based on the patient?s income, expense and number of dependents in conjunction with the sliding fee schedule. Of the 25 patients selected for teswork, we noted the following: ? 2 patients that had no proof of income declaration and sliding fee application form on file ? 2 patients that were charged the incorrect sliding fee amount, which resulted in the Center overcharging 1 patient by $10, while 1 patient was undercharged by $5. Questioned Costs $5 in net overcharges for sliding fee patients sampled. Causes and Effect: The potential causes for the above errors are as follows: ? - Error by staff in determining the patient?s ability to pay. ? - Patients did not complete the required form necessary to determine patient?s ability to pay. As a result, the determination of patients fees are not consistent with the sliding fee schedule. Recommendation We recommend that the Center?s procedures for determination of sliding fees be strengthened to ensure 1) income is properly verified and adequately documented and 2) the sliding fee discount is properly determined and applied. The Center should also provide additional training to staff involved in the sliding fee process and ensure that appropriate individuals are properly monitoring and reviewing the Center?s compliance with program requirements. This will help ensure that the proper sliding fee is charged to patients and that program goals and objectives are being met.
Views of Responsible Officials and Planned Corrective Actions 1. It is noted that 3 of the 4 claims were handled by a former employee, who clearly was not sufficiently trained to process the sliding fee discount application appropriately. 2. We will re-train staff in the sliding fee discount application process and review the sliding fee discount applications in the future at the management level. 3. Management will ensure that a Spanish language version of the sliding fee discount application will be available to staff and patients at all times. Responsible person: Samson Mael, Director of Clinic Operations Expected Implementation Date: January 31, 2020
FAC accepted this audit on March 19, 2019 — management decision was due September 19, 2019.
FAC accepted this audit on April 2, 2018 — management decision was due October 2, 2018.
GSA_MIGRATION
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GSA_MIGRATION
FAC accepted this audit on February 1, 2017 — management decision was due August 1, 2017.
GSA_MIGRATION
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GSA_MIGRATION
2015-002
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