U.S. Department of Homeland Security
Immigration and Customs Enforcement
Office of Professional Responsibility
Management Inspections and Detention Oversight
Washington, DC 20536-5501

Office of Detention Oversight
Compliance Inspection

Enforcement and Removal Operations
Los Angeles Field Office
Adelanto Correctional Facility
Adelanto, California

September 18 - 20, 2012

COMPLIANCE INSPECTION
ADELANTO CORRECTIONAL FACILITY
LOS ANGELES FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...............................................................................................1
INSPECTION PROCESS
Report Organization .................................................................................................6
Inspection Team Members .......................................................................................6
OPERATIONAL ENVIRONMENT
Internal Relations .....................................................................................................7
Detainee Relations ...................................................................................................7
ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ................................................................................8
Detainee Handbook ..................................................................................................9
Food Service ..........................................................................................................10
Funds and Personal Property .................................................................................12
Grievance System ..................................................................................................13
Law Libraries and Legal Material..........................................................................14
Medical Care ..........................................................................................................16

EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Compliance Inspection (CI) of the Adelanto Correctional Facility (ACF) in
Adelanto, California, from September 18 to 20, 2012. ACF is owned and operated by the GEO
Group, Inc. (GEO) under contract with the City of Adelanto. ACF has two facilities, both of
which are adjacent to each other: the East facility, which opened in August 2011, and the West
facility, which opened in August 2012; ODO inspected both during this CI. Both serve as major
facilities with whom ICE contracts in the Southern California area. Since ACF opened, U.S.
Immigration and Customs Enforcement (ICE), Office of Enforcement and Removal
Operations (ERO) has housed male detainees of all classification levels (Level I – lowest threat,
Level II – medium threat, Level III – highest threat) at ACF for periods in excess of 72 hours
pursuant to an intergovernmental service agreement (IGSA) with the City of Adelanto. The
average length of stay at ACF is 30 days. ICE does not detain females at ACF; all 1,300 beds are
reserved exclusively for male ICE detainees. GEO provides both the food service and medical
care at ACF. Commissary services are provided under contract by Keefe Group. ACF does not
hold any accreditations.
The average daily population (ADP) at ACF in September 2012 was 909, a significant increase
from the August 2012 ADP of 683 and the July 2012 ADP of 605. The ADP is increasing as
ERO moves detainees out of Mira Loma and relocates them to ACF and other alternate detention
facilities within the area of responsibility of the ERO Field Office Director, Los Angeles,
California (FOD Los Angeles). ACF will absorb a large number of detainees from Mira Loma.
According to GEO officials, ACF is expected to reach its full capacity of 1,300 beds by
November 2012. At the time of this inspection, ACF housed a total of 922 detainees
(245 Level I, 538 Level II, and 139 Level III).
The FOD Los Angeles is responsible for ensuring facility compliance with ICE policies and the
Performance Based National Detention Standards (PBNDS). An Assistant Field Office
Director (AFOD) stationed at ACF is the highest-ranking ERO official at the facility. In addition
to the AFOD, ERO staff at ACF is comprised of(b)(7)e Supervisory Detention and Deportation
Officers (SDDO) (b)(7)eDeportation Officers (DO) (b)(7)e Immigration Enforcement Agents (IEA),
and (b)(7)e Enforcement and Removal Assistants (ERA). The AFOD stated that ACF will absorb
ERO personnel assigned to Mira Loma once ICE terminates that contract. ACF has a full-time
ACF Compliance Manager and an ERO compliance team is permanently stationed at ACF to
oversee compliance with the PBNDS. These teams engage in active self-inspections of the
facility similar to the ODO method, which involves fully inspecting all components of the
PBNDS using the text of each standard as a guide. An ERO Detention Service Manager (DSM)
currently assigned to Mira Loma will be re-assigned to ACF to monitor facility compliance with
the PBNDS.
ODO observed communication and esprit de corps need to be improved between ACF and ERO
staff. ODO observed morale levels of ICE and ACF personnel assigned at the East and West
facilities are different. The personnel at the East facility reported enthusiasm about their jobs,
while personnel assigned to the West facility (where the ICE and ACF administrators are
physically located) expressed a lack of motivation. ODO shared this concern with both the ACF
and ERO staff during the closeout briefing conducted on September 18, 2012.
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The Warden is the highest ranking official at ACF and is responsible for oversight of daily
operations. The total number of ACF staff employed at the facility is (b)(7)e In addition to the
Warden, ACF supervisory staff consists of an Assistant Warden, a deputy administrator, (b)(7)e
managers,(b)(7)ecaptain, a chief of security,(b)(7)elieutenants,(b)(7)esergeants, (b)(7)edetention officers,
(b)(7)emedical staff, and
(b)(7)eadministrative and maintenance staff.
In March 2012, an ICE detainee who had been housed at ACF died of alcoholic liver disease,
sepsis, multi-organ failure, and bronchopneumonia after being transported to the Victor Valley
Community Hospital in Victorville, California. This was the first ICE detainee death to ever
occur at ACF. Following the death, ODO conducted a Detainee Death Review (DDR) to
determine compliance with the PBNDS and established policies and procedures. Based on the
findings of the DDR, ODO concluded ACF medical staff failed to provide adequate health care
to the detainee, and failed to comply with the requirements of the ICE PBNDS. The
investigation disclosed several egregious errors committed by ACF medical staff, including
failure to perform proper physical examinations in response to symptoms and complaints, failure
to pursue any records critical to continuity of care, and failure to facilitate timely and appropriate
access to off-site treatments. ODO concluded the detainee’s death could have been prevented
and that the detainee received an unacceptable level of medical care while detained at ACF.
In November 2011, ERO Detention Standards Compliance Unit contractor, MGT of America,
Inc., conducted an annual review of the PBNDS at the ACF East facility. ACF received an
overall rating of “Does Not Meet Standards,” yet was found compliant with 39 of 40 standards
reviewed. The inspection concluded medical officials were not conducting detainee health
appraisals within 14 days of arrival, and registered nurses were performing health assessments
without training or certification from the Clinical Director.
In July 2012, ERO Detention Standards Compliance Unit contractor, The Nakamoto Group, Inc.,
conducted a pre-occupancy inspection of the ACF West facility. At that time, there were no ICE
detainees housed at the West facility. ACF did not receive any rating since the review was only
a pre-occupancy review.
During this CI, ODO reviewed 17 PBNDS at both the ACF East and West facilities. Eleven
standards were determined to be fully compliant. Ten deficiencies were identified in the
following six standards: Detainee Handbook (1 deficiency), Food Service (2), Funds and
Personal Property (1), Grievance System (1), Law Libraries and Legal Material (2), and Medical
Care (3).
This report details all deficiencies identified by ODO and refers to the specific, relevant sections
of the PBNDS. ERO will be provided a copy of this report to assist in developing corrective
actions to resolve all identified deficiencies. These deficiencies were discussed with ACF and
ERO staff on-site during the inspection, as well as during the closeout briefing conducted on
September 18, 2012. Of particular concern, lavatories for kitchen workers in the West facility
did not have appropriate supplies for hand-washing before handling or preparing food. Further,
ODO’s review of 30 medical records of newly-arrived detainees indicated ten were not reviewed
by a physician within 24 hours, as required by the PBNDS. Furthermore, 12 of 25 sick call
requests reviewed by ODO were not triaged within 48 hours as required. ODO also found (b)(7)e

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of(b)(7)emedical staff did not have current cardiopulmonary resuscitation (CPR) or emergency first
aid training.
Detainees receive the ICE National Detainee Handbook and an ACF detainee handbook upon
admission. The handbooks are available in both English and Spanish. Translation services are
available for those detainees speaking languages other than English and Spanish. The ACF
detainee handbook is missing information about how to file medical grievances but otherwise
includes all required information. Detainees are required to sign for the handbooks, and a receipt
is generated and placed in detainees’ detention files. Furthermore, detainees are provided
adequate hygiene supplies and clothing as required by the PBNDS.
The food service operation is managed by GEO staff and supported by a crew of detainee
workers. ODO verified all food service staff and workers received medical clearances. ODO
verified the temperature of selected food items served in the dining rooms and on carts met the
PBNDS requirements. Review of the master cycle menu confirmed it was reviewed and certified
as nutritionally adequate by a registered dietician. ODO verified religious and medical diets are
provided in accordance with the standard. As noted earlier, hand-washing facilities in the West
facility did not meet the PBNDS requirements.
ACF maintains an electronic grievance log to document and track all formal and informal
grievances submitted by detainees. ODO verified grievance forms are placed in the detention
file of each detainee submitting a grievance. ACF staff tries to resolve most complaints
informally during daily interactions with detainees. ACF provides detainees an opportunity to
file both formal and informal grievances, and grievance forms are readily available. ODO’s
review of grievances showed they were answered in a timely manner as required by the PBNDS.
There are three libraries in the facility: one in the West facility, one in the East facility, and one
inside the Special Management Units (SMU). The libraries in the East and West facilities are
used by the respective general populations. The libraries have adequate seating and workspaces.
All libraries are well-lit and reasonably isolated from noisy areas. ODO verified the Lexis-Nexis
legal resource software was installed and updated on September 5, 2012. However, the law
libraries do not have all the reference materials required by the PBNDS either in hard-copy
format or electronically in the law libraries’ computers. In addition, the required rules and
procedures provided in the local detainee handbook are not posted in all three libraries.
Medical services at ACF are provided by the GEO Care Division. The primary intake area and
medical unit are in the West facility. The Health Services Administrator (HSA) provides
administrative oversight of medical services, and a full-time physician serves as the Clinical
Director (CD). The current HSA and CD were hired as replacements following the March 2012
detainee death, but the former HSA currently holds the position of Assistant HSA. In addition to
the HSA, CD, and Assistant HSA, full-time clinical staffing consists of a psychologist, a dentist,
a dental assistant, (b)(7)enurse practitioners(b)(7)e registered nurses (RN),(b)(7)elicensed vocational
nurses (b)(7)e medical records clerks, and(b)(7)emedical data entry clerk. ACF informed ODO a
significant portion of the nursing staff is new to ACF, and efforts are on-going to monitor and
enhance performance, including improving interaction with custody staff. Part-time staff
includes an additional psychiatrist, an X-ray technician, and a lab technician. ODO finds staffing
sufficient to meet the health care needs of the detainee population at its current level of
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922 detainees. ACF notified ODO that contingencies are in place to address the increase in
population from Mira Loma. According to the HSA and GEO’s Director of Correctional Health,
a proposal has been submitted to increase medical staffing by(b)(7)epositions to support the
impending population increase.
ACF has a comprehensive intake packet, which assures all necessary forms are initiated for the
medical record, and detainees receive information on accessing medical care and health issues.
Included in the packet is a Health Services Notice, which provides information on sick call
procedures and reporting medical emergencies; and Intake Education Information, which
acknowledges that during the intake process, the detainee has been provided with information on
medical services, nutrition, personal hygiene, oral care and hygiene, HIV/AIDS, hepatitis, TB
testing and prevention, boils and skin lesions, substance abuse, and sexual assault prevention.
ODO cites the intake packet as best practice because it assures necessary forms and documents
supporting delivery of health care are initiated and included in the medical record, and detainees
receive important information on health issues and care.
There have been no suicides or attempted suicides since ACF opened in August 2011. ACF
informed ODO that 29 ICE detainees have been on suicide watch in the past year. Review of
medical records for ten of the ICE detainees on suicide watch confirmed compliance with the
PBNDS and local policy. ODO verified screening for suicide potential occurs as part of intake
screening, and detainees at risk for suicide are referred to medical staff. ODO inspected the two
observation rooms used for suicide watch and verified they are free of fixtures that could be used
to facilitate a suicide attempt. Inspection of(b)(7)edetention and(b)(7)emedical staff training records
confirmed all completed the required initial and annual suicide prevention training.
ACF has a designated Sexual Abuse and Assault Prevention and Intervention (SAAPI)
Coordinator. ACF informs detainees of the SAAPI program in the detainee handbook, during
orientation, and by postings in the intake area and housing units. The information is in both
English and Spanish, and includes toll-free telephone numbers. Detainees are screened during
the intake process for sexual abuse victimization history, as well as predatory history to
determine potential sexual aggressors. ACF separates detainees with a history of predatory or
abusive sexual behavior from detainees with a history of victimization. Staff is required to
attend pre-service, quarterly, and annual training on the SAAPI program. ODO verified
completion of the required training upon review of(b)(7)etraining records. The training curriculum
is comprehensive and includes all required elements. In interviews staff knew the SAAPI
program and how to handle any information received concerning possible sexual abuse or
assault. ODO verified ACF has the SAAPI-related program, policy, training, reporting
procedures, reviews, and investigations protocols.
The SAAPI coordinator informed ODO there were two incidents of reported sexual abuse and
assault from the opening of ACF in August 2011 to present. ODO reviewed each case file and
found both were complete and included documentation of notification to ICE, local law
enforcement, and other required agencies and individuals. One case was initiated as a grievance
and subsequently withdrawn by the detainee; however, ERO management determined the
allegation was unsubstantiated. The second case was investigated by ACF and referred to the
Adelanto Sheriff’s Department. Documentation indicates the alleged victim informed the
investigating deputy that he wanted no contact with law enforcement or reference to him as a
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victim of sexual battery, and did not want the alleged perpetrator prosecuted. The Sheriff’s
Department closed the matter as an informational report without substantiating the allegation.
ERO personnel assigned to ACF were kept informed during each step of the investigation
process in both cases. ODO confirmed ACF followed its local facility policy and the PBNDS,
including completion of the required medical examination by facility health care personnel.
OPR was not notified regarding either incident, and there were no related entries in JICMS. As
of May 2012, ERO is obligated to report any sexual assault incidents to OPR.
Detainee requests are logged and responded to within 72 hours of ERO receipt. ERO has placed
small red lockboxes for detainee requests in or near each of the ICE detainee housing units.
These lockboxes are only accessible to ERO personnel, who retain the keys. ERO personnel
pick up the detainee requests on a daily basis. The field office has a local policy and procedure
to ensure and document that ICE IEAs and SDDOs conduct weekly announced and unannounced
visits to housing units to address detainee concerns and inquiries, as required by the Model
Protocol on Staff-Detainee Communication. The ERO schedules are conspicuously posted in
each housing unit. Scheduled visits are documented on the Facility Liaison Visit Checklist as
required by the Model Protocol. Weekly telephone maintenance is also conducted and recorded
on a log.
The SMU at ACF has 32 double-occupancy cells. At the time of the inspection, there were
14 ICE detainees in the SMU: six in disciplinary segregation and eight in administrative
segregation. ODO observed the SMU at ACF to be well-lit, temperature appropriate, and
sanitary. ODO reviewed the Facility Liaison Visit Checklists and confirmed ERO staff regularly
visit the SMU to interact with detainees and to closely monitor the living conditions in the SMU.

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INSPECTION PROCESS
ODO primarily focuses on areas of noncompliance with the ICE National Detention Standards or
the ICE PBNDS, as applicable. The PBNDS apply to ACF. In addition, ODO may focus its
inspection based on detention management information provided by the ERO Headquarters (HQ)
and ERO field offices, and on issues of high priority or interest to ICE executive management.
Inspection objectives are to evaluate the welfare, safety, and living conditions of detainees, and
to determine compliance with applicable laws, policies, regulations, and procedures.
ODO reviewed the processes employed at ACF to determine compliance with current policies
and detention standards. Prior to and during the inspection, ODO collected and analyzed
relevant allegations and detainee information from multiple ICE databases, including the Joint
Integrity Case Management System (JICMS), the ENFORCE Alien Booking Module (EABM),
and ENFORCE Alien Removal Module (EARM). ODO also gathered facility facts and
inspection-related information from ERO HQ staff to best prepare for the site visit at ACF.

REPORT ORGANIZATION
This report documents inspection results, serves as an official record, and is intended to provide
ICE and detention facility management with a comprehensive evaluation of compliance with
policies and detention standards. It summarizes those PBNDS that ODO found deficient in at
least one aspect of the standard. ODO reports convey information to best enable prompt
corrective actions and to assist in the on-going process of incorporating best practices in
nationwide detention facility operations.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
PBNDS, ICE policy, or operational procedure. When possible, the report includes contextual
and quantitative information relevant to the cited standard. Deficiencies are highlighted in bold
throughout the report and are encoded sequentially according to a detention standard designator.
Comments and questions regarding the report findings should be forwarded to the Deputy
Division Director, OPR ODO.

INSPECTION TEAM MEMBERS

(b)(6), (b)(7)c

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Special Agent (Team Leader)
Special Agent
Detention and Deportation Officer
Contract Inspector
Contract Inspector
Contract Inspector

6

ODO, Phoenix
ODO, Phoenix
ODO, Phoenix
Creative Corrections
Creative Corrections
Creative Corrections

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed supervisory ICE and ACF staff, including the ACF Warden, chief of security,
compliance manager, and the ERO AFOD. ACF staff stated ERO personnel conduct weekly
scheduled and unscheduled visits to detainee housing units at the facility. During the interviews,
ICE and ACF personnel stated the working relationship between the two agencies is positive and
morale is high; however, ODO observed morale levels of ICE and ACF personnel assigned at the
East and West facilities are different. The personnel at the East facility state their enthusiasm
about their jobs, while personnel assigned to the West facility where the ICE and ACF
administrators are physically located, express a lack of motivation. ODO shared this concern
with both the ACF and ERO staff during the closeout briefing conducted on September 18, 2012.
ERO staff expressed concerns relating to the timeliness in response to sick call submissions and
replenishing of hygiene supplies daily. During the inspection, ODO verified the hygiene
supplies at two randomly-selected housing units were fully stocked. The AFOD indicated ERO
constantly receives complaints about medical care from detainees. For example, detainees are
not seen within 48 hours of the sick call slip submission, as required by the PBNDS. This
information is cited as a deficiency under the Medical Care PBNDS portion of this report.

DETAINEE RELATIONS
ODO interviewed 45 randomly-selected male detainees to assess the overall living and detention
conditions at ACF. None of the detainees complained about recreation, food service, hygiene
supplies, telephone access, religious services, visitation, or the law library. All detainees knew
who their DO was. An ICE visitation schedule is posted in the housing unit dayrooms.
Twenty-eight of 45 detainees complained about the timeliness of responses to sick-call requests;
detainees are seen three to five days after their sick call request submission. ODO’s review of
25 sick call requests found that 12 of the requests were not triaged by ACF medical staff within
48 hours of receipt, as required by the PBNDS.

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ICE PERFORMANCE BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 17 PBNDS and found ACF fully compliant with the following
11 standards:
Admission and Release
Correspondence and Other Mail
Disciplinary System
Personal Hygiene
Sexual Abuse and Assault Prevention and Intervention
Special Management Units
Staff-Detainee Communication
Suicide Prevention and Intervention
Telephone Access
Terminal Illness, Advance Directives, and Death
Use of Force and Restraints
As these standards were compliant at the time of the review, a synopsis for these standards was
not prepared for this report.
ODO found deficiencies in the following six standards:
Detainee Handbook
Food Service
Funds and Personal Property
Grievance System
Law Libraries and Legal Material
Medical Care
ODO findings for each of these standards are presented in the remainder of this report.

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DETAINEE HANDBOOK (DH)
ODO reviewed the Detainee Handbook standard at ACF to determine if the facility provides
each detainee with a handbook, written in English and any other languages spoken by a
significant number of detainees housed at the facility, describing the facility’s rules and
sanctions, disciplinary system, mail and visiting procedures, grievance system, services,
programs, and medical care, in accordance with the ICE PBNDS. ODO interviewed staff and
detainees, and reviewed the facility detainee handbook and facility policies.
ACF staff informed ODO detainees are provided verbal and video orientations that include
references to the handbook. Detainees receive the ICE National Detainee Handbook and an ACF
detainee handbook upon admission. The handbooks are available in both English and Spanish.
Translation services are available for those detainees speaking languages other than English and
Spanish. Detainees are required to sign for the handbooks, and receipts are generated and placed
in detainees’ detention files. ODO randomly selected and reviewed 15 active detention files, and
verified all detainees signed an intake property form acknowledging receipt of both handbooks.
The ACF handbook informs detainees about the programs and services ACF offers, and provides
information concerning access to medical care, contraband, prohibited acts, sanctions resulting
from misconduct, correspondence and mail, grievances, telephone access, recreation, and
visitation; however, the ACF handbook does not describe how to file a medical grievance
(Deficiency DH-1). The omission of medical grievance information from the detainee handbook
is also reported as Deficiency GS-1.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DH-1
In accordance with the ICE PBNDS, Detainee Handbook, section (V)(2), the FOD must ensure,
while all applicable topics from the ICE National Detainee Handbook must be addressed, it is
particularly important that each local supplement notify each detainee of [among others]:


The detainee Grievance System, including medical grievances.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at ACF to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE PBNDS. ODO
interviewed staff and detainees, observed meal preparation and service, reviewed documentation,
and inspected food and chemical storage areas, and food preparation areas.
The food service operation is managed by GEO staff and supported by a crew of detainee
workers. ODO verified all food service staff and workers received medical clearances. There
are two kitchen areas, one in the West facility and the other in the East facility. Meals prepared
in the West facility kitchen are served in two dining rooms; meals prepared in the East facility
are delivered to the housing units on carts. ODO verified the temperature of selected food items
served in the dining rooms and on carts met the PBNDS requirements.
Review of the master cycle menu confirmed it was reviewed and certified as nutritionally
adequate by a registered dietician. Food items from the breakfast and lunch meals prepared in
both kitchens were sampled and found to be appetizing and appropriately portioned. ODO
verified religious and medical diets are provided in accordance with the standard.
The Food Service Administrator (FSA) or cook supervisors conduct daily and weekly kitchen
inspections to identify sanitation and safety concerns. The San Bernardino County Health
Department inspects the facility annually. Documentation supports the facility was found in
compliance with health and safety regulations during its last Health Department inspection on
May 30, 2012. Equipment and water temperature checks are conducted and recorded as
required. Pest control services are provided under contract on a monthly basis, verified by
inspection of statements for the past ten months.
During the inspection of the five detainee lavatories in the West facility kitchen, ODO noted
soap and paper towels were not available, and there was no readily-available hot water in one of
the five lavatories. In addition, three hand-washing stations in the kitchen did not have soap and
paper towels. Alternative hand-drying devices were not available in the lavatory or at any handwashing sink (Deficiency FS-1). ODO found one hand-washing station with hot water, soap,
and paper towels, and observed it being used by detainee workers exiting the lavatory. Prior to
completion of the review, ODO confirmed soap dispensers were installed and filled, and paper
towels were supplied in all the five lavatories. Workers repaired the hot water line in the
relevant lavatory. Because hand-washing by food service workers is critical to assuring food
safety, ODO recommends the FSA ensure water temperatures are tested, and soap and paper
towel supplies are confirmed during daily and weekly inspections of the food service areas.
ODO notes this deficiency was not found in the East facility kitchen.
ODO verified food service staff monitors detainee workers for health and cleanliness. Workers
are issued clean uniforms and appropriate attire to ensure personal and food safety. During the
inspection, ODO observed four workers being escorted from the kitchen area after changing
from food service uniforms and safety shoes following their shift. Before arriving at the housing
unit, they were called to the loading dock area to unload a delivery of food items on wood
pallets. The detainees remained in their canvas shoes and were not required to put on their safety
shoes (Deficiency FS-2). The loading dock is an FSA-designated food hazard area. When
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alerted to this by ODO, food service staff immediately required detainees to wear safety shoes as
required by the PBNDS.
During observation of the issuance of medical and religious diet trays in housing units, ODO
noted that officers followed inconsistent procedures. Some officers called detainees to the front
of the unit to be issued a tray; other officers waited for detainees on special diets to approach
them to claim a tray. ODO recommends implementation of consistent, formalized procedures to
support proper issuance of medical and religious diet trays to detainees.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE PBNDS, Food Service, section (V)(J)(9), the FOD must ensure
adequate and conveniently located toilet facilities shall be provided for all food service staff and
detainee workers.



Lavatories shall have readily available hot and cold water.
Soap or detergent and paper towels or a hand-drying device providing heated air shall be
available at all times in each lavatory.

DEFICIENCY FS-2
In accordance with the ICE PBNDS, Food Service, section (V)(J)(12)(c), the FOD must ensure
machines shall be guarded in compliance with OSHA standards:


Safety shoes shall be worn in FSA-designated foot hazard areas.

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FUNDS AND PERSONAL PROPERTY (F&PP)
ODO reviewed the Funds and Personal Property standard at ACF to determine if controls are in
place to inventory, receipt, store, and safeguard detainees’ personal property, in accordance with
the ICE PBNDS. ODO toured the facility, reviewed local policies, interviewed staff, and
inspected property storage areas.
The property storage room at ACF is located in the West facility behind one solid locked door.
ACF uses the room to secure property bins containing clothing and other personal items, such as
legal papers and books. Within the room is a secured locker for the purposes of holding large
valuables. The storage area is secured when not attended by assigned staff. The control room
staff monitors the secured locker 24 hours a day. ODO found all detainee property bins are
clearly marked with tags documenting the name and booking number of each detainee. Property
is stored and organized using a numerical system.
ODO interviewed a lieutenant and(b)(7)ecorrectional officers responsible for ensuring the
accountability, storage, and security of detainee property. During the interviews, ODO
determined ACF’s policy allows non-supervisory correctional officers access to the secured
storage locker, which holds large valuables. Access is not strictly limited to a lieutenant or a
shift-supervisor, as required by the PBNDS (Deficiency F&PP-1). ACF corrected this
deficiency on-site by limiting access to the secured locker to only the lieutenant.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY F&PP-1
In accordance with the ICE PBNDS, Funds and Personal Property, section (V)(A), the FOD must
ensure all facilities, at a minimum shall provide:



A secured locker for holding large valuables, that can be accessed only by designated
supervisor(s); and
A baggage and property storage area that is secured when not attended by assigned
admissions processing staff.

Both the safe and the large-valuables locker should be kept in either the shift supervisor’s office
or otherwise secured in an area accessible only by the shift supervisor.

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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at ACF to determine if a process to submit formal
or emergency grievances exists, and responses are provided in a timely manner, without fear of
reprisal. In addition, the review was conducted to determine if detainees have an opportunity to
appeal responses, and if accurate records are maintained, in accordance with the ICE PBNDS.
ODO interviewed staff and detainees, and reviewed local policies and procedures, the detainee
handbook, detention files, and grievance logs.
Detainees are encouraged to resolve grievances informally, but may pursue formal grievances at
any time. Detainees can file both informal and formal grievances. Grievance forms are readily
available inside the housing units. Detainees are able to appeal a grievance decision. ACF staff
tries to resolve most complaints informally during daily interactions with detainees.
ODO noted the ACF grievance coordinator maintains an electronic grievance log to document
and track all formal and informal grievances submitted by detainees. ODO verified grievance
forms are placed in the detention file of each detainee submitting a grievance. The grievance log
reflects ACF received and processed 331 grievances between January 2012 and September 2012.
Of the 331 grievances, 51 pertained to medical care; 79 pertained to facility staff; seven
pertained to food service; 66 pertained to quality of life such as television viewing, microwave
access and other similar requests; and 128 pertained to miscellaneous complaints. According to
the grievance coordinator, GEO management requires documentation regardless of the topic.
There were no grievances related to staff misconduct. The ACF detainee handbook did not
contain any information on the detainee’s right to file a medical grievance (Deficiency GS-1);
however, as noted, 51 of the grievances related to medical care.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE PBNDS, Grievance System, section (V)(B), the FOD must ensure
the facility shall provide each detainee, upon admittance, a copy of the Detainee Handbook /
local supplement, in which the grievance section provides notice of [among others]:


The right to file a grievance, including medical grievances, both informal and formal.

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LAW LIBRARIES AND LEGAL MATERIAL (LL&LM)
ODO reviewed the Law Libraries and Legal Material standard at ACF to determine if detainees
have access to a law library, legal materials, courts, counsel, and document copying equipment to
facilitate the preparation of legal documents, in accordance with the ICE PBNDS. ODO
interviewed detainees and staff, reviewed policies and the facility detainee handbook, and toured
and observed the law library.
There are three libraries in the facility, one in the West facility, one in the East facility, and one
inside the SMU. Both the West and East facility libraries are used by the respective general
populations. The libraries have adequate seating and workspaces. All libraries are well-lit and
reasonably isolated from noisy areas.
ODO verified the Lexis-Nexis legal resource software was installed and updated on
September 5, 2012. All libraries are equipped with either typewriters or computers and printers,
or both. ODO noted there were adequate supplies and writing materials available to detainees.
All libraries are under constant supervision by ACF staff.
All law libraries are open Monday through Friday (except holidays) from 7:50 am to 4:00 pm. A
schedule is posted in each housing unit indicating designated times for each housing unit,
including the SMU. A detainee can request additional time in the law library beyond the
five-hour minimum time limit by submitting a request through the housing unit manager.
A notary public, certified mail, and other such services to pursue legal matters are available to
detainees. ODO’s review of the detainee handbook found the rules and procedures governing
law library and legal materials in the facility are addressed in the handbook. Although all the
required rules and procedures are provided in the local detainee handbook, these procedures are
not posted in the three libraries (Deficiency LL&LM-1).
The legal reference materials in each of the three law libraries did not include Immigration Law
and Crimes, Guide for Immigration Advocates, Human Rights Watch, UNCHR Handbook on
Procedures and Criteria for Determining Refugee Status, Affirmative Asylum Procedures
Manual, and AILA’s Asylum Primer, 4th Edition in hard-copy format or electronically
(Deficiency LL&LM-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY LL&LM-1
In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(O), the FOD
must ensure the Detainee Handbook or supplement shall provide detainees with the rules and
procedures governing access to legal materials, including the following information:
1.
2.
3.
4.

That a law library is available for detainee use;
The scheduled hours of access to the law library;
The procedure for requesting access to the law library;
The procedure for requesting additional time in the law library (beyond the 5-hours-per-week
minimum);

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5. The procedure for requesting legal reference materials not maintained in the law library; and
6. The procedure for notifying a designated employee that library material is missing or
damaged.
7. Required access to computers, printers, and other supplies.
8. If applicable, that Lexis/Nexis is being used at the facility and that instructions for its use are
available.
These policies and procedures shall also be posted in the law library along with a list of the law
library’s holdings.
DEFICIENCY LL&LM-2
In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(E)(2)(b)(2),
the FOD must ensure, as an alternative to obtaining and maintaining the paper-based publications
in Attachment A, a facility may substitute the Lexis/Nexis publications on CD ROM. Any
materials listed in Attachment A which are not loaded onto the Lexis/Nexis CDROM must be
maintained in paper form.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at ACF to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE PBNDS. ODO toured the medical clinic, reviewed policies and procedures, examined
30 medical records, verified medical staff credentials, and observed the intake process and
medication distribution. In addition, ODO interviewed the HSA, Assistant HSA, CD,
psychiatrist, and the Director of Correctional Health Services for GEO’s Western Regional
Office.
Medical services at ACF are provided by the GEO Care Division. The primary intake area and
medical unit are in the West facility. ACF does not hold any accreditations; however, ACF
policies and procedures mirror the American Correctional Association and the National
Commission on Correctional Health Care standards. The facility is scheduled for an American
Correctional Association review in March 2013.
Administrative oversight of medical services is provided by the HSA, and a full-time physician
serves as the CD. The current HSA and CD were hired following the March 2012 detainee
death, replacing the former staff. The former HSA currently holds the position of Assistant
HSA. In addition to the HSA, CD, and Assistant HSA, full-time clinic staffing consists of a
psychologist, a dentist, a dental assistant,(b)(7)enurse practitioners,(b)(7)eRNs,(b)(7)elicensed
vocational nurses, (b)(7)e medical records clerks, and(b)(7)emedical data entry clerk. ACF medical
staff informed ODO a significant portion of the nursing staff is new to ACF, and efforts are
on-going to monitor and enhance performance, including improving interaction with custody
staff. Part-time staff includes an additional psychiatrist, X-ray technician, and lab technician.
ODO finds staffing sufficient to meet the health care needs of the detainee population at its
current level of 922 detainees. ODO was informed, however, that the detainee population will
increase to 1,300 detainees. ACF notified ODO that contingencies are in place to address the
increase in population from Mira Loma. According to the HSA and the GEO Director of
Correctional Health, a proposal has been submitted to increase medical staffing by(b)(7)epositions
to support the impending population increase.
Medical and mental health intake screenings of detainees are conducted by nursing staff at
arrival. ODO observed the screening is comprehensive, and includes taking and documenting a
complete set of vital signs. Translation during intake and all subsequent medical encounters is
provided by Spanish-speaking staff, or a telephone language interpretation service for those
speaking languages other than English or Spanish. Intake screening includes testing for
tuberculosis (TB) by way of chest X-ray (CXR), read immediately by a tele-radiology service.
ODO confirmed screening and CXRs were completed as required in all 30 records reviewed;
however, ten of 30 screenings were not reviewed by a physician within 24 hours as required by
the PBNDS (Deficiency MC-1). ODO notes the facility policy requires physician reviews of
intake screenings.
ACF has a comprehensive intake packet, which assures all necessary forms are initiated for the
medical record, and detainees receive information on accessing medical care and health issues.
Included in the packet is the Consent to Medical, Dental and Mental Health Services, and
Authorization for Release of Information, both of which are signed by the detainee. Obtaining
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authorization to release information assures that medical history and treatment information may
be obtained from other sources as necessary. In addition, the packet includes a Health Services
Notice, which provides information on sick call procedures and reporting medical emergencies;
and Intake Education Information, which acknowledges that during the intake process, the
detainee has been provided with information on medical services, nutrition, personal hygiene,
oral care and hygiene, HIV/AIDS, hepatitis, TB testing and prevention, boils and skin lesions,
substance abuse, and sexual assault prevention. ODO cites the intake packet as a best practice
because it ensures necessary forms and documents supporting delivery of health care are initiated
and included in the medical record, and detainees receive important information on health issues
and care.
Detainees with medical conditions or chronic diseases identified at intake receive physical
examinations (PEs) conducted by the CD. Appropriately trained RNs conduct PEs on detainees
with no known medical issues. Of the 30 records reviewed, ODO found 20 PEs were conducted
by the CD and ten were conducted by RNs. All PEs were completed well within the 14 days
required by the standard. The CD completed the PEs within 24 hours of referral, and the average
timeframe across all 30 PEs was three days. ODO verified all PEs were hands-on, and the
physician reviewed the PEs conducted by the RNs.
Review of ACF’s chronic care program verified procedures are in place to ensure detainees
receive treatment, monitoring, and routine follow-up. A color-coded file system is in place to
distinguish chronic care patients from healthy detainees, and a computer system is used to
support the efficient scheduling of follow-up appointments. Review of chronic care records
confirmed the CD thoroughly documented examinations and reviews of lab results and consult
reports. Although not a deficiency, ODO notes nurses did not consistently record detainees’
weights as part of chronic care evaluations. The HSA stated she would address this matter with
the nursing staff.
Detainees are referred to community providers for services beyond the scope of care provided by
the facility. ODO was informed the facility has improved its partnership with the local hospital
to facilitate mutual exchange of medical information, including patient history, emergency room
and hospital admissions, and lab, X-ray, and consultation reports. ODO confirmed the presence
of such documentation in detainees’ medical records, and verified the presence of signed
authorizations to release information. Review of 30 Medication Administration Records
confirmed physician’s orders were accurately reflected, and detainees received medications in
the dosage and frequency ordered.
ODO’s observation of medication distribution found detainees are identified prior to receiving
medications, and officers ensured the line of detainees awaiting their medications was organized
and controlled by correctional officers.
Detainees access care by completing written medical requests available in English and Spanish,
and placing them in secure medical lockboxes in each housing unit. ACF medical personnel
collect the sick call requests daily. Although local policy mirrors the PBNDS requirement that
sick call requests be triaged within 48 hours, review of 25 sick call requests found 12 were
triaged three to five days following submission (Deficiency MC-2). Review by ODO confirmed
that these 12 sick call requests did not document medical concerns of a significant nature;
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nonetheless, ODO recommends the facility takes steps to ensure triage is conducted and
documented in the medical record on a timely basis.
Review of(b)(7)erandomly-selected correctional and ICE staff training records verified current
CPR, automated external defibrillator (AED), and emergency first aid training. Out of
(b)(7)emedical staff credentials and certifications reviewed, ODO found(b)(7)eRNs and (b)(7)elicensed
vocational nurses did not have current CPR, AED, or first aid certifications (Deficiency MC-3).
The HSA informed ODO the RNs and licensed vocational nurses would complete the necessary
training to obtain certifications on Friday, September 21, 2012.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE PBNDS, Medical Care, section (V)(I)(1), the FOD must ensure the
clinical medical authority shall be responsible for review of all health screening forms within
24 hours or next business day to assess the priority for treatment (for example, Urgent, Today, or
Routine).
DEFICIENCY MC-2
In accordance with the ICE PBNDS, Medical Care, section (V)(N), the FOD must ensure each
facility shall have a sick call procedure that allows detainees the unrestricted opportunity to
freely request health care services (including mental health and dental services) provided by a
physician or other qualified medical staff in a clinical setting. This procedure shall include
[among others]:


All facilities must have an established procedure in place to ensure that all sick call requests
are received and triaged by appropriate medical personnel within 48 hours after the detainee
submits the request. In an urgent situation, the housing unit officer shall notify medical
personnel immediately.

DEFICIENCY MC-3
In accordance with the ICE PBNDS, Medical Care, section (V)(O), the FOD must ensure a plan
shall be prepared in consultation with the facility's clinical medical authority or the
administrative health authority. The plan will include the following [among others]:


All detention staff shall receive cardio pulmonary resuscitation (CPR, AED), and emergency
first aid training annually.

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