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

Office of Detention Oversight
Compliance Inspection
Enforcement and Removal Operations
ERO Los Angeles Field Office
Adelanto Detention Facility
Adelanto, California

July 8–10, 2014

COMPLIANCE INSPECTION
ADELANTO DETENTION FACILITY
ERO LOS ANGELES FIELD OFFICE
TABLE OF CONTENTS
INSPECTION PROCESS
Report Organization .............................................................................................................1
Inspection Team Members ...................................................................................................2
EXECUTIVE SUMMARY ...........................................................................................................3
OPERATIONAL ENVIRONMENT
Detainee Relations .......................................................................................................................... 8
ICE 2011 PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................9
Food Service ......................................................................................................................10
Funds and Personal Property .............................................................................................12
Grievance System ..............................................................................................................14
Law Libraries and Legal Material......................................................................................16
Sexual Abuse and Assault Prevention and Intervention ....................................................17
Telephone Access ..............................................................................................................25

INSPECTION PROCESS
The U.S. Immigration and Customs Enforcement (ICE), Office of Professional
Responsibility (OPR), Office of Detention Oversight (ODO) conducts broad-based compliance
inspections to determine a detention facility’s overall compliance with the applicable ICE
National Detention Standards (NDS) or Performance-Based National Detention
Standards (PBNDS), and ICE policies. ODO bases its compliance inspections around specific
detention standards, also referred to as core standards, which directly affect detainee health,
safety, and well-being. Inspections may also be based on allegations or issues of high priority or
interest to ICE executive management.
Prior to an inspection, ODO reviews information from various sources, including the Joint Intake
Center (JIC), Enforcement and Removal Operations (ERO), detention facility management, and
other program offices within the U.S. Department of Homeland Security (DHS). Immediately
following an inspection, ODO hosts a closeout briefing at which all identified deficiencies are
discussed in person with both facility and ERO field office management. Within days, ODO
provides ERO a preliminary findings report, and later, a final report, to assist in developing
corrective actions to resolve identified deficiencies.

REPORT ORGANIZATION
ODO’s compliance inspection reports provide executive ICE and ERO leadership with an
independent assessment of the overall state of ICE detention facilities. They assist leadership in
ensuring and enhancing the safety, health, and well-being of detainees and allow ICE to make
decisions on the most appropriate actions for individual detention facilities nationwide.
ODO defines a deficiency as a violation of written policy that can be specifically linked to ICE
detention standards, ICE policies, or operational procedures. Deficiencies in this report are
highlighted in bold and coded using unique identifiers. Recommendations for corrective actions
are made where appropriate. The report also highlights ICE’s priority components, when
applicable. Priority components have been identified for the 2008 and 2011 PBNDS; priority
components have not yet been identified for the NDS. Priority components, which replaced the
system of mandatory components, are designed to better reflect detention standards that ICE
considers of critical importance. These components have been selected from across a range of
detention standards based on their importance to factors such as health and safety, facility
security, detainee rights, and quality of life in detention. Deficient priority components will be
footnoted, when applicable. Comments and questions regarding this report should be forwarded
to the Deputy Division Director, OPR ODO.

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INSPECTION TEAM MEMBERS

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

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Section Chief (Team Lead)
Inspections & Compliance Specialist
Inspections & Compliance Specialist
Contractor
Contractor
Contractor
Contractor

2

ODO
ODO
ODO
Creative Corrections
Creative Corrections
Creative Corrections
Creative Corrections

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EXECUTIVE SUMMARY
ODO conducted a compliance inspection of the Adelanto Detention Facility (ADF) in Adelanto,
California, from July 8 to 10, 2014. ADF, which opened in 2011, is owned by the GEO Group,
Inc. and operated by GEO Corrections & Detention. ERO began housing detainees at ADF in
August 2011 under an IGSA contract. Male detainees of security classification levels I through
III are detained at the facility for periods in excess of 72 hours. The inspection evaluated ADF’s
compliance with the 2011 PBNDS.
The ERO Field Office
Director (FOD), in Adelanto,
California, is responsible for ensuring
facility compliance with the 2011
PBNDS and ICE policies. A
minimum of (b)(7)eERO staff oversee
daily detention operations at ADF. A
Detention Service Manager (DSM) is
on site.

Capacity and Population Statistics

Quantity

Total Bed Capacity

1,290

ICE Detainee Bed Capacity

1,290

Average Daily Population

1,217

Average ICE Detainee Population

1,217

Average Length of Stay (Days)

51

Male Detainee Population (as of 07/08/14)

1,209

Female Detainee Population (as of 07/08/14)

N/A

A Facility Administrator is responsible for oversight of daily facility operations and is supported
by(b)(7)epersonnel. The GEO Group, Inc. provides food services and medical services. ADF is
accredited by the American Correctional Association (ACA). The ADF campus consists of two
separate buildings (East and West), both with detainee housing units and food service areas.
During the inspection, construction of a new wing was underway to add a new lobby and
housing units.
In September 2012, ODO conducted an inspection of ADF under the 2008 PBNDS. ODO
reviewed 17 standards and found ADF compliant with 11 standards. ODO found a total of
26 deficiencies in the remaining six standards.
During this inspection ODO reviewed 16 standards and found ADF compliant with ten
standards. ODO found a total of 26 deficiencies, nine of which relate to priority components, 1 in
the remaining six standards: Food Service (2 deficiencies), Funds and Personal Property (2),
Grievance System (3), Law Libraries and Legal Material (2), Sexual Abuse and Assault
Prevention and Intervention (16), and Telephone Access (1). ODO identified seven areas of
concern and made one recommendation related to ADF’s sexual abuse and assault program.
This report details all deficiencies and refers to the specific, relevant sections of the 2011
PBNDS. ERO will be provided a copy of this report to assist in developing corrective actions to
resolve all identified deficiencies. ODO discussed preliminary deficiencies with ADF and ERO
management during a closeout briefing conducted on July 10, 2014.
ODO observed new detainees being processed into ADF during the inspection. The intake
process at ADF is a comprehensive process involving the collection of emergency contact
1

Deficient priority components were found in the following four standards: Food Service, Funds and Personal
Property, Law Libraries and Legal Material, and Sexual Abuse and Assault Prevention and Intervention.

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information, completion of medical and SAAPI questionnaires, issuance of the detainee
handbook, collection of fingerprints and photographs, and screening by medical staff. Upon
completion of medical screenings, detainees are interviewed by a classification officer who
issues a color-coded wrist band denoting the appropriate classification level. Classification staff
is not on site on weekends. ERO staff does not provide ADF staff Risk Classification
Assessment forms.
ADF’s orientation video, which includes “Know Your Rights” and a video on preventing sexual
abuse and assault, is shown continuously while detainees wait for intake processing. The video
rotates between English and Spanish versions.
Funds, valuables, and personal property are inventoried and receipted during intake. Property
and valuables are secured in both the East and West buildings. All U.S. currency is deposited
into a commissary account for the detainee. Foreign currency is treated as valuable property, and
stored in a separate sealed valuable property bag separate from any other valuable property.
Property rooms are secured and accessible only to a lieutenant and (b)(7)eofficers. Although
access is limited and documenting controls are in place, the Funds and Personal Property
standard states that the large valuables locker shall be accessible only to the shift supervisor.
This represents a repeat deficient priority component from ODO’s September 2012 inspection.
The personal property inventory form is missing one component.
ADF has a comprehensive policy addressing the classification of detainees. ODO observed the
classification process for three arriving detainees, and reviewed 40 detention files. The files
contained all necessary documentation supporting proper assignment of classification levels.
Detainees are issued the ICE National Detainee Handbook and the ADF detainee handbook
during the intake process. ODO reviewed 40 detention files to verify receipt of the detainee
handbook. Every handbook is numbered and a detainee signs for the specific handbook issued to
them during intake. Every officer who has contact with detainees is also provided a copy of the
handbook and receives training on its contents. ADF’s detainee handbook is available in both
English and Spanish and was last revised in June 2014. The handbook is reviewed annually by a
committee and the warden has a final review.
ADF has a comprehensive policy addressing all requirements of the Detainee Transfers standard.
ODO observed the processing of detainees being transferred to other facilities and reviewed the
archived files of seven detainees previously transferred from ADF. All required documentation
was available, including property and funds receipts, and medical transfer summaries, files and
medications in sealed envelopes marked “confidential” with the detainees’ names and Anumbers. The files also included copies of forms provided to detainees by ERO notifying them
of the name, address, and telephone number of the receiving facility.
ODO reviewed 137 formal disciplinary actions involving detainees during the 12 months
preceding this inspection. ODO reviewed randomly-selected cases and confirmed rule violations
were investigated within 24 hours. Detainees were served with notice, hearings were conducted
in a timely manner, and sanctions were within established guidelines. ODO observed an
Institution Disciplinary Panel hearing during the inspection and found it was professionally
conducted and met all requirements of the standard.
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The food service operation at ADF is operated by GEO staff. A food service manager oversees
the operation and has a staff consisting of a production supervisor,(b)(7)ecook supervisors, (b)(7)e
food service workers, and a clerk. ADF operates two separate kitchen facilities, one in the West
building and one in the East building. ODO observed preparation and sampled the noon meal on
Wednesday during the inspection.
Overall sanitation of the food services areas was good during the inspection. The detainee and
staff restrooms were clean and had hot and cold water, trash receptacles, hand soap in dispensers,
and paper towels; however, the detainee restroom did not have a sign reminding detainees to
wash their hands prior to returning to work. The facility initiated corrective action during the
course of the inspection.
ADF does not have a procedure for identifying and handling time-sensitive emergency
grievances requesting urgent access to legal counsel and the law library. Although ADF’s
handbook informs detainees of the opportunity to file informal and formal grievances, it states
detainees cannot file an informal and formal grievance on the same issue at the same time, and
doing so results in both grievances being returned without processing. Detainees may appeal any
grievance decision to the grievance committee. If a detainee is unsatisfied with the grievance
committee’s decision, he may further appeal to the facility administrator or ERO. The grievance
committee does not document in the grievance log the dates appeals are filed.
ADF has a designated law library in the East and West buildings of the facility. None of the
computers contained an updated version of LexisNexis. This represents a deficient priority
component. ADF initiated corrective action during the course of the inspection by updating
LexisNexis. The detainee handbook notifies detainees that the law library is available for use
and includes all of the required information; however, ADF does not post these policies and
procedures in the law library.
Healthcare at ADF is provided 24 hours a day, seven days a week by the GEO Group, Inc. The
staffing plan calls for (b)(7)epositions, including a Health Services Administrator (HSA), assistant
HSA,(b)(7)e physicians (b)(7)e nurse practitioners (NP),(b)(7)ephysician assistant-certified (PA-C), (b)(7)e
registered nurses (RN), and(b)(7)elicensed vocational nurses (LVN). In addition, mental health
services are provided by (b)(7)epsychiatrists and (b)(7)epsychologists, and dental services are
provided by (b)(7)edentists and(b)(7)edental assistants. There are (b)(7)e medical records clerks, (b)(7)e
medical data entry clerk,(b)(7)e X-ray technician, and (b)(7)elab technicians. At the time of the
review, the HSA and assistant HSA positions were vacant, and an RN was serving as acting
HSA. Credential files for(b)(7)eselect staff were current and verified through the National
Practitioner Data Bank, with no license restrictions. Cardiopulmonary resuscitation, automated
external defibrillator and first aid training were current for all medical staff.
Medical and mental health screenings are completed within 12 hours of detainee arrival, as
verified by ODO’s review of 40 detainee medical records. Screenings are conducted by nursing
staff in two dedicated medical rooms in the intake area. Detainees are screened for tuberculosis
(TB) upon intake by way of purified protein derivative and results are read and documented by
nursing staff after 48 hours. Documentation of the TB screening was confirmed during medical
record review. Of the 40 medical records reviewed, 32 were detainees with chronic medical
conditions. The medical records for detainees with chronic health care needs are maintained in a
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different color folder than those used for other detainees. ODO’s review confirmed treatment
plans were included in the records and included diagnostic testing and routine monitoring. ODO
found signed general consent for treatment forms were included in all 40 medical records
reviewed, and specific consent was obtained for psychotropic medications.
Detainees access health care services by submitting written request forms available in English
and Spanish. The forms are deposited in a secure drop-box in the housing units, and are picked
up twice daily by nursing staff. ODO’s review found the requests are date-stamped and triaged
the same day to determine if the need is emergent, routine or appropriate for written response
only. Physician-approved nursing protocols are followed to administer over-the-counter
medications and provide routine treatment, and referrals to mid-level providers or physicians are
made when medical issues are beyond the nursing staff’s knowledge or scope of practice. The
GEO Track system is used to schedule non-urgent provider appointments, which ODO found
were completed the same or next day. Detainees in the Special Management Units (SMUs)
access health care in the same manner.
Detainees are initially screened for suicide risk by nursing staff during the intake process.
Further screening is completed by the psychologist during mental health evaluation the next day.
In the event a detainee is determined “at risk” by nursing or security staff at any point during the
detention period, he is seen by a mental health professional the same day. Discontinuation of
suicide watch is the responsibility of the psychiatrists and psychologists.
ODO was informed 115 detainees were placed on suicide watch and eight detainees attempted
suicide in the 12 months preceding the inspection. According to the mental health professionals,
the suicide attempts involved minor gestures and did not result in injuries. ODO reviewed the
medical records of detainees placed on suicide watch, including two suicide attempts. The
records documented suicide watch management consistent with the standard and ADF’s policy,
and discontinuation of the status by mental health professionals following suicide risk
assessment. The mental health team submits a weekly report on detainees on suicide watch to
the warden and ERO.
ADF’s H-1 Unit is the designated SMU for detainees assigned to administrative segregation and
disciplinary segregation, with separation afforded by cell assignment. SMU documentation
showed 286 detainees were placed on administrative segregation and 328 sanctioned with
disciplinary segregation during the 12 months preceding this inspection. A random review of 40
prior placements confirmed segregation orders were issued, required reviews were conducted,
and the detainees received privileges and services consistent with facility policy and the
standard.
During the inspection, eight detainees were on administrative segregation and seven were
serving disciplinary segregation sanctions. Segregation orders and documentation of status
reviews were available and complete for all 15 detainees. Of the eight detainees on
administrative segregation, four were pending disciplinary hearings for fighting and four were on
protective custody. ODO interviewed the four detainees on protective custody and all confirmed
they were on the status at their own request and refused alternative housing. All four were seen
weekly by a psychologist for mental health issues, and written reports were provided to ERO
documenting the detainees’ status as determined in the weekly mental health evaluation.
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The Assistant Warden serves as the sexual abuse and assault program coordinator and is
responsible for program oversight, staff training, and coordination with external law enforcement
agencies. All staff with regular detainee contact receives four hours of pre-service training on
the Prison Rape Elimination Act (PREA), and three hours every year thereafter.
ODO identified numerous deficiencies and areas of concern with ADF’s Sexual Abuse and
Assault Prevention and Intervention (SAAPI) program. While the facility has policies and some
procedures in place, ODO found wide inconsistencies across the facility’s policies, procedures,
practices and record keeping. Of greatest concern were the discoveries that ADF does not report
all allegations of sexual abuse and assault to ERO and case files are not properly maintained. 2
These findings represent deficiencies in several priority components.
ODO found no deficiencies with the staff-detainee communication standard. Staff-detainee
communications at ADF are supported by Spectrum, a private contractor. 3 Spectrum staff
handles the administrative functions associated with the standard, such as collecting, responding
to and tracking detainee requests directed to ICE, and preparing facility liaison checklists.
Detainees have the option of bypassing Spectrum staff and interacting directly with ERO, if
requested. According to Spectrum staff, they handled over 4,500 detainee requests between
January 1, 2014 and July 10, 2014. The top three subjects of detainee requests during that period
were court dates, bonds/parole, and asylum.
Talton Communications provides telephone service at ADF. Each housing pod at ADF contains
one phone for every nine detainees. Telephones remain on 24 hours a day seven days a week. If
paying by debit or pre-paid collect, local and long distance call charges are $0.10 per minute.
Local and long distance collect call charges, and international debit call charges, are $0.15 per
minute. Federal, state, and local taxes do apply. These rates are posted in every telephone area
in each pod. ODO conducted functional checks of telephones in detainee housing units and all
were found to be in good working order. Housing officers execute and log telephone
serviceability checks on a routine and consistent basis, and report outages and issues. However,
officers do not test the free call platform, as required by the 2011 PBNDS.
ADF’s written policies on use of force and restraints address all the requirements of the standard,
including confrontation avoidance and using force only as a last resort. All security staff
complete training in the use of force and restraints upon hire and annually, which was confirmed
through review of(b)(7)erandomly-selected staff training records. Use of force and personal
protection equipment was well maintained and accounted for in both the East and West
buildings. Based on documentation and staff interviews, ODO determined 28 calculated and 16
immediate use-of-force incidents occurred in the 12 months preceding this inspection. A review
of video and written documentation in five randomly-selected calculated and five immediate useof-force incidents confirmed full compliance with the standard, including post-incident medical
examinations, after action reviews, and notification of ERO.

2

At the time of the inspection, the program coordinator reportedly had only been at ADF and in her role since
November 2013. Likewise, the ERO Assistant Field Office Director had reportedly been assigned to ADF for only
two months.
3
The Spectrum contract is managed by ICE.

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OPERATIONAL ENVIRONMENT
DETAINEE RELATIONS
ODO interviewed 47 randomly-selected detainees of all classification levels to assess the
conditions of confinement at ADF. Detainees of all classification levels (not including those in
SMUs) are permitted a minimum of 12 hours out of cell time daily. Interview participation was
voluntary and none of the detainees made allegations of abuse, discrimination or mistreatment.
The majority of detainees reported being satisfied with facility services and their treatment by
ADF, ERO and Spectrum staff. There were a few complaints about food service, the law library
and medical care.
Food Service: Approximately 35 percent of the detainees interviewed complained food service
was unsatisfactory, citing small portion sizes and a lack of variety in the menu. ODO reviewed
food service at ADF and found the menu at the time of the inspection well-balanced, with an
adequate caloric count.
Law Library: All detainees stated they have access to the law library. One detainee stated there
are not enough computers for all who would like to use them. ODO looked into the issue and
found there are a sufficient number of computers to accommodate the detainee population size.
Medical Care: Approximately half of the detainees interviewed made specific medical
complaints about their medical care. ODO reviewed each case and found medical care provided
was appropriate and timely in each case

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ICE 2011 PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 16 PBNDS and found ADF fully compliant with the following
ten standards:
1. Admission and Release
2. Custody Classification System
3. Detainee Handbook
4. Detainee Transfers
5. Disciplinary System
6. Medical Care
7. Significant Self-Harm and Suicide Prevention and Intervention
8. Special Management Units
9. Staff-Detainee Communication
10. Use of Force and Restraints
As the standards above were compliant at the time of the inspection, a synopsis for these
standards is not included in this report.
ODO found 26 deficiencies in the following six standards.
1.
2.
3.
4.
5.
6.

Food Service
Funds and Personal Property
Grievance System
Law Libraries and Legal Material
Sexual Abuse and Assault Prevention and Intervention
Telephone Access

Findings for these standards are presented in the remainder of this report.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at ADF to determine if detainees are provided with a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE 2011 PBNDS.
ODO reviewed policy and procedures, inspected all areas of the food service operation, observed
meals being prepared and served, and interviewed staff and detainees.
The food service operation at ADF is operated by GEO staff. A food service manager oversees
the operation and has a staff consisting of a production supervisor,(b)(7)ecook supervisors, (b)(7)e
food service workers, and a clerk. ADF operates two separate kitchen facilities, one in the West
building and one in the East building. Each kitchen has a work crew of(b)(7)edetainees assigned to
three shifts. Detainee workers are paid $1 daily.
ODO’s review of documentation for all employees and(b)(7)erandomly-selected detainee workers
confirmed all were medically cleared to work in the food service department. The detainee
workers’ files also documented completion of an orientation and training program prior to being
assigned a designated job in the kitchen. Detainees are visually inspected for visible health
issues and hygiene concerns prior to starting their shift, then change to white uniforms. Detainee
workers, staff, and visitors wear hairnets and beard guards for facial hair. Gloves are worn for
all persons preparing and serving food.
The East building has a satellite system of meal service, and the West building has a dining hall.
Documentation confirmed the general, religious, and medical diet menus are certified by a
registered dietician, and average 2,300 calories per day. The menu is on a 42-day cycle,
exceeding the standard. At the time of the inspection, 63 detainees were on medical diets and 15
detainees were receiving religious diets.
ODO observed preparation and sampled the noon meal on July 9, 2014. The items served were
consistent with the menu. In the West building, staff took food temperatures upon preparation
and while on the serving line in the dining hall. Temperatures were maintained within the
required ranges for both hot and cold food items. However, due to the satellite feeding system in
the East building, cold food temperatures exceeded the acceptable minimal threshold.
Temperatures for the freezer, cooler, and dishwasher are recorded on each shift. The staff and
detainee restrooms were checked. Inspection of the dry storage room found it orderly and clean
and the required clearances from the ceiling, floors and walls were met. There were no signs of
insect or rodent infestation in the dry storage area or anywhere in the food service department.
ODO reviewed documentation indicating pest control services are provided by a local contractor
monthly and as needed.
ODO observed the overall sanitation of the food services areas was good during the inspection.
Detainees were observed following “clean as you go” procedures, and the floors, surfaces, and
all equipment were cleaned between shifts. The detainee and staff restrooms were clean and had
hot and cold water, trash receptacles, hand soap in dispensers, and paper towels; however, the
detainee restroom did not have a sign reminding detainees to wash their hands prior to returning
to work (Deficiency FS-1). The facility initiated corrective action during the course of the
inspection. Reminder signs were posted in the staff restroom and at hand washing locations
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throughout the kitchen. The food service administrator conducts inspections of the food service
areas in both buildings on a weekly basis. A monthly inspection of the area is conducted by a
multi-disciplinary team, including the infectious disease nurse. The San Bernadino County
Division of Environmental Health Services inspects the Food Service areas annually. The last
inspection was on June 11, 2014, and no health concerns or violations of code were cited.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with ICE 2011 PBNDS, Food Service, section (V)(J)(9)(c), the FOD must ensure,
“Adequate and conveniently located toilet facilities shall be provided for all food service staff
and detainee workers.
c. Signs shall be prominently displayed.”

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(b)(7)e

DEFICIENCY F&PP-2
In accordance with the ICE 2011 PBNDS, Funds and Personal Property, section (V)(I)(1), the
FOD must ensure, “The personal property inventory form must contain the following
information at a minimum:
1. date and time of admission.”

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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at ADF 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 2011
PBNDS.
ADF’s policy and detainee handbook both address the informal and formal grievance process,
emergency grievances, medical grievances, the availability of assistance in filing a grievance,
procedures for appeal and the opportunity to file a complaint about officer misconduct. ADF
does not have a procedure for identifying and handling time-sensitive, emergency grievances
involving urgent access to legal counsel and the law library (Deficiency GS-1). Although
ADF’s handbook informs detainees of the opportunity to file informal and formal grievances, it
states detainees cannot file both grievances on the same issue at the same time, and doing so will
result in both grievances being returned without processing (Deficiency GS-2).
Grievance forms are available in the housing units and detainees may obtain assistance from
another detainee or facility staff in preparing a grievance. AFD provides detainees with
envelopes in which to seal grievances, identifying them as sensitive or medically sensitive.
Detainees deposit their grievances in a locked grievance box available in each of the housing
units. The facility forwards any grievances determined to allege staff misconduct to ERO.
ADF maintains a log to document and track grievances filed by detainees. Three hundred and
fifty-six formal grievances were filed by detainees in the 12 months preceding the inspection and
all were addressed within reasonable timeframes. The grievance subjects break down as follows:
96 involved medical issues; 47 related to food; 29 involved property issues; 19 involved legal
issues; 14 referenced staff misconduct; and 151 involved miscellaneous issues such as housing
unit conditions, television, canteen, etc. Responses are provided to detainees in writing and a
copy is placed in the detention file. The allegations involving staff misconduct were referred to
ERO. No patterns or trends were noticed among the grievances.
Detainees may appeal any grievance decision to the grievance committee. If a detainee is
unsatisfied with the grievance committee’s decision it may be further appealed to the facility
administrator or ERO. The grievance committee does not document in the grievance log the
dates appeals are filed (Deficiency GS-3).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE 2011 PBNDS, Grievance System, section (V)(C)(2), the FOD must
ensure, “Written procedures shall also cover urgent access to legal counsel and the law library.”
DEFICIENCY GS-2
In accordance with the ICE 2011 PBNDS, Grievance System, section (V)(C)(3), the FOD must
ensure, “The detainee may file a formal grievance at any time during, after, or in lieu of lodging
an informal complaint.”
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DEFICIENCY GS-3
In accordance with the ICE 2011 PBNDS, Grievance System, section (V)(C)(3)(b)(2)(d), the
FOD must ensure, “The GAB shall note the grievance log with the following information:
•

date appeal filed.”

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LAW LIBRARIES AND LEGAL MATERIAL (LL&LM)
ODO reviewed the Law Libraries and Legal Material standard at ADF 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 2011 PBNDS. ODO
observed the law library, interviewed staff and detainees and reviewed policies as well as the
detainee handbook.
ADF has designated law libraries in the East and West buildings of the campus. The East
building is equipped with 12 computers and the West building has 14. None of the computers
contained an updated version of LexisNexis (Deficiency LL&LM-1). 5 ADF initiated corrective
action during the course of the inspection and received an updated version. Installation of the
new version on all computers in both law libraries was initiated on July 10, 2014.
The designated rooms for law-library use are well-lit, contain sufficient furnishings, and are
equipped with adequate equipment and supplies to support legal research and case preparation.
Legal documents can be printed and copies are made with the assistance of a staff member.
Detainees may request use of the law library by submitting a request form. Detainees are
afforded a minimum of five hours per week between 7:50 a.m. and 4 p.m., and additional time is
available upon request. ADF affords the same law library privileges to detainees in SMUs and a
designated computer is located in the SMU housing unit to prevent comingling.
Facility staff informed ODO that illiterate and limited English proficient detainees are provided
assistance with their legal paperwork, as needed. Detainees with appropriate language, reading,
and writing abilities are allowed to provide assistance. The law library custodian provides
indigent detainees free envelopes, stamps, notary services, and certified mail for legal matters.
ADF provides detainees all the required law library notices in the detainee handbook, but does
not post them in the law library (Deficiency LL&LM-2).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY LL&LM-1
In accordance with the ICE 2011 PBNDS, Law Libraries and Legal Material, section
(V)(E)(1)(a)(2), the FOD must ensure that computers in the law library contain an updated
version of LexisNexis.
DEFICIENCY LL&LM-2
In accordance with the ICE 2011 PBNDS, Law Libraries and Legal Material, section (V)(N), the
FOD must ensure the policies and procedures governing access to legal materials, “Shall also be
posted in the law library.”

5

Priority Component. This is a repeat deficiency from ODO’s September 2012 inspection.

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SEXUAL ABUSE AND ASSAULT PREVENTION AND INTERVENTION
(SAAPI)
ODO reviewed the Sexual Abuse and Assault Prevention and Intervention (SAAPI) standard at
ADF to determine if facilities act to prevent sexual abuse and assaults on detainees, provide
prompt and effective intervention and treatment for victims of sexual abuse and assault, and
control, discipline, and prosecute the perpetrators, in accordance with the ICE 2011 PBNDS.
No deficiencies were identified by ODO during its 2012 inspection, when the facility was under
the 2008 PBNDS. DHS CRCL and ERO inspection reports from February 2013 and December
2013, respectively, did not identify any deficiencies in this standard. ADF signed a contract
modification with ICE on May 23, 2013, agreeing to implement the 2011 Performance-Based
National Detention Standards. ODO identified 16 deficiencies and seven areas of concern during
this inspection.
ODO reviewed a variety of documents for this inspection, including facility policies, the detainee
handbook, a sexual abuse and assault incident tracking log, intake notices, intake questionnaires,
sexual abuse and assault case files, training materials, and staff training records.
The facility PREA coordinator, the nursing supervisor, and various intake, classification, and
custody staff were interviewed as part of this inspection. All staff with regular detainee contact
receives four hours of pre-service training on PREA, and three hours every year thereafter.
Further, ODO toured and observed the intake area, medical department, and the central control
rooms and housing units in both of ADF’s East and West Buildings.
The Facility Administrator’s signature of approval was missing from the July 1, 2013,
Prevention of Sexual Assault and Abuse policy, and the policy was not fully compliant with the
standard. Facility administrators are required to ensure written policy and procedures are in
place and the facility is in full compliance with the standard within 90 days of the effective date
of the standard (Deficiency SAAPI-1). 6
ADF management does not notify ERO of all allegations of sexual abuse and assault
(Deficiency SAAPI-2). ADF management reported to ODO a total of 13 incidents, but was only
able to produce evidence of one notification to ERO. ERO staff was unable to verify receipt of
any notifications. 7 The PREA coordinator stated the ERO Field Office is notified of every
incident, but only after the facility first determines whether the allegation is credible. 8
ADF’s policies do not include the requirements for coordination with ICE OPR
(Deficiency SAAPI-3). While the policy references GEO’s Office of Professional
6

ADF’s Prevention of Sexual Assault and Abuse, Forensic Data Collection and General Incident Report policies
were referenced as part of this inspection. No other policies referencing sexual abuse and assault were provided by
ADF in response to ODO’s data request.
7
ADF reported 13 incidents for the 12 months preceding the inspection. Two of the 13 incidents were documented
in JICMS. ADF management provided ODO evidence of notification for only one of the two incidents in JICMS.
The incident occurred January 4, 2014; ADF management reported the incident to ICE via email on January 14,
2014. ERO Field Office staff was unable to verify receipt of any notifications.
8
Priority Component.

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Responsibility, the ICE Officer in Charge (OIC) and the ICE Assistant Field Office Director
(AFOD), there is no mention of, or requirements for, coordination with ICE OPR. 9
ADF’s policies fail to specify the procedures for reporting an allegation or suspicion of sexual
assault through the chain of command, including the written documentation requirements to
ensure each allegation is properly addressed (Deficiency SAAPI-4). 10 ODO found wide
inconsistencies in the quality of documentation in the case files.
ADF’s polices fail to specify the responsibilities of medical staff to report allegations or
suspicions of assault to appropriate staff (Deficiency SAAPI-5). The policy states alleged abuse
may be reported to any staff member; however, the standard calls for specific references to the
responsibilities of medical staff.
None of the policies reviewed by ODO specified the evidence protocol to be used following an
allegation of abuse or assault (Deficiency SAAPI-6). The PREA coordinator stated evidence
collection is part of in-service training, but ODO did not find these protocols in any of the
policies provided for review.
ADF has no procedures for coordinating internal administrative investigations with the assigned
criminal investigative entity to ensure non-interference with criminal investigations
(Deficiency SAAPI-7).
ADF’s policies fail to specify how a victim’s legal needs shall be addressed
(Deficiency SAAPI-8). Medical, mental health and custody are addressed in the policy, but
there are no references to legal needs.
ADF’s policies fail to provide instructions on how to contact the DHS OIG and ICE OPR in the
event of an alleged incident. Although the policy references the DHS OIG, ICE OIC and ICE
AFOD, there are no instructions in the policy on how to reach these offices and individuals
(Deficiency SAAPI-9).
ADF’s training materials lack instruction on documentation and referral procedures of all
allegations or suspicion of sexual abuse or assault (Deficiency SAAPI-10). 11
ADF does not provide detainees the name of the PREA coordinator (program coordinator), or
designated staff member, and information on how to contact him or her (Deficiency SAAPI-11).
This information does not appear in the detainee handbook, the PREA memo or in the any of the
orientation videos.
None of the information provided to detainees states the prohibition against retaliation, including
an explanation that reporting an assault shall not negatively impact immigration proceedings
(Deficiency SAAPI-12). 12

9

Priority Component.
Priority Component.
11
Priority Component.
12
Priority Component.
10

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None of the information provided to detainees references the right to receive treatment or
counseling (Deficiency SAAPI-13). 13
Neither ADF’s policies nor the GEO 2013 Employee Handbook specifically notify staff
suspected of perpetrating sexual abuse or assault that they will be removed from all duties
requiring detainee contact pending the outcome of an investigation (Deficiency SAAPI-14). 14
The PREA coordinator does not maintain two types of case files: general and administrative.
Facility management maintains only one file containing all information, including medical
records (Deficiency SAAPI-15).
ADF case files were inconsistent and incomplete with regard to documentation. Examples of
missing information included names of the victim(s) and assailant(s); crime characteristics;
detailed reporting timelines; the staff member receiving the report of sexual assault; date(s) and
time(s) the report was received; steps taken to communicate the report up the chain of command;
all reports, medical forms, supporting memos and video; and any other evidentiary materials
(Deficiency SAAPI-16).
In addition to the deficiencies above, ODO identified areas of concern. These concerns did not
rise to the level of deficiencies; however, they should be carefully monitored and addressed to
avoid possible noncompliance in the future. These concerns are as follows:
ODO found a minimum of seven different definitions for detainee-on-detainee and staff-ondetainee abuse across ADF’s policies, PREA tracking logs, and training materials. All the
definitions differ in semantics and none match ICE’s definitions exactly. These definitions
exclude the ones contained in the ICE Sexual Assault Awareness pamphlet, which is posted in all
housing units, and the definitions contained in the medical care protocols. Inconsistent
definitions invite confusion among staff and detainees and may result in serious and legitimate
allegations being unreported.
ODO found wide inconsistencies and the need for clarification across ADF’s policy manual,
training materials, employee handbook and detainee handbook. Examples of information
needing consistency and clarification are: 1) the requirement that any staff member make take a
report; 2) the disciplinary actions for staff who accused of or found to be engaging in sexual
abuse or assault; 3) forensic evidence collection being performed by an outside party; and 4) the
appropriate response to allegations or suspicions of sexual assault on detainees with disabilities.
Continuity and clarification of information reduces the risk of misapplication.
Prevention and intervention strategies should be effectively communicated to detainees to
prevent risk of abuse. ADF broadcasts a 20-minute video with prevention and intervention
strategies in both the intake area and housing units daily. The video plays in conjunction with
the “Know Your Rights” video, meaning the prevention and intervention strategies are not
available every 20 minutes. ODO identified three problems: First, there are several chances for
detainees to miss the prevention and intervention strategies. Second, the video audio is only
available in English. The standard requires detainee notification, orientation and instruction to
13
14

Priority Component.
Priority Component.

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be in a language detainees understand. Third, due to poor acoustics in the holding cells, the
video audio is difficult to hear and understand. The prevention and intervention strategies are
unavailable to detainees in writing.
ADF completes a PREA Risk Assessment questionnaire for all incoming detainees. The form
includes seven yes/no questions about sexual history and is implemented by classification staff.
The form is used to determine where and how detainees should be housed. During interviews,
medical and classification staff answered differently when asked how the form is used and what
types of responses trigger additional action by staff. Classification and medical staff should be
retrained in the purpose and use of the risk questionnaire.
Classification staff stated during the inspection that when it comes to identifying sexual
aggressors, they rely solely on the detainee’s willingness to disclose information. The ERO
Field Office should ensure ADF routinely receives Form 1-213 in order to make informed
decisions.
ADF’s PREA coordinator informed ODO a group of specially trained staff conduct an initial
investigation when an incident of sexual abuse or assault is reported. This occurs before any
notifications are made to county or ICE officials, in order to first determine whether the incident
meets the county and ERO’s criteria. There are no written criteria on what and how much
information trained staff is to collect. ICE OPR and ERO Prevention of Sexual Assault
Coordinators recommend conducting “initial assessments,” rather than investigations, in order to
determine what is reportable, and avoid any delays in formally reporting incidents to ICE.
Interviews of alleged detainee victims should be limited to questions necessary to confirm the
basic facts of the allegation.
The PREA coordinator informed ODO the sheriff’s office is only contacted when the allegation
involves “penetration” and if preliminary medical findings confirm the allegation. All
allegations involving criminal conduct should be reported to the local law enforcement agency.
All infectious testing is performed offsite. During an interview with the nursing supervisor,
ODO learned infectious testing is only offered to alleged victims if and when the county sheriff’s
office recommends. The nursing supervisor stated it generally takes 24 hours to get an
investigative result from the county. Further, prophylactics are only offered if a doctor
determines necessary. Infectious testing should never be delayed and consent to test need only
come from the patient, not an outside entity.
While the ERO Field Office and ADF staff appear to have a good working relationship, it was
clear during the inspection the two parties do not communicate effectively when it comes to
alleged sexual abuse and assault incidents. Further, despite repeated requests by ODO, the ERO
Field Office was unable to produce any documentation they received notifications from ADF
about alleged sexual abuse and assault incidents. Notifications and communications regarding
sexual abuse and assault incidents should be documented in writing.
The PREA coordinator informed ODO there are no existing memorandums of understanding
with community victim resource centers. The facility tried establishing one with the county, but

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they could not come to agreement on confidentiality terms. ADF management stated they are
continuing to identify opportunities for agreements with other agencies.
ODO recommends ADF management perform a comprehensive review of all written policies,
logs, training materials, and other documents that address sexual abuse and assault, to ensure all
definitions and policies are consistent with PREA and ICE standards.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SAAPI-1
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(A), the FOD must ensure, “The facility administrator shall ensure that,
within 90 days of the effective date of this detention standard, written policy and procedures are
in place and that the facility is in full compliance with its requirements and guidelines. The
facility must meet all other requirements in this standard on the effective date of the standard.”
DEFICIENCY SAAPI-2
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(A)(3), the FOD must ensure, “Each facility administrator shall have
written policy and procedures for a Sexual Abuse or Assault Prevention and Intervention
Program that includes, at a minimum:
3. the requirement that any allegation to staff of sexual assault or attempted sexual assault
be reported immediately to a supervisor and to ERO.”
DEFICIENCY SAAPI-3
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(A)(6), the FOD must ensure, “Each facility administrator shall have
written policy and procedures for a Sexual Abuse or Assault Prevention and Intervention
Program that includes, at a minimum:
6. the requirements for coordination with the ICE Office of Professional Responsibility
(OPR) for investigation or referral of incidents of sexual assault to another investigative
agency, and discipline and prosecution of assailants…”
DEFICIENCY SAAPI-4
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(3), the FOD must ensure, “The facility administrator shall review and
approve the local policy and procedures and shall ensure that the facility:
3. specifies procedures for reporting an allegation or suspicion of sexual assault through the
facility’s chain of command, including written documentation requirements to ensure that
each allegation or suspicion is properly reported and addressed;”

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DEFICIENCY SAAPI-5
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(4), the FOD must ensure, “The facility administrator shall review and
approve the local policy and procedures and shall ensure that the facility:
4. specifies medical staff’s responsibility to report allegations or suspicions of sexual assault
to appropriate facility staff;”
DEFICIENCY SAAPI-6
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(5), the FOD must ensure, “The facility administrator shall review and
approve the local policy and procedures and shall ensure that the facility:
5. specifies the evidence protocol to be used, including access to a forensic medical exam;”
DEFICIENCY SAAPI-7
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(7), the FOD must ensure, “The facility administrator shall review and
approve the local policy and procedures and shall ensure that the facility:
7. specifies procedures for coordination of internal administrative investigations with the
assigned criminal investigative entity to ensure non-interference with criminal
investigations;”
DEFICIENCY SAAPI-8
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(10), the FOD must ensure, “The facility administrator shall review and
approve the local policy and procedures and shall ensure that the facility:
10. specifies how a confirmed or alleged victim’s future safety, medical, mental health and
legal needs shall be addressed;”
DEFICIENCY SAAPI-9
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(14), the FOD must ensure, “The facility administrator shall review and
approve the local policy and procedures and shall ensure that the facility:
14. provides instructions on how to contact DHS/OIG or ICE/OPR to confidentially report
sexual abuse or assault.
DEFICIENCY SAAPI-10
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(E)(10), the FOD must ensure the, “Sexual Assault Prevention and
Intervention Program shall be included in training for employees, volunteers and contract
personnel and shall also be included in annual refresher training thereafter. The level and type of
training for volunteers and contractors will be based on the services they provide and their level
of contact with detainees; however, all volunteers and contractors who have any contact with
detainees must be notified of the facility’s zero –tolerance policy. The facility must maintain
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written documentation verifying employee, volunteer and contractor training. Training shall
include:
10. instruction on documentation and referral procedures of all allegations or suspicion of
sexual abuse and/or assault.”
DEFICIENCY SAAPI-11
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(F), the FOD must ensure, “The facility shall provide detainees with the
name of the program coordinator or designated staff member and information on how to contact
him or her. Detainees will also be informed that they can report any incident or situation
regarding sexual abuse, assault or intimidation to any staff member.”
DEFICIENCY SAAPI-12
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(F)(6), the FOD must ensure, “The facility administrator shall ensure
that the orientation program, required by standard “2.1 Admission and Release,” and the detainee
handbook required by standard “6.1 Detainee Handbook,” notify and inform detainees about the
facility’s zero tolerance policy for all forms of sexual abuse and assault. Following the intake
process, the facility shall provide instruction to detainees on the facility’s Sexual Abuse and
Assault Prevention and Intervention Program and ensure that such instruction includes (at a
minimum):
6. prohibition against retaliation, including an explanation that reporting an assault shall not
negatively impact the detainees immigration proceedings;”
DEFICIENCY SAAPI-13
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(F)(7), the FOD must ensure, “The facility administrator shall ensure
that the orientation program, required by standard “2.1 Admission and Release,” and the detainee
handbook required by standard “6.1 Detainee Handbook,” notify and inform detainees about the
facility’s zero tolerance policy for all forms of sexual abuse and assault. Following the intake
process, the facility shall provide instruction to detainees on the facility’s Sexual Abuse and
Assault Prevention and Intervention Program and ensure that such instruction includes (at a
minimum):
7. right of a detainee who has been subjected to sexual abuse or assault to receive treatment
and counseling.”
DEFICIENCY SAAPI-14
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(I)(2), the FOD must ensure, “When an employee, contractor or
volunteer is alleged to be the perpetrator of detainee sexual abuse and/or assault, it is the facility
administrator’s responsibility to ensure that the incident is promptly referred to the appropriate
law enforcement agency having jurisdiction for investigation and reported to the Field Office
Director. The local government entity or contractor that owns or operates the facility shall also

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be notified. Staff suspected of perpetrating sexual abuse or assault shall be removed from all
duties requiring detainee contact pending the outcome of an investigation.”
DEFICIENCY SAAPI-15
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, section (V)(L), the FOD must ensure, “Monitoring and evaluation are essential for
assessing both the rate of occurrence of sexual assault and agency effectiveness in reducing
sexually abusive behavior. The program coordinator is responsible for an annual review of
aggregate data (omitting personally identifying information) and shall present the findings to the
Field Office Director and ICE/ERO headquarters for use in determining changes to existing
policies and practices to determine whether changes are needed to further the goal of eliminating
sexual abuse. Accordingly, the facility administrator must maintain two types of files.”
DEFICIENCY SAAPI-16
In accordance with the ICE 2011 PBNDS, Sexual Assault and Abuse Prevention and
Intervention, sections (V)(L)(1)(a-d) and (V)(L)(2)(a-d), the FOD must ensure, “Accordingly,
the facility administrator must maintain two types of files.
1. General files include:
a. the victim(s) and assailant(s) of a sexual assault;
b. crime characteristics;
c. detailed reporting timeline, including the name of the staff member receiving the
report of sexual assault, date and time the report was received, and steps taken to
communicate the report up the chain of command; and
d. all formal and/or informal action taken.
2. Administrative investigative files include:
a.
b.
c.
d.

all reports;
medical forms;
supporting memos and videotapes, if any; and
any other evidentiary materials pertaining to the allegation.”

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TELEPHONE ACCESS (TA)
ODO reviewed the Telephone Access standard at ADF to determine if the facility provides
detainees with reasonable and equitable access to telephones to maintain ties with family and
others in the community, in accordance with the ICE 2011 PBNDS. ODO interviewed facility
staff and detainees; reviewed policy, procedures, and the detainee handbook; and conducted
functionality tests on the telephones located in detainee housing units.
Detainees have reasonable and equitable access to telephones at ADF. The telephone availability
ratio per detainee is at the optimal level, as set forth in the 2011 PBNDS. In each housing pod,
there is approximately one phone per nine detainees. Telephones remain on 24 hours per day,
seven days per week. There is no limit in duration, except in instances of high demand, when
detainees are expected to limit calls to 20 minutes. ADF has a TTY available for deaf or
hearing-impaired detainees. Detainees in the SMU maintain telephone access privileges. Five
rolling mobile telephone stations with postings are wheeled outside of an individual cell,
allowing detainees to access and operate the phones through the cell port.
Talton Communications is the telephone service provider. If paying by debit or pre-paid card,
collect, local and long distance call charges are $0.10 per minute. Local and long distance
collect call charges, and international debit call charges, are $0.15 per minute. Federal, state, and
local taxes do apply. These rates are posted in every telephone area in each pod.
ODO conducted telephone operability checks and tested random numbers from the pro bono
legal providers list, and found the telephones and speed-dial numbers all in good working order.
Listings for pro bono services, the DHS OIG, consulates, and embassies were posted above the
phones in each housing pod in both English and Spanish during the inspection. Monitoring
notifications and unmonitored call procedures were posted in English and Spanish on the wall in
every telephone area.
ADF staff conducts telephone checks daily, which consists of ensuring each telephone has a dial
tone. Officers execute and log these checks on a routine and consistent basis, and report outages
and issues. However, officers do not test the free call platform, as required by the 2011 PBNDS
(Deficiency TA-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TA-1
In accordance with the ICE 2011 PBNDS, Telephone Access, section (V)(A)(4)(a), the FOD
must ensure, “Facility staff members are responsible for ensuring on a daily basis that telephone
systems are operational and that the free telephone number list is posted. After ensuring that
each phone has a dial tone, when testing equipment the officers must be able to demonstrate that
an individual has the ability to make calls using the free call platform.”

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