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
Phoenix Field Office
Central Arizona Detention Center
Florence, Arizona

April 9 - 11, 2013

COMPLIANCE INSPECTION
CENTRAL ARIZONA DETENTION FACILITY
PHOENIX 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
Food Service ............................................................................................................9
Grievance System ..................................................................................................11

housed at CADC. ODO verified the staffing plan is reviewed annually. Training files and
credential files for all medical staff are complete, and licenses are primary source verified.
Detainees requiring medical services beyond the scope of care provided by CADC are
transferred to a detention facility capable of providing adequate care, or to the Florence Anthem
Hospital, which is approximately nine miles away. Emergency medical transportation is
provided by an ambulance service located approximately two miles from the facility.
There are three separate medical areas within CADC. The main clinic, which is used primarily
for inmates, has five examination/treatment rooms, administrative offices, mental health offices,
a laboratory, a pharmacy, and a medical records area. A second clinic is used primarily for the
ICE detainee population and includes a ten-bed observation area, four negative pressure rooms
for tuberculosis isolation, a two-chair dental suite, an x-ray room, a nurses’ station, and two wellequipped examination rooms with adequate privacy and emergency response equipment. A
detention officer stationed within the clinic provides custody supervision. A third satellite clinic
is currently closed and non-operational.
ODO observed all aspects of the admission process to be efficient and timely. Nursing staff
conduct routine intake screenings of detainees in a private examination room within 12 hours of
admission. Mental health, dental issues, and sexual assault history are addressed. All females
are tested for pregnancy. Detainees are screened for symptoms of tuberculosis and receive a
purified protein derivative test at admission. If the purified protein derivative test is positive, a
chest x-ray is completed on-site to rule out tuberculosis. The Clinical Director reviews all intake
screening forms the next business day to assess priority for treatment. A hands-on physical
examination and a dental examination are completed within 14 days of admission. ODO
examined 30 medical records for females, chronic care patients, and randomly-selected healthy
detainees. ODO confirmed full compliance with PBNDS requirements for an intake screening,
tuberculosis test, physical examination, and dental screening in all 30 medical records reviewed.
Detainees are not charged co-pays or other fees for health care services or medications. CADC
management stated the language line telephone translation service is used to facilitate proper
communication of medical information to non-English speaking detainees when necessary.
Detainees request healthcare services by completing a medical request form in duplicate. The
completed request forms, printed in English and Spanish, are deposited by detainees in readily
accessible lockboxes for collection by medical personnel. Collection occurs once daily, seven
days a week. The original form is filed in the medical record, and the detainee receives a copy.
ODO confirmed the forms are available in each housing unit. A registered nurse conducts a
face-to-face triage in each housing unit. A review of medical records confirmed next-day triage,
with medical requests addressed timely and appropriately.
Sick call is conducted in the clinic on a daily basis using physician-approved protocols provided
by CCA. There were no detainees housed in the Special Management Unit (SMU) at the time of
the review; however, ODO confirmed that per CADC policy, nurses conduct twice daily face-toface wellness checks of each detainee housed in the SMU. During these wellness checks,
medical request forms are collected. Segregation sick call appointments are conducted in a
private examination room located within the SMU.

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Nursing staff administer medications using a secure medication cart. A wristband worn by each
detainee is read using a hand-held scanner to access the electronic Medication Administration
Record. This electronic system can access the entire medical record for reference. The Health
Services Administrator stated this system has reduced medication errors dramatically. ODO
cites this as a best practice.
ODO confirmed there were no suicide attempts during the 12 months preceding this CI. During
this CI, there were no detainees on suicide watch. ODO reviewed the CADC suicide prevention
training plan and noted all required elements are covered in accordance with the PBNDS. ODO
confirmed suicide prevention training for all correctional and medical staff is current. ODO
verified CADC policy requires officers to conduct and document 15-minute checks of detainees
placed on suicide watch in accordance with the PBNDS.
CADC has a designated Sexual Abuse and Assault Prevention and Intervention (SAAPI)
Coordinator. Information regarding the SAAPI program is provided in the detainee handbook,
during orientation via the facility orientation video, and through postings in each housing unit.
Upon arrival at CADC, detainees are screened for victimization risk and to identify potential
sexual aggressors. Potential aggressors are identified and are immediately transferred to another
facility. Detainees with a history of, or who are at risk for, victimization are referred to mental
health staff for further evaluation and assistance. ODO confirmed the facility did not have any
sexual abuse or assault allegations reported to the Joint Intake Center.
The administrative SMU and the disciplinary SMU at CADC are well lit, temperatureappropriate, and sanitary. ODO verified medical, custody, and administrative personnel visit the
SMU as required by the PBNDS. At the time of this inspection, there were no detainees in
administrative or disciplinary segregation. During the 12 months preceding this CI, four
detainees were placed in administrative segregation. Three of the four detainees were pending
investigation and possible disciplinary hearings after engaging in physical altercations. The
fourth detainee was in protective custody. Per agreement with ERO, the detainees placed in
administrative segregation were removed from the facility within 24 hours and placed at an
alternate location within the ERO inventory of facilities.
Detainees use secure lockboxes located in each housing unit to submit written requests. An ERO
officer collects the completed request forms on a daily basis. Detainee requests are
electronically logged and responses are provided to detainees within 72 hours of receipt. ERO
officers conduct weekly scheduled visits to detainee housing units to address questions or
concerns. Detainee request forms are printed in English and Spanish.
ERO officer visitation schedules and Department of Homeland Security, Office of Inspector
General Hotline posters are conspicuously displayed throughout the facility. ODO verified
scheduled and unannounced supervisory and non-supervisory staff visits are conducted and
documented by ERO staff.
CADC has a comprehensive written policy governing the use of force. Facility personnel do not
use four-point restraints, restraint chairs, or electro-muscular disruption devices. Protective
equipment and hand-held video cameras designated for use in calculated use of force incidents
are available in three locations within the facility to facilitate quick access and accelerated
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response times. There were no use of force incidents at CADC during the 12 months preceding
this CI.

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

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, San Diego
Creative Corrections
Creative Corrections
Creative Corrections

Central Arizona Detention Center
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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the Warden, the Assistant Warden, an Assistant Field Office Director, and a
Supervisory Detention and Deportation Officer. During the interviews, all personnel stated the
working relationship between CADC and ERO is excellent, and morale is high.
The Warden and the Assistant Field Office Director stated sufficient personnel are assigned to
handle the current detainee population at CADC, and ERO officers visit the housing units
multiple times each week to communicate with ICE detainees and address issues or concerns.

DETAINEE RELATIONS
ODO interviewed 25 randomly-selected detainees to assess the overall living and detention
conditions at CADC. ODO received no complaints regarding food service, the grievance
process, issuance and replenishment of hygiene supplies, law libraries and legal material,
sending and receiving mail, medical care, religious services, or visitation. Approximately
300 of the 359 detainees at CADC at the time of this CI had been housed at the facility for
fewer than ten days after being temporarily re-located to CADC due to a lack of bed space in
other regions of the United States.

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ICE PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 16 PBNDS and found CADC fully compliant with the following
14 standards:
Admission and Release
Classification System
Detainee Handbook
Disciplinary System
Funds and Personal Property
Law Libraries and Legal Material
Medical Care
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 areas was not
prepared for this report.
ODO found deficiencies in the following two standards:
Food Service
Grievance System
Findings for each of these standards are presented in the remainder of this report.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at CADC 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, inspected storage areas, observed meal preparation and service, and reviewed
policy and relevant documentation.
The food service operation at CADC is managed under contract by Trinity Services Group,
Incorporated. Food service personnel consist of the Food Service Director,(b)(7)e assistant
managers, and (b)(7)esupervisors. Food service staff is supported by(b)(7)einmate food service
workers. There are no ICE detainees assigned to work in food service. ODO verified staff and
inmate workers receive medical clearances prior to assignment to food service.
Review of documentation confirmed the master cycle menu was certified as nutritionally
complete by a registered dietician on April 12, 2012. A menu for the subsequent 12 months was
approved by a registered dietician and ready for implementation on April 13, 2013. Three hot
meals per day are prepared for approximately 2,400 inmates and detainees. A review of
documentation confirmed medical diets are provided as ordered by healthcare providers, and
detainee requests for religious diets are forwarded to the Chaplain for verification and approval.
ODO reviewed documentation confirming a ceremonial meal schedule developed by the
Chaplain is in place.
The facility has a satellite system of meal service. After meals are prepared in the kitchen, they
are transported to six satellite serving lines located in the corridors outside the housing units.
Detainees are escorted to the serving line, receive a tray, and return to the housing unit to eat.
ODO observed serving of the noon meal on the first and second day of the inspection. Food
temperatures were checked with a thermometer and confirmed to meet PBNDS requirements. A
random tray was chosen from the serving line and sampled. The food items were consistent with
the menu and found to be of good quality and taste. ODO noted the counter for serving
detainees was constructed to separate and insulate hot foods from cold foods, but the sneeze
guard was missing. ODO confirmed sneeze guards were missing from every serving line in the
facility. ODO inspected the serving carts on the satellite serving lines and confirmed they also
were not equipped with sneeze guards as required by the PBNDS (Deficiency FS-1). Sneeze
guards shield food items from bacteria and viruses spread by sneezes and coughs.
No knives are used in the food service operation at CADC. A correctional officer supervises
inventories and maintains all tools used in the kitchen. ODO confirmed monthly vermin and pest
control treatments are completed. Documentation confirms food service supervisors complete
daily sanitation inspections and submit the results to the Food Service Director. Pinal County
Environmental Health Services in Florence, Arizona, conducted an annual external inspection of
the CADC food service operation on February 12, 2013, and no code violations were identified.
ODO found sanitation throughout the kitchen and serving line areas to be at an acceptable level.
ODO confirmed temperatures of the coolers and freezers met requirements. ODO inspected the
two dry storage areas and verified products were properly stored.

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STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE PBNDS, Food Service, section (V)(D)(5), the FOD must ensure the
serving counter shall be designed and constructed to separate and insulate the hot foods on the
one hand and the cold foods on the other. A transparent "sneeze guard" is required.

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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at CADC to determine if a process to submit
formal or emergency grievances exists, and if responses are provided in a timely manner without
fear of reprisal. In addition, ODO reviewed the grievance logbook 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 reviewed local policies and procedures, the detainee
handbook, detention files, and grievance logs.
CADC has a policy and procedure in place requiring staff to respond to emergency grievances,
including medical grievances, within 24 hours. CADC has a policy requiring all medical
grievances be received by the health authority within 24 hours, or the next business day.
ODO confirmed no grievances were reported within the 12 months preceding this CI. CADC
policy does not require medical grievances to be placed in individual medical files as required by
the PBNDS (Deficiency GS-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS-1
In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure
medical grievances are maintained in the detainee’s medical file.

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