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
San Francisco Field Office
Contra Costa County West
Detention Facility
Richmond, California

February 5 – 7, 2013

COMPLIANCE INSPECTION
CONTRA COSTA COUNTY WEST
DETENTION FACILITY
SAN FRANCISCO FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................4
Inspection Team Members ...................................................................................................4
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................5
Detainee Relations ...............................................................................................................5
ICE PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................6
Detainee Classification System............................................................................................7
Detention Files .....................................................................................................................8
Disciplinary Policy.............................................................................................................10
Environmental Health and Safety ......................................................................................11
Key and Lock Control ........................................................................................................13
Medical Care ......................................................................................................................14
Staff-Detainee Communication .........................................................................................18
Tool Control .......................................................................................................................19

EXECUTIVE SUMMARY
The Office of Professional Responsibility (OPR), Office of Detention Oversight (ODO)
conducted a Compliance Inspection (CI) of the Contra Costa County West Detention
Facility (CCCWDF) in Richmond, California, from February 5 to 7, 2013. In April 2010, U.S.
Immigration and Customs Enforcement (ICE) began housing detainees at CCCWDF under an
Intergovernmental Service Agreement with Contra Costa County. CCCWDF is owned and
operated by the Contra Costa County Sheriff’s Office. The facility has a capacity of 1,096 beds,
300 of which are dedicated to adult male and female detainees of all classification levels (Level I
– lowest threat, Level II – medium threat, Level III – highest threat) for periods in excess of
72 hours. Remaining bed space at CCCWDF is reserved for prisoners of the U.S. Marshals
Service, and inmates from State and local law enforcement agencies in the surrounding area.
The average daily detainee population at CCCWDF is 145. The average length of stay for an
ICE detainee is 17 days. At the time of inspection, the CCCWDF housed 131 male detainees
(102 Level I, 29 Level II), and 33 female detainees (25 Level I, eight Level II). There were no
Level III detainees held at the facility during this CI.
The Contra Costa County Sheriff’s Office supervises and manages security operations,
maintenance service, and food service. Contra Costa County Health Services provides medical
care. CCCWDF holds no accreditations.
The Enforcement and Removal Operations (ERO), Field Office Director (FOD), San Francisco,
California (FOD San Francisco), is responsible for ensuring facility compliance with ICE
policies and the National Detention Standards (NDS). There are no ICE personnel stationed at
CCCWDF. An ERO San Francisco Assistant Field Office Director (AFOD) is designated as the
Officer-in-Charge (OIC), and an ERO San Francisco Supervisory Detention and Deportation
Officer (SDDO) is the Assistant OIC.
The Assistant Sheriff is the highest ranking official in the Contra Costa County Custody Services
Division and is responsible for all custody-related operations in Contra Costa County. There are
(b)(7)e Captains assigned to the Custody Services Division who share responsibilities. Another
Captain at CCCWDF is responsible for the Hospital Security Program and the Custody
Alternative Program. CCCWDF employ (b)(7)e Facility Commander,(b)(7)eOperations Sergeant, (b)(7)e
shift Sergeants, and b)(7)eDeputy Sheriffs. Remaining supervisory staff consists of a Food Services
Director and a Programs Director. There are(b)(7)eadditional non-law enforcement, nonsupervisory staff. All personnel assigned to CCCWDF are Contra Costa County Sheriff’s Office
employees.
In September 2011, ODO conducted a CI at CCCWDF. Of the 24 NDS reviewed, 11 standards
were found to be fully compliant. The remaining 13 standards accounted for 29 deficiencies.
In November 2011, ERO Detention Standards Compliance Unit contractors the Nakamoto
Group, Incorporated, conducted an annual review of the NDS at CCCWDF. The facility
received an overall recommended rating of “Meets Standards,” and was found compliant with all
standards reviewed.

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During this CI, ODO reviewed 17 NDS. Nine standards were fully compliant. ODO identified
17 deficiencies in the following eight standards: Detainee Classification System (1 deficiency),
Detention Files (4), Disciplinary Policy (1), Environmental Health and Safety (2), Key and Lock
Control (2), Medical Care (5), Staff-Detainee Communication (1), and Tool Control (1).
ODO reviewed 25 medical files and confirmed in ten of 25 cases a physician did not review the
physical examination (PE) documentation in a timely manner. One of the 25 files contained no
documentation of a PE. None of the 25 detainees whose files were inspected received a dental
screening examination. ODO confirmed CCCWDF has used detainees for translation services.
ODO verified the CCCWDF security officer has not successfully completed an approved
locksmith training program, and CCCWDF does not have a designated tool control officer.
These are repeat deficiencies from the 2011 ODO inspection.
This report details all deficiencies identified by ODO and refers to the specific, relevant sections
of the NDS. 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 ERO management
and CCCWDF personnel on-site during the inspection, as well as during the closeout briefing
conducted on February 7, 2013.
CCCWDF provides detainees the opportunity to file formal and informal grievances. CCCWDF
staff attempts to resolve complaints informally during daily interactions with detainees.
Grievance forms are readily available in English and Spanish within the housing units.
CCCWDF maintains an electronic grievance log to document and track all formal grievances
submitted by detainees. ODO verified grievance forms are placed in individual detention files.
The grievance log reflects CCCWDF received and processed four formal grievances between
January 2012 and January 2013. There was no discernible pattern in the four grievances filed.
Medical services at CCCWDF are provided by Contra Costa County Health Services. Medical
staffing consists of a Health Services Administrator (HSA), a Medical Director, and a Medical
Supervisor. Current medical staffing at CCCWDF includes a physician (b)(7)e egistered
nurses (RN), (b)(7)e licensed vocational nurses, a dentist, and a dental assistant. Mental health
services are provided by a Mental Health Clinical Specialist on-site Monday through Saturday,
and a contract psychiatrist who sees patients four hours a week.
Detainees access healthcare services via a telephone nurse triage service. A telephone dedicated
for this purpose is located in each detainee housing unit, with direct connection to the triage
nurse in the clinic. ODO cites this as a best practice, because it affords detainees an immediate
and confidential means of seeking health care. In addition to the telephone system, detainees
may complete sick call request forms available in English and Spanish. ODO confirmed nonmedical personnel are not involved in the collection or review of the forms, all requests are
triaged, and sick call is completed in a timely manner.
CCCWDF is transitioning from a corrections-specific electronic medical record (EMR) system
to the EMR system used by Contra County Regional Hospital. This change is intended to
improve communication among detention centers and hospitals in Contra Costa County. Utility
in the corrections environment has proven problematic, and interface incompatibilities have
resulted in a lengthy transition, and continuity of care challenges. The HSA stated CCCWDF
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healthcare staff is working to troubleshoot the program with the company providing the EMR
system. Until that process is complete, the clinic is using a monitoring log that lists the most
recent medical activity, as well as the next physician chart review or appointment.
There have been no detainee deaths or suicide attempts since the facility began housing detainees
in December 2010. During this CI, there were no detainees on suicide watch. ODO verified
documentation of suicide prevention training for all correctional and medical staff is current, and
facility policy requiring officers to conduct and document 15-minute checks of detainees placed
on suicide watch is in accordance with the NDS.
CCCWDF Custody Administrative Services employs (b)(7)eLieutenant,(b)(7)eSergeant, and (b)(7)e
specialists who oversee policy and procedure. CCCWDF has a policy that addresses the Prison
Rape Elimination Act (PREA). During this inspection, ODO observed ICE PREA posters
conspicuously posted in all detainee housing units, and confirmed the CCCWDF orientation
video discusses PREA.
At the time of the inspection, there were no detainees in administrative or disciplinary
segregation. The Administrative Special Management Unit (SMU) and the Disciplinary SMU at
CCCWDF are well lit, temperature-appropriate, and sanitary. ODO reviewed Facility Liaison
Visit Checklists and confirmed ERO officers regularly visit the SMU to interact with detainees
and monitor living conditions in each SMU.
Under the CCCWDF staff-detainee communication policy, detainees have the opportunity to
submit written questions, requests, or concerns to CCCWDF and ERO staff via written request
forms available throughout the facility. The completed request forms, which are available in
English and Spanish, are deposited by detainees in readily-accessible lockboxes for collection by
an ERO officer. Detainee requests are logged and responded to within 72 hours of receipt. ERO
officer visitation schedules and Department of Homeland Security Office of Inspector General
Hotline posters are conspicuously posted throughout the facility. ODO verified regular and
unannounced supervisory and non-supervisory staff visits are conducted and documented by
ERO staff. Weekly telephone checks and maintenance are recorded on a log.
CCCWDF has a comprehensive written policy governing the use of force. The facility does not
use four-point restraints, restraint chairs, or electro-muscular disruption devices on detainees.
Protective equipment and hand-held video cameras, for use during calculated use of force
incidents, are readily available in several locations within the facility for quick access and
accelerated response time. Since January 1, 2012, there has been one use of force incident
involving a detainee at CCCWDF; this immediate use of force resulted in a detainee being
handcuffed after becoming combative with a CCCWDF Sheriff’s Deputy. ODO confirmed all
use of force protocols were followed during this incident.

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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 NDS or ICE Performance-Based National
Detention Standards, as applicable. The NDS apply to CCCWDF. In addition, ODO may focus
its inspection based on detention management information provided by ERO Headquarters and
ERO field offices, and on issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at CCCWDF 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 CCCWDF.

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 NDS 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
NDS, 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

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

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

Contra Costa West Detention Facility
ERO San Francisco

OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the AFOD, the SDDO, a CCCWDF Captain, and a CCCWDF Lieutenant.
During the interviews, all ERO and CCCWDF employees stated the working relationship
between ERO and CCCWDF staff is excellent, and morale among ERO and CCCWDF
employees is high.
The SDDO stated the excellent working relationship between ERO and contract employees
enables the facility to run smoothly. The Captain and Lieutenant stated that ERO supervisors
and officers visit detainees in the housing units a minimum of twice a week. The AFOD and
SDDO stated ERO has adequate resources and equipment to carry out all assigned duties and
responsibilities.

DETAINEE RELATIONS
ODO interviewed 14 randomly-selected detainees (ten male, four female) to assess the overall
living and detention conditions at CCCWDF. There were no complaints concerning food
service, the grievance system, the law library, medical care, personal hygiene items, recreation,
religious services, staff-detainee communication, or visitation. All detainees interviewed stated
they had not been strip searched, nor had they experienced verbal, physical, or sexual abuse by
staff or detainees at CCCWDF.

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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 17 NDS and found CCCWDF fully compliant with the following nine
standards:
Detainee Grievance Procedures
Detainee Handbook1
Emergency Plans
Food Service
Special Management Unit
Suicide Prevention and Intervention
Telephone Access
Terminal Illness, Advance Directives, and Death
Use of Force
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 eight standards:
Detainee Classification System
Detention Files
Disciplinary Policy
Environmental Health and Safety
Key and Lock Control
Medical Care
Staff-Detainee Communication
Tool Control
Findings for each of these standards are presented in the remainder of this report.

1

Deficiencies relating to omissions from the detainee handbook are noted under the relevant NDS that requires the
information. See Detainee Classification System (Deficiency DCS-1) and Disciplinary Policy (Deficiency DP-1).
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DETAINEE CLASSIFICATION SYSTEM (DCS)
ODO reviewed the Detainee Classification System standard at CCCWDF to determine if there is
a formal classification process for managing and separating detainees based on verifiable and
documented data, in accordance with the ICE NDS. ODO reviewed detention files, logbooks,
policies, and procedures, and interviewed staff.
Upon admission to the facility, each detainee receives the ICE National Detainee Handbook and
a facility handbook. Both handbooks provide an overview of the rules, regulations, policies, and
procedures that each detainee is required to follow.
The ICE National Detainee Handbook and the facility handbook provide information regarding
the criteria for detainee security classification, which includes criminal behavior, criminal
convictions, immigration history, disciplinary record, current custody status, and any other
information considered relevant to determining the most appropriate custody level; however,
ODO confirmed the facility handbook lacks procedures by which a detainee may appeal a
classification determination (Deficiency DCS-1). Proper classification ensures each detainee is
placed in the appropriate category, and physically separated from detainees in an incompatible
category. Permitting a detainee to appeal a classification finding enables facility management to
re-evaluate custody levels on a case-by-case basis.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DCS-1
In accordance with the ICE NDS, Detainee Classification System, section (III)(I)(2), the FOD
must ensure the detainee handbook’s section on classification will include the following: the
procedures by which a detainee may appeal his/her classification.

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DETENTION FILES (DF)
ODO reviewed the Detention Files standard at CCCWDF to determine if files are created
containing all significant information on detainees housed at the facility for over 24 hours, in
accordance with the ICE NDS. ODO reviewed detention files, logbooks, policies, and
procedures, and interviewed staff.
As part of the intake process, CCCWDF staff creates a detention file when a detainee is admitted
to the facility. ODO randomly selected and reviewed ten active detention files to determine if
required documentation was present. ODO verified staff members created a detention file as part
of admissions processing when a detainee is admitted to CCCWDF, but officers completing the
admissions portion of the detention file failed to note file activation (Deficiency DF-1).
None of the ten active files reviewed contained a Detainee Classification System Primary
Assessment Form, which is required by the NDS to be in every detention file (Deficiency DF-2).
A Detainee Classification System Primary Assessment Form is used to evaluate criminal history.
ERO requires the use of a classification form as a guide for placing detainees into housing units
with detainees of the same or compatible classification levels. This is a repeat deficiency from
the September 2011 ODO inspection. ODO identified a classification worksheet within the
facility Jail Management System. The Jail Management System worksheet is similar to the
Classification System Primary Assessment Form, and meets the intent of the NDS. CCCWDF
management corrected the deficiency on-site by directing that the completed worksheet be
placed in each detention file.
ODO randomly selected and reviewed ten archived detention files to determine the presence of
required documentation. ODO confirmed staff members placed documentation required by the
NDS within all ten files; however, the officers failed to note the file was complete and ready for
archiving (Deficiency DF-3).
ODO determined CCCWDF permits authorized personnel to remove detention files from within
the secured area; however, ODO confirmed there was no logbook (Deficiency DF-4). The NDS
requires facilities to maintain a logbook for the purposes of documenting the removal of
detention files, and to record tracking information such as the detainee’s name and A-number;
date and time removed; reason for removal; name, signature, title, and department of person
removing the file; date and time returned; and signature of person returning the file. A well
maintained logbook enables facility management to locate an original detention file should it
become lost or misplaced. CCCWDF management corrected the deficiency on-site prior to
conclusion of the CI by instituting the use of a logbook noting the required information.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DF-1
In accordance with the ICE NDS, Detention Files, section (III)(A)(2), the FOD must ensure the
officer completing the admissions portion of the detention file will note that the file has been
activated. The note may take the form of a generic statement in the Acknowledgment Form.

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DEFICIENCY DF-2
In accordance with the ICE NDS, Detention Files, section (III)(B)(1)(b), the FOD must ensure
the detainee detention file will contain either originals or copies of forms and other documents
generated during the admissions process. If necessary, the detention file may include copies of
material contained in the detainee’s A-File. The file will, at a minimum, contain the following:
Classification Work Sheet.
DEFICIENCY DF-3
In accordance with the ICE NDS, Detention Files, section (III)(E)(3), the FOD must ensure the
officer closing the detention file will make a notation (on the acknowledgement form, if
applicable) that the file is complete and ready for archiving.
DEFICIENCY DF-4
In accordance with the ICE NDS, Detention Files, section (III)(F)(2)(a-e), the FOD must ensure,
at a minimum, a logbook entry recording the file’s removal from the cabinet will include:
a.
b.
c.
c.
d.
e.

The detainee’s name and A-File number;
Date and time removed;
Reason for removal;
Signature of person removing the file, including title and department;
Date and time returned; and
Signature of person returning the file.

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DISCIPLINARY POLICY (DP)
ODO reviewed the Disciplinary Policy standard at CCCWDF to determine if sanctions imposed
on detainees who violate facility rules are appropriate, and if the discipline process includes due
process requirements, in accordance with the ICE NDS. ODO reviewed detention files,
logbooks, policies, and procedures, and interviewed staff.
Upon admission to the facility, each detainee receives the ICE National Detainee Handbook and
a facility handbook. Both handbooks provide an overview of the rules, regulations, policies and
procedures that each detainee is required to follow. However, neither handbook advises
detainees of the right to protection from unnecessary or excessive use of force, personal injury,
disease, property damage, and harassment. Both handbooks also fail to note the right of freedom
from discrimination based on race, religion, national origin, sex, handicap, or political beliefs
(Deficiency DP-1).

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DP-1
In accordance with the ICE NDS, Disciplinary Policy, section (III)(A)(5)(a)(b), the FOD must
ensure the detainee handbook or equivalent, issued to each detainee upon admittance, shall
provide notice of the facility’s rules of conduct, and of the sanctions imposed for violations of
the rules. Among other things, the handbook shall advise detainees of the following:
a. The right to protection from personal abuse, corporal punishment, unnecessary or excessive
use of force, personal injury, disease, property damage, and harassment;
b. The right of freedom from discrimination based on race, religion, national origin, sex,
handicap, or political beliefs.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at CCCWDF to determine if the
facility maintains high standards of cleanliness and sanitation, safe work practices, and control of
hazardous materials and substances, in accordance with the ICE NDS. ODO toured the facility,
interviewed staff, reviewed policies, and examined documentation of inspections, hazardous
chemical management, and fire drills.
During a tour of the facility, ODO observed a high level of sanitation. The food service
department is well maintained and clean.
All hazardous substances used in the facility are listed in a master index, which includes Material
Safety Data Sheets, emergency contact information, and documentation of periodic review.
Material Safety Data Sheets binders are present in every area where hazardous substances are
stored and used. ODO confirmed the accuracy of chemical inventories. During interviews,
ODO confirmed that staff understands the proper storage and handling of chemicals.
With one exception, ODO verified all chemicals, flammables, and combustible materials are
stored and issued as required by the NDS. During inspection of the barbershop in Housing Unit
Number Seven, ODO found an aerosol can of Clippercide labeled “Highly Flammable” stored in
an unsecured cabinet that did not meet the requirements for flammables. The cabinet was not
constructed to code and was not labeled “Flammable-Keep Fire Away” (Deficiency EH&S-1).
Proper storage of flammable and combustible substances is critical to preventing potential injury
to staff and detainees, particularly in the event of a fire. ODO confirmed a detainee serving as
the barber is routinely issued Clippercide to disinfect clippers in the barbershop, and the detainee
uses the product unsupervised by a staff member (Deficiency EH&S-2). Detainees must be
closely monitored when working with hazardous substances to ensure proper use and prevent the
risk of injury. During the inspection, facility management corrected both deficiencies by
removing Clippercide and substituting a non-flammable disinfectant.
CCCWDF has an extensive fire control plan approved by the City of Richmond Fire Department.
The Fire Department completed the most recent fire inspection of CCCWDF on October 5, 2012,
and found no violations of applicable regulations or codes. The Contra Costa County General
Services Division, Life Safety Shop completed an annual inspection of the fire suppression
system on January 31, 2013, and found no deficiencies. ODO verified required weekly and
monthly fire and safety inspections are conducted by facility staff. Monthly fire drills are
conducted and documented in accordance with the NDS.
CCCWDF is on the city water and sewer system. The California Department of Public Health
and the U.S. Environmental Protection Agency certify the drinking water is tested and meets
federal standards. Facility staff tests emergency power generators bi-weekly and contracts with
the RL Stevens Company to perform monthly generator inspections and maintenance, which
exceeds the NDS requirement for quarterly testing. Review of documentation confirmed all
required power generator testing is conducted.
Review of documentation confirmed medical sharps and syringes are inventoried on each shift.
ODO verified the accuracy of the inventories. Medical waste is handled properly within the
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facility and removed by Stericycle, Incorporated, a licensed bio-hazard transporter. Blood-borne
pathogen protective gear and clean-up kits are readily available for spills.
The dedicated barbershop at CCCWDF has a sink with hot and cold running water, and
sanitation guidelines are conspicuously posted.
ODO verified CCCWDF contracts with an exterminator for pest control inspections and
eradication. Documentation confirmed pest control inspections are conducted monthly; there
was no visible evidence of rodent or pest infestation at the facility.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(F)(4)(a)(c) the
FOD must ensure every storage cabinet will:
a. Be constructed according to code and securely locked at all times;
c. Be conspicuously labeled: “Flammable-Keep Fire Away.”
DEFICIENCY EH&S-2
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(E)(3), the FOD
must ensure qualified staff will closely monitor detainees working with hazardous substances.

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KEY AND LOCK CONTROL (K&LC)
ODO reviewed the Key and Lock Control standard at CCCWDF to determine if facility safety
and security is maintained by requiring keys and locks to be controlled and maintained, in
accordance with the ICE NDS. ODO interviewed staff, inspected emergency keys, reviewed
policy and documentation, and observed use, accountability, and maintenance of keys and locks
throughout the facility.
All facility personnel receive training and are held accountable for key control. ODO verified
keys are inventoried, accounted for, and maintained in a secure and responsible manner.
Procedures are in place to address lost, broken, or compromised keys. Inspection confirmed lock
systems are properly maintained. An inspection of every lock in the facility was conducted by
staff in December 2012, and a more limited inspection was conducted in January 2013. An
inspection of all keys and locking systems in the facility is scheduled to occur every four months.
The NDS requires the designated Security Officer to complete an approved locksmith training
program, and for the duties of the position to be addressed in a written job description. At
CCCWDF, the Operations Sergeant has informally been assigned the duties of Security Officer.
A maintenance worker performs locksmith duties. The duties of Security Officer are not
addressed in the post order for the Operations Sergeant, and no written position description has
been developed (Deficiency K&LC-1). Formal designation of responsibility and a written
position description support accountability and proper management of the key and lock control
program. Neither the Operations Sergeant nor the maintenance worker performing locksmith
duties has completed a locksmith training program (Deficiency K&LC-2). Formal locksmith
training ensures designated personnel are appropriately certified to have the required knowledge
and skills to maintain keys and locks within a detention facility.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY K&LC-1
In accordance with the ICE NDS, Key and Lock Control, section (III)(A)(1), the FOD must
ensure the Security Officer shall have a written position description that includes duties,
responsibilities, and chain of command.
DEFICIENCY K&LC-2
In accordance with the ICE NDS, Key and Lock Control, section (III)(A)(2), the FOD must
ensure all security officers shall successfully complete an approved locksmith-training program.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at CCCWDF to determine if detainees have access to
healthcare and emergency services to meet health needs in a timely manner, in accordance with
the ICE NDS. ODO reviewed policies and procedures, staff credentials, and training files;
toured areas where medical services are provided; examined 25 detainee medical records; and
interviewed the HSA, the Medical Director, the Nursing Program Manager, and other personnel
assigned to the Medical Unit.
The clinic is operated by Contra Costa County Health Services. No current accreditations are
held; however, the HSA maintains individual certification with the National Commission on
Correctional Health Care (NCCHC). Administrative oversight of the clinic is provided by the
HSA, who also serves as HSA for the Contra Costa County Martinez Facility (CCCMF). The
HSA is on-site at CCCWDF one day a week, and available by telephone 24 hours a day. Doctors
Hospital San Pablo, located approximately four miles from CCCWDF, is used for emergency
services, and Contra Costa Regional Hospital, which is located approximately 25 miles from
CCCWDF, is used for specialty services. According to the HSA and Nurse Program Manager,
CCCWDF does not accept detainees requiring more than minimal on-going medical care for
chronic conditions such as diabetes and hypertension. In the event a detainee requires medical
isolation, suicide monitoring, or critical care, custody staff is notified and arrangements are made
through ERO for transfer to an appropriate facility. ODO determined the staffing schedule,
scope of services, and available outside resources are sufficient to meet the health needs of
detainees with a low level of acuity.
The clinic is comprised of two separate medical and dental units for male and female detainees.
Examination rooms are sufficient in size and number. The dental examination room, blood draw
stations, and emergency care areas are organized, sanitary, and well equipped. The medical
records office, which was secured throughout the ODO inspection, has several work stations and
a large conference table. The medication room contains a unit dose machine, which is supplied
and inventoried monthly by a pharmacist from CCCMF. The electronically-labeled medication
dose packs are delivered to the housing units and administered to detainees by nurses. Pharmacy
technicians conduct random audits to ensure detainees who are authorized to carry prescribed
medications maintain compliance with dosing schedules.
A review of the training records for(b)(7)ecustody personnel and the entire medical staff confirmed
all are certified in first aid and cardiopulmonary resuscitation (CPR), as well as suicide
prevention. Copies of current CPR cards are present in all medical credential files, and all
medical credentials are primary-source verified.
Intake medical and mental health screening is completed by nurses at CCCMF and entered into
an EMR. In addition, tuberculosis (TB) screening by way of a purified protein derivative skin
test is completed at CCCMF. When detainees arrive at CCCWDF, a nurse immediately reviews
the EMR intake screening to ensure appropriate medical follow-up. ODO confirmed
comprehensive intake screening and TB clearance in all 25 medical records reviewed.
A hands-on PE is completed by an RN trained by a physician. Of 25 records reviewed, one had
no documentation of a completed PE. In 24 records, ODO confirmed an RN completed a PE
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within 14 days as required by the NDS; however, four of the 24 had not been reviewed by a
physician (Deficiency MC-1), and ten were reviewed by a physician beyond 14-days
(Deficiency MC-2). The PE process is not complete until finalized by a provider. Deficiency
for delinquent PE completions was cited during the September 2011 ODO inspection.
Translation services are available through a language line service via a portable telephone
located in the clinic. ODO noted a medical file documented a nurse using a Spanish speaking
detainee for translation during a clinical assessment. There was no documentation the detainee
being assessed consented to translation by another detainee (Deficiency MC-3). The HSA and
Nurse Program Manager stated use of detainees rather than the language line service has been an
ongoing problem due to new hires, and additional training or other corrective action will be
implemented.
There was no documentation of 14-day dental screenings by a qualified provider in any of the
25 medical records reviewed (Deficiency MC-4). The HSA and Nurse Program Manager stated
they were unaware of the requirement. As dental health may be related to many physical
illnesses, including heart disease, diabetes, and HIV, a thorough assessment is necessary for
early detection and treatment.
Detainees access healthcare services via a telephone nurse triage service. A telephone dedicated
for this purpose is located in each detainee housing unit, with direct connection to the triage
nurse in the clinic. ODO cites this as a best practice, because it affords detainees an immediate
and confidential means of seeking health care. In addition to the telephone system, detainees
may complete sick call request forms available in English and Spanish. ODO confirmed nonmedical personnel are not involved in the collection or review of the forms, all requests are
triaged, and sick call is completed in a timely manner.
Detainees sign general consent for treatment forms at intake. A review of 25 medical records
found two files where specific consent was obtained for the administration of psychotropic
medications. There were no other files reflecting specialized procedures requiring specific
consent.
Prior to the transfer of a detainee, the OIC is notified of any medical or psychiatric condition
requiring clearance. Medical files of transferring detainees are placed in sealed envelopes
marked Confidential Medical/Mental Health, bearing labels with the name and date of birth of
the detainee, but the labels do not include the A-Number (Deficiency MC-5). This is a repeat
deficiency from the September 2011 ODO inspection.
ODO notes a concern related to the transition from a corrections-specific EMR to the current
EMR activated July 1, 2012, which is the system used by Contra County Regional Hospital.
This change was deemed necessary for improved communication among county detention
centers and hospitals. EMR was initially developed for use in hospitals. Utility in the
corrections environment has proven problematic, and interface incompatibilities have resulted in
a lengthy transition and continuity of care challenges. It is noted in three of the four cases where
a PE was not reviewed by a physician, it was due to the erroneous deletion of a scheduled chart
review in the EMR system.

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The HSA stated the company providing the new EMR system is working with CCCWDF
healthcare staff to troubleshoot the system. Until that process is complete, the clinic is using a
monitoring log that lists the most recent medical activity, as well as the next physician chart
review or appointment. A log and the low acuity level of detainees at CCCWDF mitigate the
risk related to the EMR transition; however, ODO recommends all necessary actions be taken to
ensure the system fully supports delivery and documentation of health care services in a
correctional setting.
On January 7 to 8, 2013, an audit conducted by ICE Health Service Corps identified four major
areas of concern related to chronic care services: insufficient documentation, failure to meet
timeframe requirements, absence of treatment refusal forms, and inadequate follow-up regarding
outside appointments with medical specialists. A detailed corrective action plan developed by
the clinical team under the guidance of the Medical Director was implemented on
January 11, 2013. Progress toward meeting the requirements of the corrective action plan could
not be assessed given that only one month had elapsed at the time of the CI. ODO noted the
medical records reviewed were chronic care cases, and there were no documented violations of
NDS chronic care requirements, or a recurrence of issues identified in the ICE Health Services
Corps report.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with ICE NDS, Medical Care, section (III)(D), the FOD must ensure health
appraisals will be performed according to NCCHC and JCAHO standards. In accordance with
NCCHC, Standards for Health Services in Jails, 2008, J-E-04, Initial Health Assessment, the
responsible physician shall document his or her review of physician assistant, nurse practitioner,
RN or other practitioner health assessments when significant findings are present.
DEFICIENCY MC-2
In accordance with ICE NDS, Medical Care, section (III)(D), the FOD must ensure the health
care provider of each facility will conduct a health appraisal and physical examination on each
detainee within 14 days of arrival at the facility.
DEFICIENCY MC-3
In accordance with ICE NDS Medical Care, section (III)(D), the FOD must ensure, if language
difficulties prevent the health care provider/officer from sufficiently communicating with the
detainee for purposes of completing the medical screening, the officer shall obtain translation
assistance. Such assistance may be provided by another officer or by a professional service, such
as a telephone translation service. In some cases, other detainees may be used for translation
assistance if they are proficient and reliable and the detainee being medically screened consents.
If needed translation assistance cannot be obtained, medical staff will be notified or the screening
form will be filled out to refer the detainee to medical personnel for immediate attention.
DEFICIENCY MC-4
In accordance with ICE NDS Medical Care, section (III)(E), the FOD must ensure an initial
dental screening exam should be performed within 14 days of the detainee’s arrival.

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If no on-site dentist is available, the initial dental screening may be performed by a physician,
physician’s assistant, or nurse practitioner.
DEFICIENCY MC-5
In accordance with ICE NDS Medical Care, section (III)(N), the FOD must ensure, when a
detainee is transferred to another detention facility, the detainee's medical records, or copies, will
be transferred with the detainee. These records should be placed in a sealed envelope or other
container labeled with the detainee's name and A-number and marked "MEDICAL
CONFIDENTIAL."

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STAFF-DETAINEE COMMUNICATION (SDC)
ODO reviewed the Staff-Detainee Communication standard at CCCWDF to determine if
procedures are in place to allow formal and informal contact between detainees and key ICE and
facility staff, and if ICE detainees are able to submit written requests to ICE staff and receive
responses in a timely manner, in accordance with the ICE NDS. ODO interviewed staff and
detainees, toured and observed housing units, and reviewed ERO visitation records and Facility
Liaison Visit Checklists.
The facility allows detainees to have informal and formal access and interaction with CCCWDF
and ERO staff. Detainees have the opportunity to submit written questions, requests, or concerns
to CCCWDF and ERO staff by asking for a request form. Detainee request forms are available
upon request in each housing unit.
ODO reviewed the ERO Detainee Request Log and noted the logbook does not contain columns
or blocks for recording the date the request was forwarded to ICE, or the date a response was
provided to the detainee (Deficiency SDC-1).
ERO personnel conduct weekly announced and unannounced visits to facility living areas, and
document the visits and subsequent detainee interviews on a Facility Liaison Visit Checklist.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SDC-1
In accordance with the ICE NDS, Staff-Detainee Communication, section (III)(B)(2), the FOD
must ensure all requests shall be recorded in a logbook specifically designed for that purpose.
The log, at a minimum, shall contain:
a.
b.
c.
d.
e.
f.
g.

The date the detainee request was received;
Detainee’s name;
A-number;
Nationality;
Officer logging the request;
The date that the request, with staff response and action, is returned to the detainee; and
Any other site-specific pertinent information.

In IGSAs, the date the request was forwarded to ICE and the date it was returned shall also be
recorded.

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TOOL CONTROL (TC)
ODO reviewed the Tool Control standard at CCCWDF to determine if tools are properly
classified, identified, inventoried, stored, and issued, in accordance with the ICE NDS. ODO
reviewed policy and tool inventories, interviewed staff, and inspected tools and areas where tools
are stored and maintained.
The facility has a comprehensive policy addressing the classification and control of tools. ODO
verified inventories and control procedures for tools in maintenance, food service, medical, the
armory, landscaping, and engraving were accurate and met the requirements of the NDS.
Maintenance tools are securely stored in an area outside the secure perimeter of the facility, and
are brought into the facility on tool carts. Each cart has a list of its tools, color-coded by
function. The color scheme is set in facility policy. ODO observed staff maintained direct and
constant control of tool carts, and observed tool control being practiced by various staff members
during the review.
Though the policy and tool control practices meet the requirements of the standard, ODO noted
the designated Tool Control Officer is the Custody Administrative Assistant (CAA). The CAA
is an administrative staff member responsible for collecting and maintaining inventories and tool
control documentation. The authority and duties of the CAA do not include developing and
overseeing tool control procedures and accountability (Deficiency TC-1). To ensure
comprehensive oversight of all aspects of tool control, an individual should be designated who
has knowledge and training in security and tool control procedures. This is a repeat deficiency
from the September 2011 ODO inspection of CCCWDF.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY TC-1
In accordance with the ICE NDS, Tool Control, section (III)(B), the FOD must ensure the
Officer in Charge (OIC) shall designate the person responsible for developing and implementing
tool-control procedures, along with an inspection system to ensure accountability.

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