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
Eloy Detention Center
Eloy, Arizona

July 10 – 12, 2012

FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law
enforcement, management, and employee information. It has been written for the express use of the
Department of Homeland Security to identify and correct management and operational deficiencies. In
reference to ICE Policy 17006.1, issued 09/22/05; any disclosure, dissemination, or reproduction of this
document, or any segments thereof, is prohibited without the approval of the Assistant Director, Office of
Professional Responsibility.

COMPLIANCE INSPECTION
ELOY DETENTION CENTER
PHOENIX FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................5
Inspection Team Members ...................................................................................................5
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................6
Detainee Relations ...............................................................................................................6
ICE PERFORMANCE BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................7
Key and Lock Control ..........................................................................................................8
Use of Force and Restraints .................................................................................................9

EXECUTIVE SUMMARY
The Office of Professional Responsibility, Office of Detention Oversight (ODO) conducted a
Compliance Inspection (CI) of Eloy Detention Center (EDC) in Eloy, Arizona, on July 10-12,
2012. The facility opened in 1994 and began housing inmates from the U.S. Bureau of Prisons
(BOP) and detainees from the former Immigration and Naturalization Service during that same
year. In 2006, the facility terminated its contract with BOP, and the U.S. Immigration and
Customs Enforcement (ICE) signed an Intergovernmental Service Agreement (IGSA) with the
City of Eloy to use EDC as a dedicated IGSA facility to house ICE detainees of all security
classification levels (Level I – lowest threat; Level II – medium threat; Level III – highest threat)
for over 72 hours. The 1,596 bed, 392,000 square foot facility is owned and operated by
Corrections Corporation of America (CCA). Of the 1,596 beds, 1,100 are designated for male
detainees and 496 are designated for female detainees. The average daily detainee population at
EDC is 1,487. The average length of stay is 51 days. At the time of inspection, the facility
housed 962 male detainees (534 Level I; 243 Level II; 185 Level III) and 470 female detainees
(409 Level I; 50 Level II; 11 Level III). Food service is provided under contract by Trinity
Services Group. EDC holds accreditation from the American Correctional Association.
The Enforcement and Removal Operations (ERO), Field Office Director, Phoenix, Arizona
(FOD Phoenix), is responsible for ensuring facility compliance with ICE policies and the
Performance Based National Detention Standards (PBNDS). An Assistant Field Office Director
(AFOD) is stationed at EDC and is the highest ranking ERO official at the facility. In addition to
the AFOD, ERO staff at EDC is comprised of(b)(7)e upervisory Detention and Deportation
Officers (SDDO) (b)(7)eDetention Operations Supervisor (DOS), (b)(7)eSupervisory Immigration
Enforcement Agents (SIEA) (b)(7)e eportation Officers (DO),(b)(7)eImmigration Enforcement
Agents (IEA), (b)(7)e upervisory Enforcement and Removal Assistant,(b)(7)eEnforcement and
Removal Assistants (ERA), and (b)(7)e Mission Support Specialists. A permanently assigned
ERO Detention Service Manager (DSM) monitors facility compliance with the PBNDS.
The Warden is the highest ranking CCA official at EDC and is responsible for oversight of daily
operations. In addition to the Warden, CCA supervisory staff consists of the Assistant Warden,
the Chief of Security, the Assistant Chief of Security, (b)(7)eShift Supervisors, and (b)(7)e Assistant
Shift Supervisors. Detention staff consists of(b)(7)eSenior Correctional Officers and (b)(7)e
Correctional Officers.
Medical services are provided by the ICE Health Service Corps (IHSC) and contractors STG
International and Staffing Dynamics International. Medical staff is comprised of the Health
Services Administrator (HSA), the assistant HSA, an administrative assistant, a staff physician, a
psychiatrist, a psychologist, a social worker, a dentist, a dental hygienist, a dental technician, (b)(7)e
pharmacists, (b)(7)epharmacy technicians, a nurse manager,(b)(7)enurse practitioners(b)(7)eregistered
nurses (b)(7)e icensed practical nurses,(b)(7)eradiology (x-ray) technician (b)(7)e medical records
technicians, and (b)(7)e medical assistants. During the inspection, EDC management stated that
the clinical director (CD) position has been vacant since May 2009. Although ODO found
medical staffing at EDC adequate to meet the health care needs of detainees, it is recommended
that the facility fill the CD position as soon as possible, because the CD position is designated as
the clinical and medical authority at EDC responsible for supervising clinical care at the facility.
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In April 2011, ODO conducted a QAR at EDC of 24 PBNDS. Of the standards reviewed, 14
were in full compliance. The remaining ten standards accounted for 13 deficiencies.
In January 2012, ERO Detention Standards Compliance Unit contractor, The Nakamoto Group,
Inc., conducted an annual review of the PBNDS at EDC. EDC received an overall rating of
“Meets Standards” and was found compliant with 40 standards reviewed. One standard was
identified as not applicable to the facility.
During this CI, ODO reviewed 17 PBNDS. Fifteen standards were determined to be fully
compliant. Two deficiencies were identified in the following two standards: Key and Lock
Control (1 deficiency) and Use of Force and Restraints (1). ODO observed numerous key-inknob locks on doors in detainee-accessible areas and reviewed a video recording of a calculated
use of force incident that did not contain close-ups of the detainee’s body during the postincident medical examination to document the presence or absence of injuries. The deficiency
identified in the Key and Lock Control PBNDS is a repeated deficiency from the April 2011
QAR. This report details both deficiencies and refers to the specific, relevant sections of the
PBNDS. ERO will be provided a copy of this report to assist in developing corrective actions to
resolve the two identified deficiencies. These deficiencies were discussed with EDC personnel
onsite during the inspection, as well as during the closeout briefing conducted on July 12, 2012.
EDC maintains an electronic grievance log to document and track all formal grievances
submitted by detainees. ODO verified grievance forms are placed in the detention file of each
detainee lodging a grievance. In January 2012, the facility trained its staff to resolve most
complaints informally during daily interactions with detainees. As a result of this training, the
number of formal grievances processed by EDC was drastically reduced and staff became aware
that many of the grievances submitted prior to January 2012 were unnecessarily submitted as
formal grievances. The grievance log reflects that EDC received and processed 60 formal
grievances between January 2012 and July 2012. Twenty-one pertained to disciplinary appeals;
18 pertained to facility staff; eight pertained to miscellaneous complaints; three pertained to food
service; three pertained to mail service; two pertained to the law library; two pertained to
recreation; two pertained to visitation; one pertained to classification. ODO confirmed there
were no grievances related to staff misconduct during this time period.
ODO reviewed the medical records of 35 detainees and confirmed that medical intake
screenings, physical examinations, and tuberculosis tests were conducted and performed in a
timely manner in all 35 cases. ODO verified medications, treatment for mental health, special
and chronic needs, and follow-up care were also provided as required. Detainees at EDC obtain
medical care by submitting sick call request forms, which are available in English and Spanish.
ODO noted that sick call request forms are efficiently and expediently triaged to determine
priority for care, and detainees are seen for sick call in a timely manner. Sick call request forms
are maintained in the detainees’ medical files, and copies are kept permanently in a three-ring
binder for review and data collection purposes.
An EDC detainee died at Tucson University Medical Center in Tucson, Arizona, on October 30,
2011, after being diagnosed with cardiomyopathy. This was the first detainee death to ever
occur at EDC. ODO conducted a Detainee Death Review of this case. There have been 42
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suicide watches in the past year and no suicides or suicide attempts since the April 2011 ODO
Quality Assurance Review (QAR). ODO examined the medical records of ten detainees who
were previously on suicide watch and confirmed that EDC was fully compliant with the PBNDS,
including the treatment, monitoring, and removal of detainees from suicide watch status by
qualified medical staff.
EDC has a designated Sexual Abuse and Assault Prevention and Intervention (SAAPI)
Coordinator and a Sexual Abuse Response Team (SART). The members of the SART include
the SAAPI Coordinator, the Victim Services Coordinator, and representatives from the security,
medical, and mental health departments. Having a SART exceeds the requirements of the
PBNDS. ODO considers the existence of the SART as a best practice, because it assures a
multi-disciplinary approach to preventing and responding to sexual abuse and assaults.
Detainees are informed of the SAAPI program via the detainee handbook, orientation, and
postings throughout the facility. ODO observed SAAPI postings in the intake areas and all
housing units; information is printed in English and Spanish. Detainees are also provided a trifold English and Spanish brochure with guidance for reporting sexual abuse or misconduct by
detainees or staff. ODO notes that the majority of detainees speak Spanish, but the facility has
seen an increase in the population of Chinese detainees. ODO recommends translating the trifold pamphlet into Chinese to ensure SAAPI information is available and understood by
Chinese-speaking detainees. Detainees are screened during the intake process for sexual abuse
victimization history, as well as predatory history to determine potential sexual aggressors. EDC
separates detainees with a history of predatory or abusive sexual behavior from detainees with a
history of victimization. The facility enters information on detainees in those categories into a
computer program which prevents the two categories from mixing. ODO cites this as a best
practice, because it assures potential victims are separated from potential predators.
Staff is required to attend pre-service, quarterly, and annual training on the SAAPI program.
ODO verified completion of training was documented in all(b)(7)epersonnel records reviewed.
ODO confirmed the training curriculum is comprehensive and inclusive of all required elements.
Staff interviews demonstrated knowledge of how to handle information received concerning
sexual abuse and assault allegations. Personnel are provided a card with step-by-step
instructions in the event they receive information concerning sexual abuse or assault. ODO
observed that all officers on duty have this card readily available. ODO cites this as a best
practice, because it assures officers have immediate access to information critical to proper
handling of alleged sexual assaults.
The EDC SAAPI coordinator stated there were four incidents of reported sexual abuse and
assault since the previous ODO QAR. ODO reviewed files related to each case and found all
were complete and included documentation of notification to ICE, local law enforcement, and
other required agencies and individuals. The SAAPI Coordinator oversaw each investigation
and implemented appropriate procedures to ensure preservation of potential evidence,
statements, and other vital information. All four incidents were investigated by the local police,
who kept ERO personnel informed of each step during the investigation. Three of the
investigations resulted in unsubstantiated allegations. The fourth incident, which was
substantiated, resulted in disciplinary action against the detainee identified as the perpetrator.

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Local facility policy and the PBNDS were followed in all of the reported incidents. All alleged
victims were medically examined by facility health care personnel and at a local hospital.
ODO highlights that the SAAPI program, facility policies, training, reporting procedures,
reviews, and investigations are all performed in accordance with the Prison Rape Elimination
Act.
At the time of the inspection, there were 26 detainees (25 males; 1 female) placed in segregation.
Specifically, 17 detainees were placed in administrative segregation, and nine detainees were
segregated for disciplinary reasons. ODO observed the Administrative Special Management
Unit (SMU) and the Disciplinary SMU at EDC to be 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 to closely monitor the living conditions in the SMU.
The FOD, the Deputy FOD, the AFOD, and the Warden all attribute the high level of PBNDS
compliance at EDC to open communication between CCA and ERO staff. The Warden gives
additional credit for the high level of PBNDS compliance to the CCA compliance team, the ERO
compliance team, and the DSM for working jointly on a daily basis. ODO notes that the FOD
Phoenix allocates ERO personnel to comprise compliance teams at most of the larger facilities
within the FOD Phoenix area of responsibility (AOR). These ERO Phoenix compliance teams
are formed without any additional funding or resources from ERO HQ and are comprised of
ERO personnel from the FOD Phoenix AOR. The FOD Phoenix team engages in active selfinspection of the facility using the ODO method, which involves fully inspecting all components
of the PBNDS using the actual text of each standard as a guide.
ODO often cites best practices observed at facilities with regard to specific internal operations
related to the continuity of care and orderly management of ICE detainees. ODO recommends
that ERO HQ study EDC standard operating procedures regarding internal compliance measures,
SAAPI, and SART, and implement them on a national level.

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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 or the ICE
PBNDS, as applicable. The PBNDS apply to EDC. In addition, ODO may focus its inspection
based on detention management information provided by the ERO Headquarters (HQ) and ERO
field offices, and on issues of high priority or interest to ICE executive management.
ODO reviewed the processes employed at EDC 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 (JICMS), the ENFORCE Alien Booking Module (EABM), and the
ENFORCE Alien Removal Module (EARM). ODO also gathered facility facts and inspectionrelated information from ERO HQ staff to prepare for the site visit at EDC.

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 classifies program issues into one of two categories: deficiencies and areas of concern.
OPR defines a deficiency as a violation of written policy that can be specifically linked to the
PBNDS, ICE policy, or operational procedure. OPR defines an area of concern as something
that may lead to or risk a violation of 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
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

5

ODO, San Diego
ODO, Phoenix
ODO, Phoenix
Creative Corrections
Creative Corrections
Creative Corrections

Eloy Detention Center
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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the Warden, the Assistant Warden, the AFOD, and the DOS. During the
interviews, all personnel from CCA and ERO stated that the working relationship between CCA
and ERO officers is excellent. The Warden and the Assistant Warden both stated that they have
consistently observed ERO officers visiting the housing units multiple times each week and
communicating with ICE detainees to address their issues or concerns. The Warden and the
Assistant Warden stated that CCA is adequately staffed to manage the current detainee
population at EDC.
The AFOD stated there are currentl (b)(7)e vacant SDDO positions,(b)(7)evacant IEA positions, and
(b)(7)e vacant ERA positions at EDC. The DOS stated that ERO is currently understaffed at EDC
and the addition o (b)(7)e IEA an (b)(7)eIEAs would be an adequate supplement to current
personnel.

DETAINEE RELATIONS
ODO randomly selected 30 male ICE detainees (5 Level I; 16 Level II; 9 Level III) and ten
female ICE detainees (5 Level I; 5 Level II) to assess the overall living and detention conditions
at EDC. One male detainee said he was concerned that he might not be receiving adequate
treatment for possible lung cancer. The medical file of this detainee reflects that a benign and
non-cancerous mass was discovered in one lung. Examination of the medical record confirmed
this detainee was receiving adequate medical treatment. ODO received no complaints
concerning access to the law library and legal materials, issuance and replenishment of basic
hygiene items, food service, recreation, religious services, visitation, issuance of the detainee
handbook, or the grievance system. ODO confirmed that in addition to outdoor recreation,
indoor recreation includes access to board games and PlayStation 3 game consoles.

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ICE PERFORMANCE BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 17 PBNDS and found EDC fully compliant with the following 15
standards:
Classification System
Detainee Handbook
Detention Files
Disciplinary System
Emergency Plans
Environmental Health and Safety
Food Service
Grievance System
Hunger Strikes
Medical Care
Sexual Abuse and Assault Prevention and Intervention
Special Management Units
Staff-Detainee Communication
Suicide Prevention and Intervention
Terminal Illness, Advance Directives, and Death
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 areas:
Key and Lock Control
Use of Force and Restraints
Findings for each of these standards are presented in the remainder of this report.

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KEY AND LOCK CONTROL (K&LC)
ODO reviewed the Key and Lock Control standard at EDC to determine if facility safety and
security is maintained by requiring keys and locks to be controlled and maintained, in
accordance with the ICE PBNDS. ODO interviewed the Security Officer and staff, observed key
and lock issuance, and reviewed facility policies, inventories, and key storage records.
The facility has a comprehensive written policy governing key and lock control. Responsibility
for the key control program is assigned to a full-time designated Security Officer at EDC. The
Security Officer has successfully completed three locksmith training programs. All facility staff
is trained and accountable for key control. A chit system is used for the accounting of keys on
24-hour posts in the housing units and segregation areas. The chits have the assigned staff
member’s photograph and identification number to support accurate issuance and accounting for
keys. There is a metal safe maintained in a secure area behind a locked door at each post. The
box contains descriptions of each key ring with a letter and number, and the number of keys on
each key ring. Keys for administrative personnel, housing unit managers, and education, food
service, maintenance, and other support services staff are maintained in an electronic control box
located outside the control center in a secure area of the administrative building. The electronic
control box is accessed via a biometric scan of the user’s right index fingerprint and entering a
numeric code. The system is equipped with an alarm system which sends a message to the
control center when a key set has not been returned by a pre-set time. This assures personnel do
not inadvertently or intentionally take keys outside of the facility. Key counts are conducted on
each shift and reviewed by a supervisor.
During the April 2011 QAR, ODO observed numerous prohibited locks installed on doors in
detainee-accessible areas. As a result, ODO cited this as a deficiency. Based on information
provided by the Security Officer, review of purchase orders, and systematic inspection of every
door located inside the secure perimeter during this inspection, ODO determined that since the
April 2011 QAR, 75 key-in-knob locks and three padlocks have been replaced with deadbolt
locks. However, ODO observed 46 key-in-knob locks still in place on doors in detaineeaccessible areas (Deficiency K&LC-1). Key-in-knob locks can be easily compromised,
potentially allowing detainees to enter unauthorized areas. EDC management stated that the
remaining 46 key-in-knob locks would be replaced.

STANDARD/POLICY REQUIRMENTS FOR DEFICIENT FINDINGS
DEFICIENCY K&LC-1
In accordance with the ICE PBNDS, Key and Lock Control, section (V)(C)(4), the FOD must
ensure either deadbolts or deadlocks shall be used in detainee-accessible areas. Locks not
authorized for use in detainee-accessible areas include, but are not limited to: snap-, key-in-knob,
thumb-turn, push-button, rim-latch, barrel or slide bolt, and removable-core-type locks
(including padlocks). Any such locks in current use shall be phased out and replaced with
mortise lock sets and standard cylinders.

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USE OF FORCE AND RESTRAINTS (UOF&R)
ODO reviewed the Use of Force and Restraints standard at EDC to determine if necessary use of
force and the use of restraints is utilized only after all reasonable efforts have been exhausted to
gain control of a subject, while protecting and ensuring the safety of detainees, staff and others,
preventing serious property damage, and ensuring the security and orderly operation of the
facility, in accordance with the ICE PBNDS. ODO toured the facility, inspected equipment,
interviewed staff, and reviewed facility policy, training records, and use of force documentation.
The facility has a comprehensive use of force policy addressing all requirements of the PBNDS,
including confrontation avoidance and using force only as a last resort. ODO reviewed the
training records o (b)(7)eofficers listed as participants in two calculated use of force incidents. The
records reflected that all(b)(7)efficers have received initial, annual, and periodic training related to
use of force.
The EDC use of force policy has provisions for use of four/five point restraints when ambulatory
restraints are insufficient to protect and control a detainee. ODO confirmed there were no
instances involving the use of four/five point restraints during the two years preceding this
inspection. Electro-muscular disruption devices are not used at EDC.
The Chief of Security stated there were two calculated and 14 immediate use of force incidents
between July 2011 and June 2012. Calculated use of force incidents are those in which there is
no imminent risk and sufficient time exists for the situation to potentially resolve without
resorting to force. In immediate use of force situations, force must be used to prevent a detainee
from harming himself, others, or property. It may be necessary for staff to respond to such a
situation without a supervisor’s direction or presence. ODO reviewed written documentation of
the 14 immediate use of force incidents and verified all 14 incidents were compliant with the
PBNDS and facility policy. ODO reviewed the video recordings of the two calculated use of
force incidents and confirmed one of the incidents was fully compliant with the PBNDS;
however, the second incident did not include close-ups of the detainee’s body during the postincident medical examination (Deficiency UOF&R-1). Video recording the presence or absence
of injuries provides important evidence in the event of a claim or allegation of excessive use of
force. ODO confirmed all other requirements of the PBNDS were met, including after action
reviews and notification to ERO.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF&R-1
In accordance with the ICE PBNDS, Use of Force and Restraints, section (V)(I)(2), the FOD
must ensure calculated use-of-force incidents shall be audiovisually-recorded in the following
order:
1. Introduction by Team Leader stating facility name, location, time, date, etc., describing the
incident that led to the calculated use of force, and naming the audiovisual camera operator
and other staff present.
2. Faces of all team members should briefly appear (with helmets removed and heads
uncovered), one at a time, identified by name and title.
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3. Team Leader offers the detainee a last chance to cooperate before team action, outlines the
use-of-force procedures, engages in confrontation avoidance, and issues use-of-force order.
4. Record entire use-of-force team operation, unedited, until the detainee is in restraints.
5. Take close-ups of the detainee's body during a medical exam, focusing on the
presence/absence of injuries. Staff injuries, if any, are to be described but not shown.
6. Debrief the incident with a full discussion/analysis/assessment of the incident.

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