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
Florence Correctional Center
Florence, Arizona

November 13 - 15, 2012

COMPLIANCE INSPECTION
FLORENCE CORRECTIONAL 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
Detention Files .........................................................................................................8
Food Service ..........................................................................................................10
Grievance System ..................................................................................................11
Hold Rooms in Detention Facilities.......................................................................13
Personal Hygiene ...................................................................................................14

exception of the ratios of toilets and washbasins to detainees, which is due to facility
infrastructure.
ODO attributes the high level of PBNDS compliance at FCC to the presence of a full-time FCC
Quality Assurance Manager and daily visits to the facility by ERO staff. ERO and FCC have a
very strong working relationship, with excellent communication. FCC management works
diligently to maintain PBNDS compliance.
This report details all deficiencies identified by ODO and refers to the specific, relevant sections
of the PBNDS. ERO will be provided a copy of this report to assist in developing corrective
actions to resolve all identified deficiencies. These deficiencies were discussed with FCC and
ERO staff on-site during the inspection, as well as during the closeout briefing on
November 15, 2012.
The food service operation is managed by CCA staff and supported by a crew of inmate workers
in the kitchen. FCC does not have a centralized location for dining. FCC provides satellite meal
service to detainees in the housing units. The satellite meals are prepared in the kitchen and
delivered on temperature-controlled carts to the housing units, where the meals are distributed by
detainees. ODO verified all food service staff and assigned inmate and detainee workers receive
medical clearances prior to working in food service. ODO verified the temperature of selected
food items met the PBNDS requirements. Review of the master cycle menu confirmed it was
reviewed and certified as nutritionally adequate by a registered dietician. ODO verified medical
diets are provided in accordance with the standard. FCC received an “E” rating (Excellent) from
the Pinal County Health Department during the last food service inspection. According to
pinalcountyaz.gov, a food establishment receives an “E” rating when no critical items are
identified during the inspection. ODO reviewed the kosher tray requirements and confirmed
FCC did not have margarine labeled as appropriate to be eaten with all meals. FCC corrected
this deficiency on-site by purchasing margarine with the appropriate label.
FCC provides detainees the opportunity to file formal and informal grievances. FCC staff
attempts to resolve complaints informally during daily interactions with detainees. Grievance
forms are readily available within the housing units. FCC maintains an electronic grievance log
to document and track all formal and informal grievances submitted by detainees. ODO verified
grievance forms are placed in the detention file of each detainee submitting a grievance;
however, medical grievance forms were not being placed in individual medical files. FCC
management corrected this deficiency on-site by placing completed medical grievance forms into
the appropriate detainee medical files.
The field office has a local policy and procedure to ensure and document that an ICE
Immigration Enforcement Agent or Supervisory Detention and Deportation Officer conducts
weekly announced and unannounced visits to housing units to address detainee concerns and
inquiries, as required by the Model Protocol on Staff-Detainee Communication. ERO visitation
schedules are conspicuously posted in each housing unit. Scheduled visits are documented on
the Facility Liaison Visit Checklist as required by the Model Protocol. Weekly telephone
maintenance is also conducted and recorded on a log.

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elements. Personnel were knowledgeable regarding the SAAPI program and how to handle
information received concerning possible sexual abuse or assault.
The special management unit (SMU) at FCC has 60 double-occupancy cells, which are used as
single-occupancy only. At the time of the inspection, there were no ICE detainees in the SMU.
ODO observed the SMU at FCC to be well-lit, temperature appropriate, and sanitary. ODO
reviewed prior Facility Liaison Visit Checklists and confirmed ERO personnel visit the SMU on
a bi-weekly basis to interact with detainees and to closely monitor the living conditions in the
SMU in accordance with the PBNDS.
FCC 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. Protective
equipment and hand-held video cameras, for use in calculated use of force incidents, are
available in several locations within the facility for quick access to the equipment and
accelerated response time. Since January 1, 2012, there have been two use-of-force incidents
involving ICE detainees at FCC. In both cases, staff used Oleoresin Capsicum (OC) spray to
prevent the detainees from injuring themselves while the detainees were on constant watch in a
cell in the medical department. The incidents took place on different dates. Both immediate
use-of-force incidents were conducted in accordance with the PBNDS.

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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 FCC. 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 FCC to determine compliance with current policies
and detention standards. Prior to and during the inspection, ODO collected and analyzed
relevant allegations and detainee information from multiple ICE databases, including the Joint
Integrity Case Management System, 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 FCC.

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)
Section Chief
Special Agent
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

5

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

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed supervisory ICE and FCC staff, including the FCC Warden, FCC Assistant
Warden, FCC Quality Assurance Manager, the ERO Assistant Officer in Charge, and the ERO
Supervisory Detention and Deportation Officer. FCC staff stated ERO personnel conduct
weekly scheduled and unscheduled visits to detainee housing units at the facility, and are present
at the facility on a daily basis. ICE and FCC personnel stated the working relationship between
the two entities is positive, and morale is high.

DETAINEE RELATIONS
ODO interviewed ten randomly-selected detainees (five Level I and five Level II) to assess the
overall living and detention conditions at FCC. None of the detainees complained about
recreation, food service, hygiene supplies, telephone access, religious services, visitation, or the
law library. Five detainees in one housing unit stated they were not provided clean bed linens,
and stated they had used the same bed linens for approximately four weeks. The housing unit
manager stated detainees are allowed to have their linen washed as indicated on the laundry
schedule posted on the housing unit bulletin board. ODO verified laundry schedules are
conspicuously posted in each housing unit. The unit manager stated FCC management will hold
a town hall meeting to address this situation. All detainees interviewed knew how to contact
their assigned Deportation Officer.

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ICE PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 18 PBNDS and found FCC fully compliant with the following
13 standards:
Classification System
Detainee Handbook
Emergency Plans
Environmental Health and Safety
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
Use of Force and Restraints
Visitation
As these standards were compliant at the time of the review, a synopsis for these standards was
not prepared for this report.
ODO found deficiencies in the following five standards:
Detention Files
Food Service
Grievance System
Hold Rooms in Detention Facilities
Personal Hygiene
ODO findings for each of these standards are presented in the remainder of this report.

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DETENTION FILES (DF)
ODO reviewed the Detention Files standard at FCC to determine if files are created containing
all significant information pertaining to detainees housed at the facility for over 24 hours, in
accordance with the ICE PBNDS. ODO reviewed detention files to ascertain whether all
required documentation was included.
As part of the intake process, FCC staff creates a detention file when a detainee is admitted to the
facility. ODO randomly selected five active and five inactive detention files for review to
determine if they contained required documentation.
All five active detention files reviewed contained original photographs, classification
worksheets, personal property inventory sheets, receipts for property and baggage, the required
Form I-385, Alien Booking Record, and housing identification cards; however, none of the five
active detention files reviewed was properly annotated to indicate it had been activated, as
required by the PBNDS (Deficiency DF-1).
All five active detention files reviewed contained a Form I-203, Order to Detain/Release, but
none of the five inactive detention files contained a Form I-203 pertaining to the release of the
detainee(Deficiency DF-2). This deficiency was corrected on-site; FCC inactive detention files
now include Form I-203.
In addition to storing and maintaining the detention files, FCC keeps a check-in and check-out
log for the detention files. However, the log does not include the signature of the person
removing the file, including the person’s title and department (Deficiency DF-3). This
deficiency was corrected on-site; FCC management modified the log to contain the required
information.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DF-1
In accordance with the ICE PBNDS, Detention Files, section (V)(A)(2), the FOD must ensure,
when a detainee is admitted to a facility, staff shall create a detainee Detention File as part of
admissions processing.
2. The officer completing the admissions portion of the Detention File shall note that the file
has been activated. The note may take the form of a generic statement in the
Acknowledgment form described below.
DEFICIENCY DF-2
In accordance with the ICE PBNDS, Detention Files, section (V)(E)(1), the FOD must ensure,
upon the detainee’s release from the facility, staff shall add final documents to the file before
closing and archiving it after inserting:


Detention file copies of completed release documents.

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DEFICIENCY DF-3
In accordance with the ICE PBNDS, Detention Files, section (V)(F)(3), the FOD must ensure a
representative of the department requesting the file is responsible for obtaining the file, logging it
out, and ensuring its return.
At a minimum, a logbook entry recording the file’s removal from the cabinet shall include:


Signature of person removing the file, including title and department.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at FCC to determine if detainees are provided a
nutritious and balanced diet, in a sanitary manner, in accordance with the ICE PBNDS. ODO
interviewed staff and detainees, reviewed documentation, inspected food preparation and storage
areas, and observed food service operations.
All work associated with food preparation and kitchen sanitation is performed under contract by
the Trinity Group. A crew of inmate workers supports the food service operation in the kitchen,
and detainee workers serve meals in the housing units. ODO verified all food service staff, as
well as inmate and detainee workers received medical clearances. Trinity personnel actively
supervise the preparation and service of meals to ensure food items are correctly prepared and
properly presented. A correctional officer conducts required area searches, and visually inspects
workers for proper grooming and absence of obvious health concerns. Food service staff
conducts weekly inspections to identify any sanitation or safety concerns. ODO confirmed the
facility is inspected annually by the Pinal County Public Health Department. The last inspection
report, dated January 12, 2012, documented compliance with regulations, and rated the food
service operation at FCC as “Excellent.”
FCC has a satellite system of meal service involving preparation of meals in the kitchen and
delivery to housing units via temperature-controlled carts. Detainee workers serve meals under
the direct supervision of staff. ODO observed meal preparation and delivery, and sampled
meals. ODO confirmed food items had good taste, portions were adequate, and temperatures
met requirements. There were no complaints about food service from detainees during the
inspection.
ODO verified nutritional analysis of the master cycle menu and determination of adequacy were
completed by a registered dietician on April 13, 2012. ODO reviewed documentation of
monthly pest control services, and conducted water and equipment temperature checks, all of
which demonstrated compliance with the standard. ODO verified food items were properly
stored, and observed a high level of sanitation throughout the food service area.
ODO identified one deficiency. The margarine purchased for common fare and kosher trays was
not labeled “pareve” or “parve” (Deficiency FS-1). Parve margarine must be served in order to
meet the requirements of the kosher diet that dairy products and meat not be served together.
FCC ordered parve margarine and received it during the review, correcting this deficiency
on-site.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE PBNDS, Food Service, section (V)(G)(5), the FOD must ensure,
with the exception of fresh fruits and vegetables, the facility's kosher-food frozen entrees shall be
purchased precooked in a sealed container, heated, and served hot. Other kosher-food purchases
shall be fully prepared, ready-to-use, and bearing the symbol of a recognized kosher-certification
agency. Any item containing pork or a pork product is prohibited. Only bread and margarine
labeled "pareve" or "parve" shall be purchased for the kosher tray.
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GRIEVANCE SYSTEM (GS)
ODO reviewed the Grievance System standard at FCC to determine if a process to submit formal
or emergency grievances exists, and responses are provided in a timely manner, without fear of
reprisal. In addition, the review determined whether detainees have an opportunity to appeal
responses, and if accurate records are maintained, in accordance with the ICE PBNDS. ODO
interviewed staff, and reviewed policies, grievance logs, detention files, and the facility
handbook.
FCC informs detainees of the procedure for filing a grievance in the facility handbook.
Procedures are in place to handle emergency grievances; however, no emergency grievances
were filed during the review period. If a grievance concerning staff misconduct is filed by an
ICE detainee, FCC policy states the allegation will immediately be forwarded to ERO. No staff
misconduct grievances were filed during the one-year period of review.
Detainees at FCC are encouraged to resolve grievances informally. All informal grievances are
handled and resolved verbally by staff, and a copy of the informal grievance is placed in the
detainee’s detention file.
Detainees may file formal written grievances by completing and submitting a detainee grievance
form, and placing it in the unit grievance box. Grievance forms are available in each housing
unit and can be obtained by requesting them from the housing unit officer. Grievances are
collected daily, except for weekends and holidays, and are forwarded to the grievance
coordinator for review. After a grievance is reviewed, the grievance coordinator assigns a
grievance number and records it in an electronic database to document the grievance and track its
progress. The grievance coordinator then forwards the grievance to the appropriate department
head for handling and response based on the nature of the complaint. Copies of grievances are
filed in the detainees’ detention files. FCC responds to formal grievances within five working
days of submission.
The detainee grievance committee (DGC), at least one member of which is an ICE employee,
conducts an investigation and provides its decision to the detainee. Detainees may appeal the
DGC’s decision to the Warden within five working days for a final response. If a detainee is
dissatisfied with the Warden’s response, the detainee may contact ERO directly.
Medical grievances are delivered directly to medical staff within 24 hours or the next business
day by the grievance coordinator; however, medical personnel were not placing medical
grievances in detainee medical files (Deficiency GS 1). FCC management corrected this
deficiency on-site by placing the completed medical grievance forms into the appropriate
medical files.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY GS- 1
In accordance with the ICE PBNDS, Grievance System, section (V)(E), the FOD must ensure
each facility shall devise a method for documenting detainee grievances, at a minimum, a
Detainee Grievance Log. The documentation shall include the date of the grievance, nature of
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the grievance in detail, and the date the grievance was resolved. Medical grievances are
maintained in the detainee’s medical file.

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HOLD ROOMS IN DETENTION FACILITIES (HR)
ODO reviewed the Hold Rooms in Detention Facilities standard at FCC to determine if detainees
placed temporarily in hold rooms awaiting further processing, are in a safe, secure, and
comfortable environment, and not confined in hold rooms for over 12 hours, in accordance with
the ICE PBNDS. ODO reviewed policies, procedures, and logs; interviewed staff; and inspected
the hold rooms. No detainees were in the hold rooms during the review; however, ODO
observed staff cleaning and inspecting the rooms after previous occupants were moved from the
area, as required by the standard.
The facility has two hold rooms for ICE detainees, each capable of accommodating 11 detainees.
Inspection of the hold rooms found they have floor drains, electrical switches located on the
outside wall, and a shared shower stall. The rooms are clean and well lit, with stainless steel
toilets and free-standing stainless steel sinks. Metal benches bolted to the floor provide adequate
seating. The ceilings are made of solid concrete. Doors are prison-gauge steel, with prison locks
and a 9 x 63 inch plexi-glass window on the outside and reinforced metal bars on the inside. The
size of the windows facilitates observation and supervision of the hold rooms from the officer
work areas. The rooms are under constant supervision by FCC staff when occupied.
All arriving detainees undergo a pat search conducted by a person of the same sex, then are
screened with a walk-through metal detector before being placed in a hold room. Strip searches
are not conducted on ICE detainees unless there is reasonable suspicion of contraband or weapon
possession, and only with supervisory and ICE ERO approval. Detainees are permitted to
shower as part of the intake process.
The facility maintains an electronic log documenting the time of arrival, movement of detainees,
and time of departure from the receiving and discharge area. The log also provides space to
record meal service and security concerns. Review of logs found detainees spend an average of
two to three hours in the hold room, well below the 12-hour maximum allowed by the PBNDS.
Officers perform and are required to document visual checks of the hold rooms every
15 minutes. ODO noted the log to document visual checks (CCA Form 9-105A) did not include
the printed name of the officer, or a comments section to document any unusual behavior or
complaints (Deficiency HR-1). FCC management corrected this deficiency prior to completion
of the review by developing and implementing a new form that provides space for the required
information.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY HR-1
In accordance with the ICE PBNDS, Hold Rooms in Detention Facilities, section (V)(D)(5), the
FOD must ensure officers shall closely supervise Hold Rooms through direct supervision that
includes:

 Visual monitoring at irregular intervals at least every 15 minutes, each time recording in the
detention log, the time and officer's printed name and any unusual behavior or complaints
under “Comments.”
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PERSONAL HYGIENE (PH)
ODO reviewed the Personal Hygiene standard at FCC to determine if the facility provides clean
clothing, bedding, linens, and towels to every detainee upon arrival, and to ascertain if the
facility provides ICE detainees with regular exchanges of items for as long as they remain in
detention, in accordance with the ICE PBNDS. ODO reviewed policies and procedures,
interviewed detainees and staff, and inspected the housing units.
FCC maintains an inventory of clothing, bedding, linens, towels, and personal hygiene items
sufficient to meet the needs of detainees. FCC has written policy and procedures for the issuance
of these items. Detainees are held accountable for the issued clothing and linen items.
ODO interviewed ten randomly-selected detainees at the two housing units in FCC. All
detainees stated they have sufficient hygiene items, such as a toothbrush, toothpaste, deodorant,
toilet paper, and soap. All detainees stated they are provided clean uniforms and undergarments.
Five detainees in one housing unit stated they were not provided clean bed linens. The five
detainees stated they had their linens for approximately four weeks. The housing unit manager
stated detainees are allowed to have their linens washed as indicated on the laundry schedule
posted on the housing unit bulletin board. ODO verified laundry schedules are conspicuously
posted in each housing unit. The unit manager stated a town hall meeting will be held to address
the situation.
FCC management stated prior to the inspection that ICE ERO and ACA inspections have always
found FCC deficient regarding the ratio of toilets and washbasins to detainees. The PBNDS
requires a ratio of one toilet and one washbasin per 12 detainees. The ratio at FCC is one toilet
per 15 detainees, and one washbasin per 14 detainees (Deficiency PH-1). The facility cannot
correct this without significant infrastructure changes. No detainees interviewed complained
about the availability of toilets and washbasins.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY PH-1
In accordance with the ICE PBNDS, Personal Hygiene, section (V)(E), the FOD must ensure
detainees shall be provided:


An adequate number of toilets 24 hours per day that can be used without staff assistance
when detainees are confined to their cells or sleeping areas.
ACA Expected Practice 4-ALDF-4B-08 requires that toilets be provided at a minimum
ratio of one for every 12 male detainees or one for every 8 female detainees. For males,
urinals may be substituted for up to one-half of the toilets. All housing units with three or
more detainees must have at least two toilets.



An adequate number of washbasins with temperature controlled hot and cold running water
24 hours per day.
ACA Expected Practice 4-ALDF-4B-08 requires one washbasin for every 12 detainees.

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