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

Dallas Field Office
Johnson County Law Enforcement Center
Cleburne, Texas

January 8 – 10, 2013

COMPLIANCE INSPECTION
JOHNSON COUNTY LAW ENFORCEMENT CENTER
DALLAS FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...............................................................................................1
INSPECTION PROCESS
Report Organization .................................................................................................7
Inspection Team Members .......................................................................................7
OPERATIONAL ENVIRONMENT
Internal Relations .....................................................................................................8
Detainee Relations ...................................................................................................8
ICE NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ...............................................................................9
Detainee Grievance Procedures ............................................................................10
Environmental Health and Safety ..........................................................................12
Food Service .........................................................................................................14
Medical Care ..........................................................................................................19
Use of Force ...........................................................................................................22

During this CI, ODO reviewed 17 NDS at JCLEC and found JCLEC compliant with
12 standards. ODO found 18 deficiencies in the following five standards: Detainee Grievance
Procedures (2 deficiencies), Environmental Health & Safety (3), Food Service (10), Medical
Care (2), and Use of Force (1). Six of the ten deficiencies identified under Food Service were
the result of poor sanitation in the food service area.
This report details all deficiencies 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 the
18 identified deficiencies. These deficiencies were discussed with JCLEC personnel on-site
during the inspection and with JCLEC management during the closeout briefing on
January 10, 2013.
Overall, ODO found JCLEC security operations and medical services to be well managed. With
the exception of the food service areas, sanitation throughout the facility was at an acceptable
level. ODO found a number of deficiencies in the food service area, some involving poor
sanitation and cleanliness.
The law library is located in a quiet, well-lit room, equipped with sufficient furnishings and
office supplies to support legal research and case preparation, including a printer, a typewriter,
and one computer with the most recent version of Lexis-Nexis. ODO confirmed required
information regarding the law library is contained in the detainee handbook, and the law library
schedule was conspicuously posted in all housing units.
Upon admission to JCLEC, detainees are medically screened, and classifications are reviewed to
ensure appropriate housing assignments. During the admission process, detainees are issued
appropriate clothing and hygiene supplies. Facility staff provides a verbal orientation informing
detainees of rules and responsibilities, and procedures for submitting requests and filing
grievances. Detainees are shown the ICE video “Know Your Rights,” and are provided with
copies of the ICE National Detainee Handbook and the facility handbook in English or Spanish,
as appropriate. Funds and valuables are properly inventoried and securely stored.
Detainees are classified by ICE prior to arrival at JCLEC, and JCLEC staff generally adheres to
the classification level determined by ICE. Upon admission, booking staff verifies classification
information with the detainees, and a supervisor reviews, verifies, and approves the ICE
classification and housing assignments. Review by ODO of 30 detention files confirmed proper
classifications and appropriate supervisory approvals. ODO verified detainees were housed
based on their classification level and in accordance with the standard. Procedures are in place at
JCLEC to reclassify detainees when necessary. The facility handbook describes the
classification process and procedures for appealing classification decisions.
ODO confirmed JCLEC policy addresses all requirements of the Detainee Transfers NDS.
Review of the process and inspection of detention files for 15 detainees transferred from JCLEC
to other facilities during the 12 months preceding the ODO inspection confirmed compliance
with the standard.
JCLEC personnel attempt to resolve detainee grievances informally at the lowest level possible.
Grievance forms are available in each detainee housing unit, and grievance procedures are
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addressed in the ICE and the facility handbooks. The JCLEC grievance system allows detainees
to file informal, formal, and emergency grievances, and to appeal grievance decisions. Detainees
are free to bypass or terminate the informal grievance process and proceed directly to filing a
formal grievance. The Grievance Coordinator oversees the grievance system and maintains a
handwritten grievance log to document and track grievances filed by detainees. A review of the
grievance log by ODO confirmed all written grievances are logged with pertinent information,
including the nature of the grievance and the date of resolution. ODO found copies of
grievances containing allegations of officer misconduct are not forwarded to ICE.
JCLEC received 265 grievances between January 1, 2012, and January 8, 2013. Of the
265 grievances reviewed, ODO noted 58 were complaints against staff, 47 concerned food
service, and 35 involved medical care. ODO noted among the 58 complaints against staff,
14 involved complaints of unprofessional behavior and inappropriate language used by staff,
which identified an actual officer. ODO confirmed the Warden counseled the staff members
identified in the grievances. Meal portion size was the primary complaint related to food service.
No trend was noted regarding medical care grievances. The remaining 125 grievances were
complaints related to commissary supply, clothing, property, telephone access, sanitation, and
other miscellaneous issues, with no trends identified.
Review of JCLEC policy by ODO confirmed prohibited acts are classified as minor and major,
and can be referred for criminal prosecution if warranted. Graduated severity scales for
prohibited acts and disciplinary consequences are in place, and policy requires that minor
violations be informally settled whenever possible. Detainee rights under the disciplinary
system, to include appeal rights, are addressed in the detainee handbook and posted in the
housing units. ODO randomly selected and reviewed 11 disciplinary packets completed between
August 2012 and January 2013. ODO verified incident reports in all 11 cases clearly
documented rule violations and were properly investigated within 24 hours. Detainees were
served with notices, and hearings were timely and properly conducted. Sanctions imposed were
within established guidelines.
The JCLEC Maintenance Supervisor is responsible for safety compliance with JCLEC policy
and the NDS. ODO confirmed all flammable, caustic, and toxic substances are accurately
inventoried and stored, to include medical sharp objects and syringes. JCLEC has an approved
fire prevention plan, and the facility is inspected annually by the Cleburne Fire Prevention
Bureau. JCLEC staff conducts monthly fire and safety inspections; however, monthly fire drills
are not conducted in each department. Additionally, ODO verified detainees are not evacuated
during fire drills. ODO notes that evacuating detainees during a fire drill ensures both staff and
detainees are prepared in the event of a fire emergency, and ensures emergency exits and exit
plans are functional.
ODO found significant deficiencies and a poor level of sanitation and cleanliness in the food
service area at JCLEC. Five Star manages food service operations under contract. Food service
staff consists of a Food Service Manager, (b)(7)e kitchen supervisors, and a crew of b)(7)ecounty
inmate workers. No ICE detainees work in food service. Review of documentation by ODO
confirmed all inmate workers received medical clearances to work in food service; however,
Five Star employees did not receive pre-employment medical examinations.

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JCLEC has a satellite system of meal service involving preparation of meals in the kitchen and
delivery to housing units on insulated trays. ODO observed the preparation of trays for one noon
meal during the review, and accompanied the inmate workers transporting the carts to the
housing units. The carts used to transport the trays have open metal shelves and are not secure.
ODO found the floor in the kitchen was slippery, with a greasy residue. Floor corners and walls
had significant dirt build-up. Floor drains were obstructed with food remnants. Food particles
and congealed liquids were found on surface areas of food preparation and work tables, with no
evidence they had been wiped down after use to prevent cross-contamination. This presents a
breeding ground for bacteria and potential food-borne illness. Food items were observed on the
floor behind the steam kettles, ovens, and stove. Greasy build-up was found in ventilation hoods
and on hood filters, posing a significant fire hazard. This also presents a breeding ground for
bacteria. The drip pan for the stove contained burnt grease and food particles. During inspection
of storage areas, ODO observed standing water in the chemical storage room. Height limits were
not maintained for stacked boxes in the dry storage area, violating the requirement to maintain an
18-inch clearance underneath sprinklers. Storage of boxes within the required clearance may
interfere with the effectiveness of the sprinklers. ODO also observed bags of bulk food items
stacked high, which poses a safety hazard if they should topple. Food particles and trash littered
the floors of the walk-in freezer and walk-in refrigerator. ODO noted a significant amount of
frozen condensation on the ceiling, walls, and shelves of the freezer. A heavy fog was blowing
from the condenser unit. These conditions signify a malfunction that should be identified and
addressed to ensure the freezer is operating properly. ODO observed obstructions in aisles and
passages, creating a safety hazard and preventing egress. ODO confirmed the Food Service
Manager does not conduct weekly inspections as required by JCLEC policy and the NDS.
Detainees stated breakfast cereal containing bugs was served the week prior to the ODO
inspection. The Food Service Manager and JCLEC management confirmed weevils were found
in bran cereal served a week prior to the CI. Inspection by ODO confirmed the infested cereal
came from packages freshly opened that morning, which traced to a singular bulk shipment
received from a local distributor. Food service staff removed and disposed of the cereal, and
notified the supplier. On the third day of this CI, weevils were again reported in cereal served
during the morning meal. Food service personnel again traced the infested cereal to freshlyopened packages of bran cereal, and reported the second occurrence of infestation to the supplier.
All food items stored in the area with the bags were inspected, and no insects were found. ODO
confirmed pest control services are provided in the food service department and throughout the
facility on a scheduled basis, and as needed. Though infestation of the cereal appears to have
occurred prior to delivery to JCLEC and was unrelated to the sanitation concerns discussed in
this report, ODO recommends that food service staff take steps to ensure delivered food items
contain no evidence of insect or rodent infestation prior to preparation and service to detainees.
Healthcare is provided by LSC, with oversight by an on-site HSA. The JCLEC clinic is open
24 hours a day, seven days a week. ODO found staffing levels at the clinic are adequate to
provide basic medical services for detainees. Nurses conduct routine intake screenings to
identify chronic care, mental health, and medication needs. A physical exam is completed by a
Registered Nurse (RN) within eight days of arrival. Detainees access health care services by
completing a sick call request form. Forms are available in English and Spanish, and are
deposited by detainees directly into a locked box located in each housing unit. Nurses collect
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sick call requests once a day, and triage the requests for clinical priority. A Licensed Vocational
Nurse (LVN) conducts sick call Monday through Friday using physician-approved protocols to
provide treatment. Medical staff visits the Special Management Unit (SMU) twice a day to
conduct face-to-face visits and respond to healthcare requests. There were no detainees in the
administrative or disciplinary SMU during the ODO review. The Clinical Medical Authority is a
contract physician who is on-site two days a week and on-call 24 hours a day. Mental health and
dental services are contracted and performed off-site. ODO found JCLEC medical policy
provides for routine dental care after 12 months of detention rather than six months as referenced
in the NDS.
Observation of medication administration revealed a standard practice not within LSC’s
Medication Service policy. Housing unit officers are allowed to administer over-the-counter
medications to detainees upon request. ODO found JCLEC officers are not trained in medication
distribution, or recognizing chronic use or abuse of issued medications. Additionally,
medications issued to detainees by officers are not reviewed by medical personnel or
documented in the individual medical records. ODO found officer distribution of over-thecounter medication is contrary to instructions provided by LSC, and poses a medical risk to
detainees. These medications may be misused and abused. Their use may be contraindicated by
prescribed medications or the detainee’s medical condition.
JCLEC has written procedures in place to temporarily segregate detainees for administrative and
disciplinary reasons. The administrative and disciplinary SMU are maintained in a sanitary
condition, and are appropriately ventilated, lit, and climate-controlled. No detainees were
housed in SMU at the time of inspection. Review of policy and documentation confirmed
security and medical staff are required to make rounds. Detainees housed in the SMU have
regular access to recreation, legal materials, medical care, telephones, visitation, recreation,
commissary, mail, religious services, clothing and bedding exchange, and hygiene items.
A comprehensive use of force policy addresses all requirements of the standard. The Major is
responsible for maintaining all documentation on use of force incidents. Since January 2012,
there have been two incidents involving immediate use of force on detainees, and no calculated
use of force incidents. Review of documentation in both immediate use of force incidents
confirmed full compliance with the standard, including after-action reviews, medical
examinations of the detainees involved, and notifications to ICE. ODO reviewed staff training
records and found all staff receive initial use of force training, but do not receive refresher or ongoing training. ODO notes refresher training ensures JCLEC personnel understand their
accountability for adherence to the policy.
JCLEC has policies and procedures in place that address suicide prevention and intervention.
ODO verified detainees are screened for suicide potential during the intake process. A review of
(b)(7)etraining files confirmed staff completes initial and ongoing suicide prevention training
covering all required topics. The Healthcare Services Administrator stated and ODO confirmed
there have been no detainee suicides at JCLEC, and no suicide attempts or suicide watches since
the October 2009 ODO inspection. Additionally, there have been no detainee deaths at JCLEC.
JCLEC has policies and procedures in place to address prevention, intervention, and handling of
alleged sexual abuse and sexual assault incidents. All staff is trained to properly address sexual
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abuse and sexual assault at the entrance training for correction officers, and each staff member
completes annual refresher training thereafter. In December 2012, JCLEC policy was revised to
reflect full compliance with the Sexual Assault and Prevention and Intervention standard of the
2011 Performance-Based National Detention Standards. ODO review of related JCLEC policy
confirmed written procedures are in place for reporting incidents through the chain-of-command,
and referral to local law enforcement. Postings on prevention of sexual abuse and assault are
conspicuously posted in each detainee housing unit. There were no incidents of alleged sexual
abuse or sexual assault at JCLEC reported during calendar year 2012.
The IEA permanently assigned to JCLEC is on-site five days per week to address detainee
requests, monitor living conditions, and conduct scheduled and unscheduled visits to each
housing unit. The SDDO conducts regular scheduled visits at JCLEC each week to observe
conditions of confinement. An ERO Detention Service Manager visits the facility on a monthly
basis to monitor facility compliance with the NDS. A review of the ICE visitor’s log showed an
AFOD visited JCLEC four times from August 2012 to December 2012. ODO verified that ICE
visitation schedules and ICE ERO staff contact information are conspicuously posted in each
housing unit. JCLEC has written procedures for detainees to submit written questions, requests,
or concerns to ICE. Detainee request forms are available in all housing units. ODO reviewed
the electronic detainee request log from July 2012 through December 2012, and confirmed all
requests were logged and responded to within 72 hours of receipt.
Detainees have reasonable and equitable access to telephones at JCLEC. The number of
telephones in the general housing areas meets the requirements of the standard. ICE staff
conducts weekly telephone serviceability checks to determine the operability of telephones in
each of the housing units. During this CI, ODO tested the telephones, and all were in good
working order.

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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 the ICE Performance-Based National
Detention Standards, as applicable. The NDS apply to JCLEC. 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 JCLEC 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 JCLEC.

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

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Special Agent (Team Leader)
Special Agent
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

7

ODO, Chicago
ODO, Houston
ODO, Atlanta
Creative Corrections
Creative Corrections
Creative Corrections

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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the JCLEC Warden, Assistant Warden, and Liaison Sergeant, as well as the
ERO AFOD, SDDO, and IEA responsible for ICE oversight of JCLEC. All personnel stated the
working relationship between JCLEC and ICE personnel is good. ODO observed positive
interactions between JCLEC personnel and ICE staff. The Assistant Warden and the Liaison
Sergeant conduct daily visits to each of the detainee housing units.
ICE personnel meet informally with JCLEC management on a weekly basis. The Warden stated
morale among JCLEC staff is high. The AFOD and the SDDO stated morale among ICE
personnel is high, and ERO has the resources necessary to carry out their duties and
responsibilities at JCLEC.

DETAINEE RELATIONS
ODO interviewed 24 randomly-selected detainees to assess detention conditions at JCLEC.
Eleven of 24 detainees stated they did not know the identity of their assigned Deportation
Officer. ODO confirmed an SDDO and an IEA visit each detainee housing unit a minimum of
once each week to observe living conditions and meet with detainees. ODO observed the ICE
visitation schedule and contact information for ERO staff were conspicuously posted in each
housing unit. ODO also reviewed logs, confirming the ICE visits. All detainees interviewed
were aware of the grievance process, and stated the grievance system is fair and functions as
described in the detainee handbook.
All detainees interviewed stated they had regular access to recreation, religious services, medical
care, telephones, and visitation. Seven detainees stated they were unaware of the existence of a
law library. ODO confirmed required information regarding the law library is contained in the
facility handbook, and the law library schedule is conspicuously posted in all housing units.
Sixteen detainees complained that food portions are inadequate. ODO verified the portion sizes
at each meal prepared during this CI met the minimum dietary guidelines. All detainees stated
the week prior to the ODO inspection, bugs were in the breakfast cereal served at the morning
meal. As reported in the Executive Summary and under the Food Service standard, JCLEC
management and the contract Food Service Manager confirmed weevils were present in
breakfast cereal served the prior week. An inspection conducted by JCLEC management
determined the cereal came from newly-opened packages of bran cereal received from a single
food distributor, and the items were contaminated prior to receipt by JCLEC.

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ICE NATIONAL DETENTION STANDARDS
ODO reviewed a total of 17 NDS and found JCLEC fully compliant with the following
12 standards:
Access to Legal Material
Admission and Release
Detainee Classification System
Detainee Handbook
Detainee Transfers
Disciplinary Policy
Funds and Personal Property
Special Management Unit – Administrative Segregation
Special Management Unit – Disciplinary Segregation
Staff-Detainee Communication
Suicide Prevention and Intervention
Telephone Access
As these 12 standards were compliant at the time of the review, a synopsis for these standards is
not prepared for this report.
ODO found deficiencies in the following five standards:
Detainee Grievance Procedures
Environmental Health and Safety
Food Service
Medical Care
Use of Force
Findings for each of these standards are presented in the remainder of this report.

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DETAINEE GRIEVANCE PROCEDURES (DGP)
ODO reviewed the Detainee Grievance Procedures standard at JCLEC to determine if a process
to submit formal or emergency grievances exists, and responses are provided in a timely manner,
without fear of reprisal. In addition, the review was conducted to determine if detainees have an
opportunity to appeal responses, and if accurate records are maintained, in accordance with the
ICE NDS. ODO interviewed staff and detainees, and reviewed policies and procedures, the
detainee handbook, detention files, and the grievance log.
The grievance system at JCLEC allows detainees to file informal, formal, and emergency
grievances, and to appeal grievance decisions. JCLEC staff attempts to resolve detainee
grievances informally and at the lowest level possible. Grievance forms are available in all
detainee housing units, and grievance procedures are addressed in the ICE and the facility
handbook. All detainees interviewed were aware of the grievance system, and stated the
grievance system is fair and functions as described in the detainee handbook. Detainees are free
to bypass or terminate the informal grievance process and proceed directly to filing a formal
grievance.
The Detainee Grievance Coordinator maintains a handwritten grievance log. When a written
grievance is resolved, the original grievance is filed in the grievance log and a copy is placed in
the individual detention file. Oral grievances are not documented in the grievance logbook
(Deficiency DGP-1). A review of the grievance log confirmed written grievances are logged
with all pertinent information, including the nature of the grievance and the date of resolution.
As a matter of practice, staff advised that grievances involving staff misconduct are not
forwarded to ICE (Deficiency DGP-2). ICE must be afforded the opportunity to independently
review or investigate any allegation of officer misconduct.
JCLEC received 265 grievances between January 1, 2012, and January 8, 2013. A review of
30 randomly-selected grievances reflected all written grievances were addressed in a timely
manner, and all resolutions were documented. ODO reviewed 20 randomly-selected detention
files of detainees who had filed a grievance. Each file contained a copy of the grievance. Of the
265 grievances reviewed, ODO noted 58 were complaints against staff, 47 concerned food
service, and 35 involved medical care. ODO noted among the 58 complaints against staff,
14 involved complaints of unprofessional behavior and inappropriate language used by staff,
which identified an actual officer. ODO confirmed the Warden counseled the staff members
identified in the grievances. Meal portion size was the primary complaint related to food service.
No trend was noted regarding medical care grievances. The remaining 125 grievances were
complaints related to commissary supply, clothing, property, telephone access, sanitation, and
other miscellaneous issues, with no trends identified.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY DGP-1
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(A)(1), the FOD
must ensure if an oral grievance is resolved to the detainee’s satisfaction at any level of review,
the staff member need not provide the detainee written confirmation of the outcome, however the

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staff member will document the results for the record and place his/her report in the detainee’s
detention file.
DEFICIENCY DGP-2
In accordance with the ICE NDS, Detainee Grievance Procedures, section (III)(F), the FOD must
ensure staff must forward all detainee grievances containing allegations of officer misconduct to
a supervisor or higher-level official in the chain of command. CDFs and IGSA facilities must
forward detainee grievances alleging officer misconduct to INS. INS will investigate every
allegation of officer misconduct.

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ENVIRONMENTAL HEALTH AND SAFETY (EH&S)
ODO reviewed the Environmental Health and Safety standard at JCLEC 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, and reviewed policies and documentation of inspections, hazardous chemical
management, and fire drills.
During a tour of the facility, ODO found sanitation levels in the detainee housing units and
medical department were good; however, sanitation in the food service department was poor.
Additional related information is contained in the Food Service section of this report.
Inspection confirmed all chemicals, flammables, and combustible materials are stored and issued
as required. Hazardous substances are strictly controlled and listed in the master index. The
master index includes Material Safety Data Sheets for all hazardous substances in the facility,
emergency contact information, and documentation of review. Material Safety Data Sheets are
also present in areas where substances are stored and used. ODO confirmed running inventories
of chemicals were accurate. During interviews, staff stated proper storage and handling of all
chemicals is understood.
JCLEC has an extensive fire control plan, which has been approved by the Cleburne Fire
Department. The City of Cleburne Fire Prevention Bureau completed the annual fire inspection
on January 13, 2012, and A & C Fire Protection completed the annual inspection of the fire
suppression system on June 14, 2012. An additional inspection was completed by Ideal Fire and
Security of Fort Worth, Texas on November 9, 2012. No violations of applicable regulations
were cited. The Compliance Officer provided documentation of required weekly and monthly
fire and safety inspections by facility staff. During inspection of the food service department,
ODO found the fire extinguisher immediately in front of the officer’s station was not adequately
charged. The gauge on the extinguisher clearly indicated the extinguisher was undercharged
(Deficiency EH&S-1). During the review, a fully charged extinguisher was installed.
Monthly fire drills are not conducted in all departments as required by the NDS. Instead, the
facility selects a minimum of four departments for fire drills each month. Review of
documentation found the selected departments varied; however, all departments did not have fire
drills every month (Deficiency EH&S-2). In addition, ODO confirmed detainees are directed to
remain on their bunks and are not evacuated during fire drills, regardless of whether medical or
security risks exist (Deficiency EH&S-3). Conducting fire drills in all areas of the facility every
month and evacuating detainees ensures staff and detainees know what to do in the event of a
fire emergency, and ensures emergency exits are functional.
JCLEC uses the city water and sewer system. Reports certify the drinking water is tested and
meets federal standards. Facility staff tests emergency power generators biweekly and contracts
Cantwell Power Solutions, LLC to perform quarterly generator inspections and maintenance.
Review of documentation confirmed all required power generator testing was conducted.

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The facility has a dedicated barbershop equipped with hot and cold running water, and
appropriate equipment. Barbershop sanitation guidelines are conspicuously posted in the
barbershop area. ODO observed barbers following sanitation protocols.
Review of documentation confirmed medical sharp objects and syringes are inventoried on each
shift. ODO inspected the inventories and found them accurate. Bio-hazardous medical waste is
removed by Stericycle, Inc., a licensed transporter. Blood-borne pathogens protection and cleanup kits, consisting of a spill clean-up and protective apparel, are located throughout the facility.
Detainees reported to ODO there was a presence of insects and rodents in the facility. ODO
verified JCLEC contracts with Carson Pest Management for pest control inspections and
eradication. Documentation supports that pest control inspections are conducted monthly, with
the most recent service occurring on December 27, 2012. Additional related information is
contained in the Food Service section of this report.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY EH&S-1
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(3)(d), the
FOD must ensure every institution will develop a fire prevention, control, and evacuation plan to
include, among other thing, the following: inspection, testing, and maintenance of fire protection
equipment, in accordance with NFPA codes, etc.
DEFICIENCY EH&S-2
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4), the FOD
must ensure monthly fire drills will be conducted and documented separately in each department.
DEFICIENCY EH&S-3
In accordance with the ICE NDS, Environmental Health and Safety, section (III)(L)(4)(b), the
FOD must ensure detainees will be evacuated during fire drills, except in areas where security
would be jeopardized or in medical areas where patient health could be jeopardized or, in
individual cases when evacuation of patients is logistically not feasible. Staff-simulated drills
will take place instead in areas where detainees are not evacuated.

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FOOD SERVICE (FS)
ODO reviewed the Food Service standard at JCLEC to determine if detainees are provided with
a nutritious and balanced diet, in a sanitary manner, in accordance with ICE NDS. ODO
inspected the food service area, interviewed staff, observed meal preparation and service, and
reviewed policy and relevant documentation.
Food service operations at JCLEC are managed by contractor Five Star. Staff consists of a Food
Service Manager, (b)(7)e kitchen supervisors, and a crew of(b)(7)ecounty inmate workers. No ICE
detainees work in food service. Review of documentation found all inmate workers receive
medical clearances to work in food service; however, the Five Star employees did not receive
pre-employment medical examinations (Deficiency FS-1). Medical examinations serve the
critical purpose of ensuring prospective food service workers do not have a communicable
disease in any transmissible stage or condition.
JCLEC has a satellite system of meal service involving preparation of meals in the kitchen and
delivery to housing units on insulated trays. ODO observed the preparation of trays for one noon
meal during the review, and accompanied the inmate workers transporting the carts to the
housing units. The temperature of the meal met the requirements of the NDS. The carts used to
transport the trays have open metal shelves and are not secure (Deficiency FS-2). Food carts
which are secure prevent food tampering and transference of contraband.
All visitors to the kitchen are required to wear hairnets, and beard nets for facial hair. Staff and
inmate workers wear gloves, hairnets, and beard nets for facial hair. Staff and some inmate
workers were observed wearing white kitchen uniforms. The uniforms were clean, but were
stained and discolored, and some inmate workers were not wearing kitchen uniforms
(Deficiency FS-3). All food service workers must wear uniforms which reflect high standards of
cleanliness and sanitation in the food service department. Prior to beginning their shift, inmate
workers are visually inspected by food service staff for proper grooming and any obvious health
concerns. Review of documentation found, on several occasions, food service staff did not allow
inmates to work because they had cold symptoms.
Knives are not used in the JCLEC food service department. ODO verified utensils are properly
controlled, food temperature requirements are met, and the menu is certified by a registered
dietitian based on a complete nutritional analysis of every master cycle menu. ODO sampled
food items and confirmed the meals served during the review were consistent with the menu.
The items were properly seasoned, of satisfactory taste, and portions were adequate. At the time
of the review, three ICE detainees were receiving medical diets and two ICE detainees were
receiving religious diets. ODO confirmed the special diets were approved and provided in
accordance with the standard.
The food service operation was inspected by the City of Cleburne Environmental Health
Department in April 2012. Two compliance issues were noted and corrected during the
inspection, and no follow-up inspection was required. Though no violations were cited by the
Health Department in April, at the time of this review, ODO found poor sanitation throughout
the JCLEC food service area. Review of the food service policy at JCLEC confirmed it requires

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the same sanitation and safety measures addressed in the ICE NDS; however, the conditions
observed by ODO indicate neither the policy nor the standard was followed.
Observed conditions were as follows: During the initial tour of the kitchen, ODO found the floor
was slippery, with a greasy residue. Floor corners and walls had significant dirt build-up.
Inspection of floor drains found they were obstructed with remnants of food, such as macaroni.
Food particles, and spilled and dried-on liquids were found on the surface areas of food
preparation and work tables, with no evidence they had been wiped down after use to prevent
cross-contamination. Food items were observed on the floor behind the steam kettles, ovens, and
stove. Greasy build-up was found in ventilation hoods and on hood filters, posing a significant
fire hazard. The drip pan of the stove contained burnt grease and food particles. During
inspection of storage areas, ODO observed standing water in the chemical storage room. Height
limits were not maintained for stacked boxes in the dry storage area, violating the requirement to
maintain an 18-inch clearance underneath sprinklers. Storage of boxes within the required
clearance may interfere with the effectiveness of the sprinklers if activated. In addition, ODO
observed bags of bulk food items stacked high, posing a safety hazard should they topple or
slide. Food particles and trash littered the floors of the walk-in freezer and walk-in refrigerator.
ODO noted a significant amount of frozen condensation on the ceiling, walls, and shelves of the
freezer. A heavy fog was blowing from the condenser unit. These conditions signify a
malfunction that should be identified and addressed to ensure the freezer is operating properly.
Obstructions were found in aisles and passages, creating a safety hazard and preventing egress.
The conditions described herein violate environmental and safety standards specified in the Food
Service NDS (Deficiency FS-4).
ODO noted basic supplies critical to maintaining food contact surfaces and worker sanitation
were not available. Specifically, there were no moist cloths for wiping spills on kitchenware,
food preparation table surfaces, and equipment (Deficiency FS-5); and soap dispensers at the
hand washing stations were empty (Deficiency FS-6). ODO noted food items in the dry storage
room were stored against the wall, less than six inches from the floor (Deficiency FS-7). Storage
of food items without ensuring adequate clearance from walls and the floor promotes pest and
rodent infestation in dry food items (Deficiency FS-8). Boxes of food in the dry storage area and
in the freezer were not dated, and no stock rotation system was in place to ensure usage of items
based on purchase date (Deficiency FS-9).
The Food Service Manager provided ODO with copies of a daily inspection form completed by
kitchen supervisors. None of the inspection forms noted any concerns or deficiencies. The Food
Service Manager does not conduct weekly inspections as required by JCLEC policy and the NDS
(Deficiency FS-10). ODO concludes JCLEC does not have an effective sanitation program to
ensure sanitation in the food service area is maintained at a high level at all times. Poor
sanitation jeopardizes food safety, thereby exposing detainees to the risk of food-borne illnesses.
ODO recommends the facility take immediate steps to improve sanitation in the food service
department. In addition, ODO recommends implementation and enforcement of comprehensive
sanitation measures on an on-going basis.
ODO conducted a second inspection of the kitchen on the third day of the review to determine if
any sanitation deficiencies had been corrected. ODO found boxes in the dry storage area had
been lowered below the 18-inch clearance requirement; and the walk-in cooler, the drip pan on
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the stove, and the ventilation hoods had been cleaned. Soap dispensers at hand-washing stations
had been filled, and moist cloths were available and soaking in a sanitizing solution. Boxes in
the dry storage area, the freezer, and the cooler had been dated. These actions are noted as
improvements; however, the overall sanitation of the food service area remained unsatisfactory.
During interviews, detainees reported insects were found in bran cereal served to detainees.
ODO received confirmation from the Food Service Manager and the Five Star District Manager.
Both stated insects were found in dry bran cereal served to detainees. When this was discovered,
the trays were immediately returned to the kitchen, and all detainees were issued new trays.
JCLEC management stated food service staff removed the bran cereal from the kitchen and
notified the supplier. On the third day of the ODO review, facility and food service staff notified
team members that insects had again been found in the bran cereal served that morning. JCLEC
management reported the kitchen supervisor on duty did not see any insects when meal trays
were prepared, but insects were found in the cereal when trays were delivered to the housing
units. Consequently, the entire facility was issued another breakfast tray with different items,
and the boxes containing the cereal were removed from the storage area and placed outside for
disposal. The boxes of cereal were not the same as the boxes that had previously been discarded.
ODO confirmed the delivery dates and inspected the boxes, each of which contained 22-pound
bags of cereal. Small black insects were found crawling on the flaps of one cardboard box. In
two other unopened boxes, ODO observed insects crawling on the outside and inside of the
plastic bags containing the cereal. The District Manager stated he reported the second
occurrence of infestation to the supplier, and inspected all food items stored in the area with the
bags. No insects were found. He also stated he requested the facility’s pest control contractor
conduct an immediate inspection and precautionary treatment of the storage area. As noted in
the Environmental Health and Safety section, ODO confirmed pest control services are provided
in the food service department and throughout the facility on a scheduled basis, and as needed.
Though infestation of the cereal appears to have occurred prior to delivery to JCLEC and was
unrelated to the sanitation concerns discussed in this report, ODO recommends food service staff
take steps to ensure delivered food items contain no evidence of insect or rodent infestation prior
to preparation and service to detainees.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY FS-1
In accordance with the ICE NDS, Food Service, section (III)(H)(3)(a), the FOD must ensure all
food service personnel (both staff and detainee) shall receive a pre-employment medical
examination. The purpose of this examination is to exclude those who have a communicable
disease in any transmissible stage or condition. Detainees who have been absent from work for
any length of time for reasons of communicable illness (including diarrhea) shall be referred to
Health Services for a determination as to fitness for duty prior to resuming work.
DEFICIENCY FS-2
In accordance with the ICE NDS, Food Service, section (III)(C)(2)(g), the FOD must ensure
food will be delivered from one place to another in covered containers. These may be individual
containers, such as pots with lids, or larger conveyances that can move objects in bulk, such as
enclosed, satellite-feeding carts. Food carts must have locking devices.
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DEFICIENCY FS-3
In accordance with the ICE NDS, Food Service, section (III)(H)(2)(a)(d), the FOD must ensure
all food service personnel shall wear clean garments, maintain a high level of personal
cleanliness, and practice good hygienic while on duty. Detainee food service workers shall be
provided with and use clean white uniforms while working in a food preparation area or on the
serving line.
DEFICIENCY FS-4
In accordance with the ICE NDS, Food Service, section (III)(H)(5)(a)(c-h)(k), the FOD must
ensure all facilities shall meet the following environmental standards:
a. Clean, well-lit, and orderly work and storage areas
c. Routinely cleaned walls, floors, and ceilings in all areas.
d. Ventilation hoods, to prevent grease buildup and wall/ceiling condensation that can drip into
food or onto food-contact surfaces. Filters or other grease-extracting equipment shall be
readily removable for cleaning and replacement.
e. Eighteen-inch clearance (minimum) underneath sprinkler deflectors.
f. Hazard-free storage areas:
 bags, containers, bundles, etc., stored in tiers; stacked, blocked, interlocked, and limited
in height for stability/security against sliding or collapsing
 no flammable material; no loose cords, debris, or other obvious accident-causers
(stumbling, tripping, falling, etc.); no pest-harborage.
g. Aisles and passageways shall be kept clear and in good repair, with no obstruction that could
create a hazard or hamper egress.
h. To prevent cross-contamination, kitchenware and food-contact surfaces should be washed,
rinsed, and sanitized after each use and after any interruption of operations during which
contamination could occur.
k. The premises shall be maintained in a condition that precludes the harboring or feeding of
insects and rodents. Outside openings will be protected by tight-fitting screens, windows,
and doors that are self-closing, controlled air curtains, etc.
DEFICIENCY FS-5
In accordance with the ICE NDS, Food Service, section (III)(H)(7)(e), the FOD must ensure
moist cloths for wiping food spills on kitchenware and food-contact surfaces on equipment shall
be clean, rinsed frequently in sanitizing solution, and used solely for this purpose. They shall
soak in the sanitizing solution between uses.
DEFICIENCY FS-6
In accordance with the ICE NDS, Food Service, section (III)(H)(9)(c), the FOD must ensure
soap or detergent and paper towels or a hand-drying device providing heated air shall be
available at all times in each lavatory. Waste receptacles shall be conveniently placed near the
hand-washing facilities.
DEFICIENCY FS-7
In accordance with the ICE NDS, Food Service, section (III)(J)(3)(e), the FOD must ensure the
following procedures apply when receiving or storing food: store food items is at least two
inches from the walls and at least six inches above the floor. Wooden pallets may be used to
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store canned goods and other non-absorbent containers, but not to store dairy products or fresh
produce.
DEFICIENCY FS-8
In accordance with the ICE NDS, Food Service, section (III)(J)(5), the FOD must ensure each
facility shall establish a written stock-rotation schedule.
DEFICIENCY FS-9
In accordance with the ICE NDS, Food Service, section (III)(J)(7)(a)(3), the FOD must ensure
proper care and control of the dry storeroom involves the following: vigilant housekeeping, to
keep the room clean and free from rodents and vermin. A drain for flushing is desirable.
DEFICIENCY FS-10
In accordance with the ICE NDS, Food Service, section (III)(H)(13)(a), the FOD must ensure the
facility shall implement written procedures for the administrative, medical, and/or dietary
personnel conducting the weekly inspections of all food service areas, including dining, storage,
equipment, and food-preparation areas. All components of the food service department, (ranges,
ovens, refrigerators, mixers, dishwashers, garbage disposal, etc.) require frequent inspection to
ensure their sanitary and operable condition. Staff shall check refrigerator and water
temperatures daily, recording the results.
The FSA or CS of food service shall inspect food service areas weekly.

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MEDICAL CARE (MC)
ODO reviewed the Medical Care standard at JCLEC 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 toured the clinic, reviewed policies and procedures, verified all medical
staff credentials, and interviewed health care and administrative staff. Medical records of
34 detainees falling in the following categories were examined: 20 healthy, eight chronic care,
and six sick calls. All records were spot-checked for timeliness and reviewed for transfer
documentation.
JCLEC currently holds no medical accreditations. Healthcare is provided by LSC. The clinic is
open 24 hours a day, seven days a week, and is administered by an HSA, who is an RN. The
Clinical Medical Authority is a contract physician who is on site two days a week, and on call
24 hours a day. Additional staff includes (b)(7)e LVNs, (b)(7)eMedical Assistant (b)(7)eMedication
Nurses (b)(7)e Medication Aides,
Medical Secretary, and one Medical Records Technician.
An RN is under contract to perform physical examinations and other duties when needed.
Mental health services are provided by a contract psychiatrist on site two days per month, and a
contract psychologist available two days per month and as needed via tele-medicine, also known
as a video-conference. ODO confirmed all professional licenses were primary source verified.
There were no vacancies at the time of the review. ODO determined staffing is adequate to
provide basic health services for detainees.
Review of training records for ten custody and all medical staff confirmed current certification in
cardio-pulmonary resuscitation and first aid. Detainees who require urgent or a higher level of
medical care are sent to Huguley Hospital in Burleson, Texas or Texas Health Hospital in
Cleburne, Texas. Detainees who require inpatient mental health treatment are sent to Huguley
Hospital. A local dentist provides dental services. ODO notes, according to facility policy,
routine dental care is provided to detainees in custody for 12 months rather than six months as
required by the NDS (Deficiency MC-1).
The clinic is comprised of an administrative office, three observation rooms with negative
pressure for tuberculosis isolation, one additional observation room, a secure medication room,
and medical records area. The medication room and medical records area are accessible only to
medical staff. Inspection of 34 detainee medical records found them complete. Supplementing
space in the clinic are three examination/treatment rooms located next to the detainee housing
units. Privacy of medical encounters is assured in all areas. Detainees are not charged a fee or
co-pay for medical services.
Intake screening is performed by nursing staff using an LSC form to compile a health history,
and identify chronic conditions and medication needs for each detainee. The physician is
available by telephone for consultation or for medical orders. If a language barrier exists, DHSLegacy INS Interpreter translation services are used for intake screening and all subsequent
medical encounters. Tuberculosis testing is by purified protein derivative skin test or a chest
X-ray. A review of 34 medical records confirmed completion of intake screening and
tuberculosis testing at admission in all 34 cases.

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Physical examinations are performed by an RN. ODO verified the physician trained both the
HSA/RN and contract RN in conducting physical examinations. All 34 medical records
reviewed documented completion of physical examinations within an average of eight days
following arrival, within the required 14-day timeframe. ODO confirmed the examinations were
thorough, and documented a hands-on evaluation of systems, health history, and appropriate
health care plans. The physician reviewed and co-signed all 34 physical examinations. Review
of eight chronic care records confirmed all included documentation of periodic evaluations and
appropriate laboratory testing. Consent for Treatment forms were present in all medical records
reviewed. Nurses make rounds in the SMU twice each day. ODO verified dental screenings
were performed consistent with the NDS.
Detainees access health care services by completing sick call request forms available in English
and Spanish. The forms are placed in secure boxes in each housing unit, and retrieved daily by
medical staff. Review of six sick call forms contained in detainee medical records confirmed
they were triaged for priority for care the same or next day. Sick call is conducted by an LVN
using Physician Directed Standing Orders. In the six cases reviewed, ODO verified the detainees
were seen for sick call within 48 to 72 hours of the request. Appropriate follow-up appointments
and referrals were completed as required.
Over-the-counter medications are available on the housing units and may be administered to
detainees by officers upon request. Available medications include Ibuprofen, Pepto-Bismol
tablets, and “cold busters.” Though over-the-counter, these medications may be misused and
abused; further, their use may be contraindicated by prescribed medications or the detainee’s
medical condition. ODO notes JCLEC officers are not trained in medication distribution, or
recognizing chronic use or abuse of issued medications. It is also noted medications issued to
detainees by officers are not reviewed by medical personnel or documented in individual medical
records. Officers record issuance of over-the-counter medications in the housing unit log, only.
LSC training materials state, “All medications will be passed out by medical staff.” The LSC
Medication Services policy states “All medication, including over-the-counter medication, are
documented on the individual’s Medication Administration Record.” Officer distribution of
over-the-counter medication is contrary to instructions provided by the health care provider
(Deficiency MC-2), and the current procedure poses a medical risk.
ODO confirmed a medical/psychiatric alert system is in place to ensure detainees with chronic
medical and mental health conditions receive clearance prior to release or transfer. Review of
the records of three detainees being transferred from JCLEC confirmed copies of their medical
records were placed in sealed envelopes marked “Medical Confidential,” and forwarded for
transfer with the detainees.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY MC-1
In accordance with the ICE NDS, Medical Care, section (III)(E)(2), the FOD must ensure routine
dental care may be provided to detainees for whom dental treatment is inaccessible for prolonged
periods because of detention for over six months. Routine dental treatment includes amalgam
and composite restorations, prophylaxis, root canals, extractions, x-rays, the repair and

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adjustment of prosthetic appliances and other procedures required to maintain the detainee’s
health.
DEFICIENCY MC-2
In accordance with the ICE NDS, Medical Care, section (III)(I), the FOD must ensure
distribution of medication will be according to the specific instructions and procedures
established by the health care provider. Officers will keep written records of all medication
given to detainees.

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USE OF FORCE (UOF)
ODO reviewed the Use of Force standard at JCLEC to determine if necessary use of force is
employed 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
NDS. ODO toured the facility, inspected equipment, and reviewed the local policies, use of
force files, training records, and other pertinent documentation.
JCLEC has a comprehensive written policy governing the use of force. ODO confirmed during
the 12 months preceding the CI, there were two immediate use of force incidents involving ICE
detainees. Review of documentation in both cases confirmed full compliance with the standard
and facility policy, including medical examinations of the detainees, notification of ICE, and
after action reviews. JCLEC management stated calculated force has never been used on a
detainee, because confrontation avoidance techniques have always proven successful.
Review ofb)(7)etraining records confirmed staff is trained in use of force in pre-employment
training; however, staff does not receive any training thereafter (Deficiency UOF-1). JCLEC
management stated ongoing training in use of force is not provided, because the Response Team
at the Sheriff’s Department would be contacted should the need arise to conduct a cell extraction
or other calculated use of force. ODO notes proper use of force training covers elements other
than calculated force, including confrontation avoidance, self-defense tactics, prohibited use of
force acts, and the requirement to use only the amount of force necessary to control the situation
and prevent injuries to both staff and detainees. Refresher training on an on-going basis ensures
personnel know and understand their accountability for adherence to the use of force policy.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY UOF-1
In accordance with the ICE NDS, Use of Force, section (III)(O), the FOD must ensure, to control
a situation involving an aggressive detainee, all staff must be made aware of their responsibilities
through ongoing training. All detention personnel shall also be trained in approved methods of
self-defense, confrontation avoidance techniques, and the use of force to control detainees. Staff
will be made aware of prohibited use-of-force acts and techniques.
Specialized training shall be required for certain non-lethal equipment e.g., OC spray/electronic
devices. Staff members will receive annual training in confrontation avoidance procedures and
forced cell-move techniques. Each staff member participating in a calculated use of force cell
move must have documentation of annual training in these areas.
Training should also cover use of force in special situations. Each officer must be specifically
certified to use a given device.
Among other things, training shall include:
1. Communication techniques;
2. Cultural diversity;
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3. Dealing with the mentally ill;
4. Confrontation-avoidance procedures;
5. Application of restraints (progressive and hard); and
6. Reporting procedures.

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