U.S. Department of Homeland Security
Immigration and Customs Enforcement
Office of Professional Responsibility
Inspections and Detention Oversight
Washington, DC 20536-5501

Office of Detention Oversight
Compliance Inspection

Enforcement and Removal Operations
San Diego Field Office
San Diego Contract Detention Facility
San Diego, California

September 11 – 13, 2012

COMPLIANCE INSPECTION
SAN DIEGO CONTRACT DETENTION FACILITY
SAN DIEGO FIELD OFFICE
TABLE OF CONTENTS
EXECUTIVE SUMMARY ...........................................................................................................1
INSPECTION PROCESS
Report Organization .............................................................................................................6
Inspection Team Members ...................................................................................................6
OPERATIONAL ENVIRONMENT
Internal Relations .................................................................................................................7
Detainee Relations ...............................................................................................................7
ICE PERFORMANCE-BASED NATIONAL DETENTION STANDARDS
Detention Standards Reviewed ............................................................................................8
Law Libraries and Legal Material........................................................................................9
Suicide Prevention and Intervention ..................................................................................10

EXECUTIVE SUMMARY
The Office of Professional Responsibility, Office of Detention Oversight (ODO) conducted a
Compliance Inspection (CI) of the San Diego Contract Detention Facility (San Diego CDF) in
San Diego, California, from September 11 to 13, 2012. The facility opened in September 1998,
and began housing detainees from the former U.S. Immigration and Naturalization Service and
inmates from the U.S. Marshals Service at that time. Currently, the facility houses male and
female U.S. Immigration and Customs Enforcement (ICE) detainees of all security classification
levels (Level I – lowest threat, Level II – medium threat, Level III – highest threat) for over
72 hours, as well as inmates from the U.S. Marshals Service.
The 1,040 bed, 243,808 square foot facility is owned by the County of San Diego and is operated
by Corrections Corporation of America (CCA). Of the 1,040 beds, 532 are assigned to male ICE
detainees and 132 are assigned to female ICE detainees. The facility can house additional ICE
detainees, if necessary. The average daily detainee population at San Diego CDF is 668. The
average length of stay for detainees is 21 days. At the time of inspection, the facility housed
540 male ICE detainees (350 Level I, 110 Level II, 80 Level III) and 127 female ICE detainees
(114 Level I, 11 Level II, 2 Level III).
CCA is contracted to provide detention services and security operations. In addition, CCA
oversees food service operations by its subcontractor Trinity Services Group, Inc. San Diego
CDF holds accreditations from the American Correctional Association, the National Commission
on Correctional Health Care, and the Joint Commission, formerly known as the Joint
Commission on Accreditation of Healthcare Organizations.
The Enforcement and Removal Operations (ERO) Field Office Director, San Diego, California
(FOD San Diego) is responsible for ensuring facility compliance with ICE policies and the
Performance-Based National Detention Standards (PBNDS). An Assistant Field Office
Director (AFOD) stationed at San Diego CDF is the highest-ranking ERO official at the facility.
In addition to the AFOD, ERO supervisory staff is comprised of (b)(7)e upervisory Detention and
Deportation Officers,(b)(7)e Detention Operations Supervisors, and (b)(7)e Supervisory Immigration
Enforcement Agents. ERO non-supervisory staff at San Diego CDF consists of (b)(7)e Deportation
Officers,(b)(7)eImmigration Enforcement Agents,(b)(7)eEnforcement and Removal Assistants, and
(b)(7)e Mission Support Specialist. The AFOD stated there are (b)(7)e vacant Immigration
Enforcement Agent positions. An ERO Detention Service Manager is permanently assigned and
monitors facility compliance with the PBNDS.
The Warden is the highest ranking CCA official at San Diego CDF and is responsible for
oversight of detention services, security operations, and food service. In addition to the Warden,
CCA supervisory staff includes(b)(7)eassistant wardens, the chief of security, the assistant chief of
security(b)(7)eshift supervisors, and(b)(7)eassistant shift supervisors. CCA non-supervisory staff
consists of (b)(7)edetention officers and(b)(7)eadministrative staff.
In May 2011, ODO conducted a Quality Assurance Review at San Diego CDF. Of the
23 PBNDS reviewed, 12 were in full compliance. The remaining 11 standards accounted for
18 deficiencies.

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In June 2012, ERO Detention Standards Compliance Unit contractor, the Nakamoto Group, Inc.,
conducted an annual review of the PBNDS. San Diego CDF received an overall rating of
“Meets Standards” and was found compliant with all 40 standards reviewed. One standard was
determined not applicable to San Diego CDF.
During this CI, ODO reviewed 18 PBNDS. Sixteen standards were determined to be fully
compliant; ODO found just two deficiencies. There was one deficiency in the Law Libraries and
Legal Material PBNDS; the law library was missing six required legal reference materials but
they were on order at the time of the inspection. ODO later confirmed with facility management
and the DSM that all missing materials were received and placed in the law library for use by
detainees. During the 2011 Quality Assurance Review, a deficiency for missing one item was
corrected on-site. The only other deficiency was in the Suicide Prevention and Intervention
PBNDS; two detainees on suicide watch status were not re-evaluated by qualified medical
personnel on Sundays. During the inspection, the Acting HSA prepared a memorandum, signed
by the clinical director, requiring the on-call provider to report to the facility on Sundays to reevaluate all detainees on suicide watch.
These deficiencies were discussed with San Diego CDF personnel onsite during the inspection,
as well as during the closeout briefing conducted on September 13, 2012. ERO will be provided
a copy of this report to assess the corrective actions to resolve the two identified deficiencies.
ODO attributes the high level of compliance with the PBNDS and the low number of
deficiencies identified at San Diego CDF to the presence of a dedicated ERO standards
compliance team and an on-site Detention Service Manager. ODO cites the standards
compliance program at San Diego CDF as a best practice, and notes the FOD San Diego
allocates personnel to comprise the compliance team without additional funding from ERO HQ.
San Diego CDF management maintains an electronic grievance log to document and track the
progress of all formal grievances submitted by detainees. The grievance log reflects San Diego
CDF had received and processed 308 formal grievances between January 2012 and
September 2012. The majority of the formal grievances for this time period were related to
complaints against staff, food service, and access to the law library and legal materials. None of
the grievances against staff alleged officer misconduct. The remainder of the formal grievances
were divided among issues such as mail, recreation, funds and personal property, religious
services, education programs, volunteer work, classification, personal hygiene, and visitation.
Medical grievances are deposited in dedicated lockboxes in the housing units and are picked up
by nursing staff for processing. A meeting is then scheduled with the Acting Health Services
Administrator (HSA) for the purpose of resolving the medical grievance. The meeting concludes
with the detainee receiving a carbon copy of the grievance resolution.
Medical services are provided by the ICE Health Service Corps and contractor STG
International, Inc. The clinic is open 24 hours a day, seven days a week, and is administered by
the Acting HSA, who is a registered nurse. Medical oversight is provided by the clinical
director. Medical staff includes a physician (b)(7)e dentists (b)(7)e dental assistants,(b)(7)epsychiatrist,
(b)(7)epsychologists (b)(7)e psychiatric registered nurses, (b)(7)e mid-level practitioners,(b)(7)eregistered
nurse manager(b)(7)efull-time registered nurses, (b)(7)e licensed vocational nurses,(b)(7)e medical
assistant,(b)(7)e certified nursing assistant, and (b)(7)e clerical staff. On-call coverage is provided
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24 hours a day, seven days a week by the clinical director, mid-level practitioners, and mental
health staff. All professional licenses were present and primary source verified with the issuing
state boards for authentication purposes.
Although there are numerous medical vacancies at San Diego CDF, ODO determined medical
staffing is adequate at the facility to meet health care needs of the current detainee population.
During this CI, there were (b)(7)evacancies: the HSA,(b)(7)ephysician, (b)(7)epsychiatric registered
nurse, (b)(7)e general registered nurse positions,(b)(7)emid-level practitioner, and(b)(7)e clerical
support positions. The Acting HSA stated recruitment is underway to fill all vacant positions.
He explained the delay in the hiring process is due to the length of time it takes to conduct
background checks and to grant the newly hired employees security clearances.
The clinic has three examination rooms, an urgent care room, a pharmacy, a dental suite, a
nursing station, a clerical area, three holding rooms, five mental health offices, and three
administrative staff offices. Satellite offices within each of the housing units serve as
supplemental examination rooms. The short stay unit has six rooms, with a total of eight beds,
and is equipped with negative air flow capability for tuberculosis (TB) isolation. A mental
health special housing unit consists of two 12-bed dormitories, with space designated for dining.
An ambulance for emergencies is located on-site. Detainees who require a higher level of care
receive medical treatment at Alvarado Hospital Medical Center in San Diego, California.
Detainees requiring psychiatric or mental health treatment are sent to the Alvarado Parkway
Institute in La Mesa, California. If a language barrier exists, bilingual staff or a translation
service is used.
Detainees are screened by nursing staff upon arrival using the ICE Health Service Corps
Form-795A. Screening includes detection for signs and symptoms of active TB. Detainees
receive a chest X-ray to confirm or rule out the presence of TB. ODO verified a chest X-ray was
completed in all 31 medical records reviewed. The medical records of three detainees who
required further testing to rule out the presence of TB showed one was isolated in a negative
pressure room pending clearance and two were transferred off-site because the negative pressure
rooms were not functioning at the time. The medical records further showed detainees who
presented no health issues during intake received a physical examination between five and ten
days after arrival, which is within the 14-day PBNDS requirement. Detainees needing chronic
care had a physical examination performed by a physician or a mid-level practitioner within
48 hours of admission, in compliance with the PBNDS. All chronic care patients are flagged in
the electronic medical record system with a medical or psychiatric alert.
There has never been a detainee death at San Diego CDF. There have been 18 suicide watches
and no suicide attempts since January 2012, the period for which records were available for
review. ODO verified detainees are screened for suicide potential during the intake process.
Detainees on suicide watch are housed under constant one-to-one observation in one of two
“safety cells” in the receiving area. The cells are free from any protrusions or objects that could
be used in a suicide attempt. All staff receives initial and ongoing suicide prevention training,
which includes the identification of suicide risk factors, recognizing the signs of suicidal thinking
and behavior, referral procedures, suicide prevention techniques, and responding to an
in-progress suicide attempt. As noted earlier, the facility addressed a deficiency by ensuring that
detainees would be re-evaluated by medical personnel daily, including Sundays.
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The Sexual Abuse and Assault Prevention and Intervention (SAAPI) program at San Diego CDF
meets all requirements of the PBNDS, and ODO cites implementation of this program as a best
practive. The facility has a designated SAAPI Coordinator and a Sexual Abuse Response
Team (SART). Members of the SART include the SAAPI coordinator, the victim services
coordinator, and representatives from the security, medical, and mental health departments. A
SART assures a multi-disciplinary approach to preventing and responding to sexual abuse and
assaults. Detainees are informed of the SAAPI program in the detainee handbook, during
orientation, and by postings in the housing units. The information is provided in English,
Spanish, and Chinese. In addition, detainees are given a brochure with information and guidance
for reporting any kind of sexual abuse or misconduct by other detainees or staff.
Staff is required to attend pre-service, quarterly, and annual training on the SAAPI program. The
training curriculum is comprehensive and includes all elements required in the PBNDS. Staff
interviews demonstrated they are knowledgeable about the SAAPI program and how to handle
information received concerning possible sexual abuse or assault. Posters pertaining to the
Prison Rape Elimination Act and sexual harassment are conspicuously displayed throughout the
facility in staff and detainee-accessible areas.
Detainees are screened during the intake process for sexual abuse victimization history, as well
as predatory history to determine potential sexual aggressors. The facility separates detainees
with a history of predatory or abusive sexual behavior from detainees with a history of
victimization. Staff enters information on detainees in these categories in a computer program to
prevent intermixing of victims and potential aggressors.
The SAAPI coordinator stated there were eight reported incidents of sexual abuse and assault
between January 2012 and September 2012. The PBNDS and local facility policy were followed
in all incidents. ODO reviewed each case and noted all documentation was complete and
included all required notifications. All reported victims received a medical examination. The
SAAPI coordinator oversaw the investigations and implemented appropriate procedures to
ensure preservation of evidence, statements, and other relevant information. All eight incidents
were investigated by the San Diego County Sheriff’s Department (SDCSD), and ERO personnel
assigned to San Diego CDF were kept informed as each investigation progressed. Seven of the
incidents were determined to be unsubstantiated by SDCSD. One incident was substantiated by
SDCSD and resulted in disciplinary action against the detainee identified as the perpetrator.
At the time of inspection, there were 24 detainees in segregation at San Diego CDF: 18 detainees
in administrative segregation and six detainees in disciplinary segregation. ODO confirmed the
administrative special management unit (SMU) and the disciplinary SMU were well-lit,
temperature-appropriate, and sanitary. ODO reviewed SMU housing records and confirmed
detainee living and health conditions were regularly monitored by custody, medical, and
administrative staff. ODO also verified the FOD was notified of all detainees placed in the SMU
for more than 30 consecutive days.
Facility management allows detainees to have formal and informal interaction with CCA and
ERO staff. Detainees submit written questions, requests, or concerns to CCA and ERO staff by
completing request forms available upon request in each housing unit. Secure drop boxes for
submitting the request forms are located throughout the facility. ODO verified detainee requests
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are documented and recorded in a logbook, and copies of the requests are placed and maintained
in individual detention files.
ODO reviewed Facility Liaison Visit Checklists from January 2012 to September 2012, and
confirmed ERO officers consistently conduct weekly announced and unannounced visits with
detainees to assess the living conditions at the facility, including the SMU to determine if a
detainee’s placement in the SMU is still warranted. ODO also verified ERO officers consistently
conduct random tests of detainee-accessible telephones on a weekly basis to ensure operability.
San Diego CDF has a comprehensive use of force policy addressing all requirements of the
PBNDS, including confrontation avoidance and using force only as a last resort. Staff receives
training in use of force and the application of restraints. Protective equipment is readily
accessible to team members and is stored in a secure room. There have been 16 uses of force
involving detainees during the past year: two calculated uses of force and 14 immediate uses of
force. Written documentation for all 16 incidents demonstrated staff complied with the PBNDS
and facility policy. ODO reviewed the video recordings of the two calculated use of force
incidents and noted proper application of the team technique, including the use of protective gear
by team members. Recording of immediate use of force incidents is not required by the PBNDS;
however, staff is trained to record immediate use of force incidents whenever possible. ODO
reviewed the video recordings of three immediate uses of force and noted staff used the
appropriate amount of force necessary to contain the situation. ODO verified detainees undergo
medical examinations following all uses of force, and a thorough after-action review is
conducted in each case.

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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 San Diego CDF. In addition, ODO may focus its
inspection based on detention management information provided by 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 San Diego CDF to determine compliance with 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 HQ staff to prepare for the site visit at San Diego CDF.

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. 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)
Supervisory Special Agent (Section Chief)
Special Agent
Special Agent
Contract Inspector
Contract Inspector
Contract Inspector

6

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

San Diego Contract Detention Facility
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OPERATIONAL ENVIRONMENT
INTERNAL RELATIONS
ODO interviewed the Warden, an Assistant Warden, the AFOD, a Supervisory Detention and
Deportation Officer, and a Detention Operations Supervisor. During the interviews, ERO and
CCA leadership stated the working relationship between the two entities is excellent, and the
morale of ERO and CCA staff is high. The Warden and the Assistant Warden both stated 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.

DETAINEE RELATIONS
ODO interviewed 25 randomly-selected male detainees (18 Level I, 4 Level II, 3 Level III) and
five randomly-selected female detainees (4 Level II, 1 Level III) to assess the overall living and
detention conditions at San Diego CDF. ODO received no complaints concerning access to the
law library and legal materials, issuance and replenishment of basic hygiene items, food service,
medical care, sending and receiving mail, recreation, religious services, visitation, the grievance
system, telephone access, issuance of detainee handbooks, or staff-detainee communication. All
detainees interviewed stated they had not been strip searched and had not observed or
experienced any verbal, physical, or sexual abuse by staff at San Diego CDF.

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ICE PERFORMANCE-BASED
NATIONAL DETENTION STANDARDS
ODO reviewed a total of 18 PBNDS and found San Diego CDF fully compliant with the
following 16 standards:
Correspondence and Other Mail
Detainee Handbook
Detention Files
Disciplinary System
Environmental Health and Safety
Food Service
Grievance System
Hold Rooms in Detention Facilities
Hunger Strikes
Medical Care
Personal Hygiene
Sexual Abuse and Assault Prevention and Intervention
Special Management Units
Staff-Detainee Communication
Tool Control
Use of Force and Restraints
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 two areas:
Law Libraries and Legal Material
Suicide Prevention and Intervention
Findings for each of these standards are presented in the remainder of this report.

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LAW LIBRARIES AND LEGAL MATERIAL (LL&LM)
ODO reviewed the Law Libraries and Legal Material standard at San Diego CDF to determine
whether detainees have access to a law library, legal materials, courts, counsel, and document
copying equipment to facilitate the preparation of legal documents, in accordance with the ICE
PBNDS. ODO interviewed detainees and staff, reviewed local policies and the facility’s local
detainee handbook, and toured and observed the facility’s law library.
There are two libraries in the facility. The main library is used by the general population; the
second library is in the SMU for use by detainees who are placed in segregation. Both libraries
are large enough to accommodate access for all detainees, and are sufficiently equipped with
adequate seating and workspace. Both libraries are well-lit and reasonably isolated from noisy
areas. The local detainee handbook addresses the rules and procedures governing the law
library and legal materials in the facility. The law libraries are open Monday through Friday
from 7:20 a.m. to 10:20 p.m. A schedule is posted in each housing unit indicating the
designated times assigned for each housing unit, including the SMU. A detainee can request
additional time in the law library beyond the five-hour minimum required by the PBNDS by
submitting a request through the housing unit manager.
The computers in the law libraries have Lexis/Nexis legal resource software installed and
updated on August 31, 2012. The main law library is also equipped with typewriters. When
equipment is damaged, a work order is prepared to have the equipment repaired. Adequate
supplies of writing materials are available to detainees. Staff continuously supervises detainees
while they are using the libraries; this is done to prevent vandalism. A notary public, certified
mail, and other such services to pursue a legal matter are available to detainees.
Attachment A from the PBNDS, listing all law books in Lexis/Nexis, is posted. However,
ODO confirmed the law library’s legal reference materials did not contain the following, either
in hard-copy format or electronically: Immigration Law and Defense, 3rd Edition; Guide for
Immigration Advocates; Human Rights Watch – World Report; American Immigration Lawyers
Association Asylum Primer, 4th Edition; Legal Research in a Nutshell, 9th Edition; and Legal
Research, Writing, and Analysis (Deficiency LL&LM-1). According to San Diego CDF staff,
these materials were on order as of September 9, 2012. ODO later confirmed with facility
management and the DSM that all missing materials were received and placed in the law
library for use by detainees. A similar deficiency was noted during the 2011 Quality Assurance
Review, but was corrected on-site when ERO staff placed a hard copy of the Affirmative
Asylum Procedures Manual in the law library.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY LL&LM-1
In accordance with the ICE PBNDS, Law Libraries and Legal Material, section (V)(E)(2)(b)(2),
the FOD must ensure, as an alternative to obtaining and maintaining the paper-based publications
in Attachment A, a facility may substitute the Lexis/Nexis publications on CD ROM. Any
materials listed in Attachment A which are not loaded onto the Lexis/Nexis CDROM must be
maintained in paper form.

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SUICIDE PREVENTION AND INTERVENTION (SP&I)
ODO reviewed the Suicide Prevention and Intervention standard at San Diego CDF to determine
whether the health and well-being of detainees are protected by training staff in effective
methods of suicide prevention, in accordance with the ICE PBNDS. ODO inspected the suicide
watch cells, interviewed medical staff and the training manager, and reviewed five suicide watch
records, suicide prevention policies and training curriculum, and(b)(7)estaff training records.
All staff receives initial and ongoing suicide prevention training, which includes the
identification of suicide risk factors, recognizing the signs of suicidal thinking and behavior,
referral procedures, suicide prevention techniques, and responding to an in-progress suicide
attempt. Review of(b)(7)etraining files confirmed staff has completed initial and ongoing suicide
prevention training covering all elements required by the PBNDS.
ODO verified detainees are screened for suicide potential during the intake process. Detainees
on suicide watch are housed under constant one-to-one observation in one of two “safety cells”
in the receiving area. The cells are suicide-resistant and free from any protrusions or objects that
could be used in a suicide attempt.
There has never been a detainee suicide at San Diego CDF. ODO confirmed there were no
suicide attempts and 18 suicide watches during 2012. According to the compliance officer, all
documentation of suicide attempts and suicide watches prior to 2012 has been archived and was
not available for review.
Consistent with the PBNDS, San Diego CDF policy requires “[a]ll patients on Suicide
Watch/Constant Observation will be evaluated daily by the mental health provider or designee.”
ODO examined five of 18 medical records of detainees who were placed on suicide watch and
noted that two detainees were not re-evaluated on a Sunday while on suicide watch status
(Deficiency SP&I-1). San Diego CDF management stated qualified medical staff is not on duty
on Sundays. Prior to the conclusion of this CI, the Acting HSA prepared a memorandum, signed
by the clinical director, requiring the on-call provider to report to the facility on Sundays to reevaluate all detainees on suicide watch.

STANDARD/POLICY REQUIREMENTS FOR DEFICIENT FINDINGS
DEFICIENCY SP&I-1
In accordance with the ICE PBNDS, Suicide Prevention and Intervention, section (V)(D), the
FOD must ensure detainees who are placed on suicide watch are to be re-evaluated by
appropriately trained and qualified medical staff on a daily basis and this re-evaluation is
documented in the detainee’s medical record.

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