S.E. Williams

On September 27, the U. S. Department of Homeland Security Office of the Inspector General (OIG), published a “Management Alert” calling for immediate remedial action at the Adelanto Immigration Processing Center in San Bernardino County. 

The report highlighted several very serious issues identified during an unannounced OIG inspection of the Adelanto facility in May of this year. The findings were in violation of ICE’s Performance-Based National Detention Standards and exposed immigrant detainees to significant health and safety risks. 

They included the discovery of nooses in detainee cells, a gross number of untimely and inadequate medical/dental care, and the improper and premature use of restrictive, disciplinary segregation.  

“ICE must ensure the Adelanto Center complies with detention standards to establish an environment that protects the safety, rights, and health of detainees,” stated John V. Kelly, Senior Official Performing the Duties of the Inspector General. He stressed, “Mitigation and resolution of these issues require ICE’s immediate attention.”

The Adelanto Center is one of more than 200 detention centers and jails that make up the U.S. Immigration and Customs Enforcement’s (ICE) national detention system. Men, women, and children apprehended by either U.S. Customs and Border Protection or ICE, are normally placed in removal proceedings and as they work through the process are detained in facilities like Adelanto that are run by ICE or contracted to private prison corporations. 

Though such detention is civil, the ICE detention system is built and operated on a correctional model. As a result, human rights advocates and others believe this approach is in direct contrast and conflicts with the intent of immigration detention.

The Adelanto Immigration Center is run by the GEO Group, a private prison corporation with a long history of having to close facilities; being sued for horrific living conditions by inmates; being the subject of several wrongful death complaints; in addition to being the subject of a class-action lawsuit over conditions in a youth correctional facility it ran in Mississippi, and the list goes on. . . 

“Once something is privatized, as these systems are, it’s all about greed and money; they are the sole driver. These systems do not care about your humanity.”
Phillip Agnew, Dream Defenders

Despite its abysmal history, GEO Group’s fortunes have grown significantly since 2016. According to the Center for Responsive Politics, it is America’s largest for-profit prison operator and a multimillion-dollar beneficiary of the Trump administration’s aggressive zero-tolerance immigration policy. Not surprisingly, the corporation gave $225,000 to a pro-Trump super PAC during the 2016 presidential campaign and donated another $250,000 to Trump’s inauguration. 

GEO’s nearly half million dollars’ investment in Trump has resulted in a lucrative quid pro quo for the prison operator. Over the last two fiscal years, it has benefited from $560 million in ICE Contracts. 

However, it is clear from the OIG findings at the Adelanto facility, GEO continues to fall far short of required expectations in ways that not only deviate from federal/state policy but according to critics, also shock the sensibilities of most reasonable and compassionate human beings. 

Commenting on the OIG findings Michael Kaufman of Sullivan & Cromwell Access to Justice and Senior Staff Attorney at the American Civil Liberties Union Foundation of Southern California stated, “ICE has ignored the ACLU’s repeated complaints about abuse and neglect at Adelanto. The OIG’s disturbing report reveals that GEO and ICE officials continue to disregard immigration detainees’ well-being, often with tragic consequences.”

Consider the following, at the time of OIG’s unannounced inspection in May, there were 307 contract guards who oversaw 1,659 detainees housed in different facilities around the center. Issues observed by OIG inspectors not only violated ICE detention standards, they represented significant threats to the safety, rights, and health of detainees.”  

One of the most significant findings centered on several nooses made from braided sheets found hanging in the facility. Although ICE standards prohibit detainees from hanging or draping objects from their beds, fixtures, or other furniture. In about 15 of 20 male detainee cells, they observed braided bedsheets, referred to as “nooses” by center staff and detainees, hanging from vents. 

The contract guard who escorted the OIG inspectors removed the first noose found but stopped after realizing many cells had nooses hanging from the vents. “We also heard the guard telling some detainees to take the sheets down,” an inspector noted.  

During a series of interviews, the detainees provided inspectors with a range of reasons for braiding and hanging bedsheets in the cells. One said, “I’ve seen a few attempted suicides using the braided sheets by the vents and then the guards laugh at them and call them ‘suicide failures’ once they are back from medical.” 

Others said the braided sheets can be easily unfurled to temporarily create privacy within cells, while others reported tying the braided sheets from one bedpost to another to serve as a clothesline. 

“ICE has not taken seriously the recurring problem of detainees hanging bedsheet nooses at the Adelanto Center; this deficiency violates ICE standards,” the OIG report stressed. Comments from one of the guards confirmed the nooses are a daily issue and very widespread. When guards were asked why they did not remove the bed sheets, they stressed it was not a high priority. 

In March 2018, an ICE contractor who conducts daily center checks reported that detainees were hanging bedsheets in their cells and began sending a weekly deficiency report to ICE for action. According to a senior ICE official, however, “local ICE management at Adelanto does not believe it is necessary or a priority to address the braided sheets issue.” OIG adamantly disagreed and insisted ICE make this issue a priority because it represents a potential risk to assist suicide attempts. 

In March 2017, a 32-yearold male died at an area hospital after he was found hanging from his bedsheets in an Adelanto cell. In the months after this suicide, ICE compliance reports documented at least three suicide attempts by hanging at Adelanto, two of which specifically used bedsheets. In addition, media reports based on 911 call logs pointed to four other suicide attempts at Adelanto between December 2016 to July 2017. In total, these reports represent at least seven suicide attempts at the facility from December 2016 to October 2017. 

Kelly noted in the agency’s report, “ICE’s lack of response to address this matter at the Adelanto Center shows a disregard for detainee health and safety.” 

ICE/GEO’s disregard for the health and safety of Adelanto detainees was further illuminated by their failure to provide timely and adequate medical/dental care. “We observed medical staff performing limited checks on detainees in disciplinary segregation, which do not effectively ensure detainee well-being. Based on interviews with detainees and medical staff and a review of independent reports, we concluded that detainees do not have timely access to proper medical care.” 

OIG inspectors observed Adelanto Center medical providers, including nurses, physicians, and mental health workers, conduct cursory walk-throughs. For example, inspectors reported watching two doctors stamp their names on detainee records, which hang outside each detainee’s cell, indicating that they visited with the detainee without having any contact with the individuals in the cells.

Inspectors also watched as a doctor asked at least four detainees if they were “ok” but never waited for a response nor conduct any further interaction. Inspectors were later told by the guards the detainees did not speak English. 


In general, according to the report, medical care for Adelanto detainees was both delayed and inadequate. From November 2017 to April 2018, detainees filed 80 medical grievances (about 34 percent of all grievances filed) with the center for not receiving urgent care, not being seen for months for persistent health conditions, and not receiving prescribed medication—often being forced to wait weeks and even months. A review of deaths at the facility since 2015, cited medical care deficiencies related to a failure to provide necessary and adequate care in a timely manner.

Those requiring dental care don’t fare any better. A review of all requests for fillings since 2014, found although the center’s two dentists identified cavities and placed detainees on a wait-list for fillings, no detainees had received fillings in the last 4 years. One detainee reported having multiple teeth fall out while waiting more than two years for cavities to be filled.

One dentist interviewed by the inspectors said he only provides “palliative care,” even suggesting “detainees could use string from their socks to floss if they were dedicated to dental hygiene.”

Some believe the blatant disregard for human life and human dignity at the Adelanto Center is unconscionable. This includes the facility’s tendency to place detainees in disciplinary segregation prematurely and inappropriately.  OIG inspectors found 14 detainees in disciplinary segregation during its visit—all 14 were placed there before they were found guilty of a prohibited act or rule. This represented a direct violation of government policy. 

One of the most egregious violations in this regard involved a disabled detainee who asked to be placed in administrative segregation but was placed in disciplinary segregation instead. He was held there inappropriately for nine days until during their inspection, OIG inspectors raised the issue to the center’s Medical Health Services Administrator. 

“Based on our file review,” they reported, “in those nine days, the detainee never left his wheelchair to sleep in a bed or brush his teeth. During our visit, we saw that the bedding and toiletries were still in the bag from his arrival. We also observed medical staff just looking in his cell and stamping his medical visitation sheet rather than evaluating the detainee, as required by ICE standards.”

Commenting on this specific incident Kaufman stated, “Some of the examples in the OIG report bordered on the macabre.” 

“Although this form of civil custody should be non-punitive, some of the center conditions and detainee treatment we identified during our visit and outlined in this management alert are similar to those one may see in criminal custody,” Kelly admonished as he called for ICE’s immediate attention to these issues. 

ICE/GEO has acted to mitigate issues identified in the report, but the OIG called for additional more expansive action. ICE has agreed to comply with the OIG recommendation for an immediate, full review of the Adelanto ICE Processing Center and the GEO Group’s management of the center to ensure compliance with ICE’s 2011 Performance-Based National Detention Standards. 

ICE has also implemented a Special Assessment Review in response to the OIG Management Alert and ICE Health Services Corps will meet to discuss an ongoing plan for providing technical assistance, monitoring and oversight to further ensure corrective actions are completed. 

These efforts began October 10th and are expected to be completed by January 31, 2019.