Inspection of Adelanto ICE Detention Facility Finds Nooses & Major Health Concerns
Several nooses were found in cells at the Adelanto GEO ICE Detention Center.

Inspection of Adelanto ICE Detention Facility Finds Nooses & Major Health Concerns

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ADELANTO – The Office of the Inspector General released a report of their findings from an unannounced inspection of the Adelanto ICE Processing Center.

The findings during the inspection on May 1, 2018, included nooses made of bed sheets in the cells, overly restrictive segregation, and untimely/inadequate detainee medical care; many of which were mentioned after numerous detainee deaths. The inspection was part of an ongoing review of  U.S. Immigration and Customs Enforcement (ICE) detention facilities. Several serious issues were noted during the visit to the Adelanto facility, violating ICE’s 2011 Performance-Based National Detention Standards. These standards were to ensure the rights, health, and safety of those detained at the facility.

The inspectors noted that 307 guards were responsible for overseeing the 1659 detainees at the center. Sixteen housing units, with 18 cells each were built to hold 4-8 detainees per cell are on the west side of the property. In addition, there were two open-bay housing modules on the east side of the property. These modules each had 7 dormitories where approximately 95 detainees were housed in each dormitory.

While guards escorted the inspectors, they found located many nooses made from braided bed sheets were found hanging from cell vents. These posed a serious risk and are against ICE’s 2011 standards. It was noted that around 15 of the 20 cells visited on the four west side housing units had what the staff referred to as “nooses”.  The guard said that the nooses are “widespread” and were a “daily issue”, according to inspectors from the Inspector General’s Office. They added that removal of these was not a high priority.

The detainees said that there were several reasons for the braided sheet nooses, including for temporary privacy in the bunk or bathroom. Some also reported tying the sheets from one bedpost to another to use as a clothesline. 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,” one detainee told inspectors.

A 32-year-old man was found hanging from bed sheets in his Adelanto cell in March 2017. Three attempts were made, all by hanging in Adelanto, two using bed sheets. Several other suicide attempts were made between December 2016 to July 2017.  

Disciplinary segregation is a practice used to separate detainees who committed a serious prohibited act or violated a rule. In addition, some detainees are put on administrative segregation for medical reasons or to protect themselves or others. Those placed in administrative segregation and those in disciplinary segregation are to be prevented from commingling. The use of restraints is not to be used on detainees whenever possible. Detainees who can not speak English or are blind or deaf should be provided with communication assistance.

During the inspection, it was learned that a disabled detainee had asked to be placed in administrative segregation and was placed in disciplinary segregation. Although restraining detainees whenever they are outside of their cells, detainees were seen all detainees in disciplinary segregation were placed in restraints by GEO Group contract guards. The center reported using the restraints for “security reasons”.

Fourteen detainees were in disciplinary segregation, all fourteen inappropriately placed before they were found guilty of a prohibited act or rule violation. Also, one detainee who requested placement in administrative segregation was being held in disciplinary segregation. “ICE standards state that a detainee shall be placed in disciplinary segregation only after a disciplinary hearing panel finds the detainee guilty of a prohibited act or rule violation and the disciplinary panel chair completes a written order for segregation,” the Officer Inspector General report said. “Yet, based on file reviews and interviews with GEO Group staff, the Adelanto Center places detainees in disciplinary segregation prior to a guilty finding and a written order for segregation. GEO Group staff indicated it is the center’s practice to place all detainees directly in disciplinary segregation after an alleged incident to prevent further issues with the detainee.”

Inadequate access to medical and dental health care was noted in the report. In the period from November 2017 to April 2018, 80 medical grievances were filed. This equates to around 34% of all grievances filed. In the grievances, detainees report not receiving urgent care, not being seen for a period of months for persistent health conditions, and not receiving prescribed medications. Four of thirteen detainees interviewed during the inspections reported waiting anywhere from weeks to months to see a doctor. They also said that scheduled appointments have been canceled without explanation. A quality improvement investigation in 2017, of the medical unit, showed that 60-80 clinic appointments were canceled due to contract guards not being available to take detainees from their cells to the appointments. Three Adelanto Center detainees reportedly died since the 2015 (fiscal year). Necessary and adequate care in a timely manner was cited in the investigation findings.

Basic Dental standards are expected of detention facilities, which include checkups, cleaning, and procedures for detainees in detention for 6 months or more. The report found that the Adelanto Center does not count the entire time the detainee spent in other ICE facilities in their calculations of the 6 months. Once the detainee has been in the Adelanto Center for 6 months, they are put on a waitlist for dental care. “Records indicated and center staff corroborated that the center was waiting for detainees to leave rather than providing cleanings,” the Officer Inspector General report said. Only two dentists staffed at the Adelanto Center are to provide care for nearly 2000 detainees. Center logs show that no detainees have received cleanings for nearly four years. It was also learned that requests for fillings since 2014 remained on the waitlist with no detainees receiving fillings during the four-year period.

These practices, according to one of the interviewed detainees was the cause of multiple teeth falling out as he waited over 2 years for fillings. “When we asked one of the dentists why fillings were not performed, he said he barely has time to do cleanings,” said the Officer Inspector General report. Based on the inspection, it was recommended that ICE reviews the Adelanto ICE Processing Center and GEO Group’s management immediately. They should work to ensure compliance with the ICE Performance-Based National Detention Standards.

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  • Nooses in Cell at Adelanto ICE Detention Center: California Office of Inspector General
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