Management Alert – 

Issues Requiring 

Action at the Adelanto 

ICE Processing 

Center in Adelanto, 

California 

September 27, 2018 

OIG-18-86 
 

 

 

 

 

DHS OIG HIGHLIGHTS

Management Alert – Issues Requiring

Action at the Adelanto ICE Processing

Center in Adelanto, California 

September 27, 2018 

Why We Did 

This Alert 

This Alert is part of an ongoing 

review to inspect U.S. Immigration 

and Customs Enforcement (ICE) 

detention facilities. We conducted an 

unannounced visit to the Adelanto 

ICE Processing Center and, using 

ICE’s 2011 Performance-Based 

National Detention Standards, we 

identified serious violations that are 

important to inform ICE of 

immediately. 

What We 

Recommend 

We recommend that ICE conduct a 

full review of the Adelanto ICE 

Processing Center and the GEO 

Group’s management of the center 

immediately to ensure compliance 

with ICE’s 2011 Performance-Based 

National Detention Standards. As 

part of this assessment, ICE must 

ensure compliance with the 

standards addressing personal 

housekeeping requirements, 

segregation, and medical care. 

For Further Information: 

Contact our Office of Public Affairs at 

(202) 981-6000, or email us at 

DHS-OIG.OfficePublicAffairs@oig.dhs.gov 

What We Found 

During our May 2018 unannounced inspection 

of the Adelanto ICE Processing Center in 

Adelanto, California, we identified a number of 

serious issues that violate ICE’s 2011 

Performance-Based National Detention Standards 

and pose significant health and safety risks at 

the facility. Specifically, we are concerned about 

the following: 

x Nooses in Detainee Cells 

x Improper and Overly Restrictive 

Segregation 

x Untimely and Inadequate Detainee 

Medical Care 

ICE must ensure the Adelanto Center complies 

with detention standards to establish an 

environment that protects the safety, rights, and 

health of detainees. Mitigation and resolution of 

these issues require ICE’s immediate attention 

and increased engagement with the center and 

its operations. 

ICE Response 

ICE concurred with the recommendation and is 

implementing corrective actions to ensure the 

Adelanto ICE Processing Center meets required 

detention standards. ICE reported that it will 

complete a full inspection of the Adelanto facility 

and a Special Assessment Review to ensure 

concerns identified in this report are fully 

inspected and addressed. We consider the one 

recommendation resolved and open. 

www.oig.dhs.gov OIG-18-86 
 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Washington, DC 20528 / www.oig.dhs.gov 

6HSWHPEHU
 

MEMORANDUM FOR: Ronald D. Vitiello 

Senior Official Performing the Duties of Director 

U.S. Immigration and Customs Enforcement 

FROM: John V. Kelly 

Senior Official Performing the Duties of the Inspector 

General 

SUBJECT: Management Alert – Issues Requiring Action at the 

Adelanto ICE Processing Center in Adelanto, California 

For your action is our final report, Management Alert – Issues Requiring Action 

at the Adelanto ICE Processing Center in Adelanto, California. We incorporated 

the formal comments provided by your office. 

The report contains one recommendation aimed at improving compliance with 

these U.S. Immigration and Customs Enforcement (ICE) detention standards 

and to strengthen its oversight of the Adelanto ICE Processing Center. Your 

office concurred with the one recommendation. 

Based on information provided in your response to the draft report, we 

consider recommendation 1 open and resolved. Once your office has fully 

implemented the recommendation, please submit a formal closeout letter to us 

within 30 days so that we may close the recommendation. The memorandum 

should be accompanied by evidence of completion of agreed-upon corrective 

actions. Please send your response or closure request to 

OIGInspectionsFollowup@oig.dhs.gov. 

Consistent with our responsibility under the Inspector General Act, we will 

provide copies of our report to congressional committees with oversight and 

appropriation responsibility over the Department of Homeland Security. We will 

post the report on our website for public dissemination. 

Please call me with any questions, or your staff may contact 

Jennifer L. Costello, Chief Operating Officer, or John D. Shiffer, Chief 

Inspector, at (202) 981-6000. 

www.oig.dhs.gov 
OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Background 

The Adelanto ICE Processing Center, owned and operated by the GEO Group, 

Inc., houses up to 1,940 U.S. Immigration and Customs Enforcement (ICE) 

detainees through an Intergovernmental Service Agreement.1 Based on this 

agreement, the Adelanto Center must comply with ICE’s 2011 PerformanceBased National Detention Standards, as revised in December 2016. These 

detention standards establish requirements for areas such as: 

x environmental health and safety: e.g., cleanliness, sanitation, security, 

admission into facilities, classification, detainee searches, segregation2 

(Special Management Units), and disciplinary system; 

x detainee care: e.g., food service, medical care, and personal hygiene; 

x activities: e.g., religious practices, telephone access, and visitation; and 

x grievance system. 

In May 2018, we visited the Adelanto ICE Processing Center as part of our 

latest round of unannounced spot inspections. At the time, 307 contract 

guards oversaw 1,659 detainees housed in different facilities around the 

center. On the west side of the center, detainees resided in 16 housing units 

consisting of 18 cells each that can hold approximately 4 to 8 detainees per 

cell. On the east side of the center, detainees resided in 2 open bay housing 

modules with 7 dormitories and an average of 94 detainees per dormitory. 

While at the center, we identified serious issues relating to safety, detainee 

rights, and medical care that require ICE’s immediate attention. These issues 

not only constitute violations of ICE detention standards but also represent 

significant threats to the safety, rights, and health of detainees. 

Nooses Made from Braided Bed Sheets Present Ongoing Safety and 

Security Risks 

ICE standards3 prohibit detainees from hanging or draping objects from their 

beds, fixtures, or other furniture. However, in about 15 of the approximately 20 

male detainee cells we visited within 4 housing units on the west side, we 

observed braided bedsheets, referred to as “nooses” by center staff and 

 1 The Intergovernmental Service Agreement (IGSA) was established between the City of 

Adelanto and ICE. 

2 Segregation is the process of separating certain detainees from the general population for 

administrative, disciplinary, or protective reasons. 

3 ICE, Performance-Based National Detention Standards, 2011, Section 5.8.V.C, Voluntary Work 

Program, Expected Practices, Personal Housekeeping Required (Revised Dec. 2016). The 

pertinent part of this standard requires detainees to maintain their immediate living areas in a 

neat and orderly manner by making their bunk beds daily; stacking loose papers; keeping the 

floor free of debris and dividers free of clutter; and refraining from hanging/draping clothing, 

pictures, keepsakes, or other objects from beds, overhead lighting fixtures, or other furniture. 

www.oig.dhs.gov 2 OIG-18-86 
Nooses Found 

Hanging in Cells 

Variety of Nooses 

Found 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

detainees, hanging from vents (see figure 1). The contract guard escorting us 

during our visit removed the first noose found in a detainee cell, but stopped 

after realizing many cells we visited had nooses hanging from the vents. We 

also heard the guard telling some detainees to take the sheets down. 

During our interviews, detainees provided a range of reasons for braiding and 

hanging bedsheets in the cells. One detainee told us, “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.” Four 

detainees told us the braided sheets can be easily unfurled to temporarily 

create privacy within the cell, specifically the bathroom area or individual bunk 

area. Two detainees reported tying the braided sheets from one bedpost to 

another to serve as a clothesline. 

Figure 1. Nooses hanging from vents in detainee cells observed by the Office of Inspector General 

(OIG) at the Adelanto Center on May 1, 2018. 

Source: OIG 

ICE has not taken seriously the recurring problem of detainees hanging 

bedsheet nooses at the Adelanto Center; this deficiency violates ICE standards. 

According to the guard escorting us, the nooses are a daily issue and very 

widespread. When we asked two contract guards who oversaw the housing 

units why they did not remove the bed sheets, they echoed it was not a high 

priority. In March 2018, an ICE contractor who conducts daily center checks 

noted 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. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

ICE must prioritize addressing the issue of sheets hanging in detainee cells, as 

they represent the potential to assist suicide acts. In March 2017, a 32-yearold male died at an area hospital after being 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. Media reports based on 911 call logs 

indicate at least four other suicide attempts at the center from December 2016 

to July 2017.4 In total, these reports represent at least seven suicide attempts 

at the Adelanto Center from December 2016 to October 2017. Nationwide, selfinflicted strangulation accounts for 4 of the 20 detainee deaths reported 

between October 2016 to July 2018, according to ICE news releases. The most 

recent ICE detainee death, on July 10, 2018, at the Stewart Detention Facility 

in Georgia, again highlights the current need to prioritize this issue, as ICE 

preliminarily attributed that death to self-inflicted strangulation. ICE’s lack of 

response to address this matter at the Adelanto Center shows a disregard for 

detainee health and safety. 

Inappropriate Segregation Restricts Detainee Rights 

Detainees may be separated from the center’s general population because they 

committed a serious prohibited act or rule violation (disciplinary segregation)5 

or to protect themselves, others and property, for medical reasons, and for 

secure and orderly facility operations (administrative segregation). ICE 

standards6 obligate the Adelanto Center to meet numerous requirements for 

segregation, including: 

x preventing the commingling of detainees in administrative and 

disciplinary segregation; 

x placing detainees in disciplinary segregation only after they are found to 

have committed a prohibited act and only when alternative dispositions 

may inadequately regulate the detainee’s behavior; 

x avoiding the use of restraints on detainees; 

 4 Paloma Esquivel, ‘We don’t feel OK here’: Detainee deaths, suicide attempts and hunger strikes 

plague California immigration facility, LOS ANGELES TIMES (Aug. 8, 2017), 

http://www.latimes.com/local/lanow/la-me-ln-adelanto-detention-20170808-story.html. 5 A prohibited act or rule violation must be classified at a “greatest” (e.g., killing, rioting, 

assault), “high” (e.g., fighting, drug possession, bribery), or “high-moderate” (e.g., theft, refusal 

to obey staff or officer orders, gambling) level as defined in ICE standards. 

6 ICE, Performance-Based National Detention Standards, 2011, Section 2.12, Special 

Management Units (Revised Dec. 2016). “This detention standard protects detainees, staff, 

contractors, volunteers and the community from harm by segregating certain detainees from 

the general population in Special Management Units with an Administrative Segregation 

section for detainees segregated for administrative reasons and a Disciplinary Segregation 

section for detainees segregated for disciplinary reasons.” 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

x providing communications assistance to detainees in segregation who 

cannot speak English or who may be blind or deaf; and, 

x providing regular access to supervisory, management, program, and 

health care staff. 

Nonetheless, our review of disciplinary segregation revealed multiple violations 

of ICE detention standards. These violations pose a significant threat to 

maintaining detainee rights and ensuring their mental and physical well-being. 

Detainees Are Placed in Disciplinary Segregation Prematurely and 

Inappropriately 

During our visit to the Adelanto Center, there were 14 detainees in disciplinary 

segregation. Through our file review, we found that the Adelanto Center 

inappropriately placed all 14 detainees in disciplinary segregation before they 

were found guilty of a prohibited act or rule violation. We also identified one 

detainee who requested placement in administrative segregation but was 

inappropriately held in disciplinary segregation for more than a week. 

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. 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. We 

reviewed files for the 14 detainees in disciplinary segregation and only found 

disciplinary panel decisions for 7 of the detainees. File reviews indicated that 

this segregation placement is also done before the disciplinary panel assesses a 

penalty for the violation and the detainee has the opportunity to appeal, 

thereby violating the detainee’s right to due process. 

This premature placement in disciplinary segregation may further restrict 

detainee rights by imposing additional sanctions not included in the 

disciplinary panel’s decision or orders. In the seven cases where we found a 

disciplinary panel decision in the detainee file, the sanctions imposed went 

beyond the penalties listed in the disciplinary panel decision. For example, 

through interviews and observations, we learned that these detainees lost the 

ability to purchase or keep commissary items in their cells while in disciplinary 

segregation, but the disciplinary panel’s decisions did not include this penalty. 

Further, according to center staff, all detainees in disciplinary segregation lose 

contact visits with family. However, neither the disciplinary segregation orders 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

for the 14 detainees nor the center handbook’s description of rule violation 

penalties listed loss of contact visits with family as an available penalty. 

Our file review also revealed that a disabled detainee who had requested to be 

placed in administrative segregation, was instead placed in disciplinary 

segregation. This violates two aspects of the Special Management Units 

standard: one requiring a guilty finding before disciplinary segregation, and 

another prohibiting commingling detainees in administrative and disciplinary 

segregation. The center initially placed the detainee in disciplinary segregation 

due to an unrelated behavioral problem in administrative segregation at the 

time of transfer but inappropriately held him there for 9 days until we raised 

the issue to the center’s Medical Health Services Administrator. Based on our 

file review, in those 9 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. After our notification, 

the Medical Health Administrator moved the detainee from segregation to 

medical for observation. 

Detainees in Disciplinary Segregation Are Improperly Handcuffed and Shackled 

According to ICE standards, placement in disciplinary segregation alone does 

not constitute a valid basis for using restraints (i.e., handcuffs and shackles) 

on detainees. However, in disciplinary segregation, we observed GEO Group 

contract guards moving six detainees in physical restraints, including 

handcuffs and shackles. The GEO Group segregation supervisor and guards 

said they place all detainees held in disciplinary segregation in restraints when 

outside their cells. The center reported using restraints for security reasons, 

though according to ICE standards, restraints should only be used if necessary 

as a precaution against escape during transfer, when directed by the medical 

officer for medical reasons, or to prevent self-injury, injury to others, or serious 

property damage. Physically restraining all disciplinary segregation detainees 

whenever they are outside their cells does not comport with ICE standards and 

gives the appearance of criminal, rather than civil, custody. 

Detainees in Disciplinary Segregation Lack Communication Assistance 

ICE standards require facilities to provide communication assistance to 

detainees in segregation with disabilities or who are limited in their English 

proficiency. During our visit, we encountered a blind, limited English proficient 

detainee in disciplinary segregation but found the center had no auxiliary aids 

or translated materials for the detainee to read or understand documents he 

was given. In addition, file reviews of the 14 detainees in disciplinary 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

segregation at the time of our visit revealed that none of the segregation orders 

or information provided to detainees while in segregation was translated or 

otherwise communicated to ensure the detainee’s understanding. Without 

proper communication assistance, ICE cannot ensure that detainees placed in 

disciplinary segregation understand the reasoning for their segregation and are 

aware of their rights. 

Failure to Provide Timely and Adequate Medical Care for Detainees 

Increases Health Risks 

ICE has not ensured that Adelanto Center general population and segregated 

detainees receive appropriate and necessary medical and dental care, as 

required by ICE standards.7 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. Also, our detainee interviews and review of 

medical records revealed that detainees are placed on waitlists for months and, 

sometimes, years to receive basic dental care, resulting in tooth loss and 

unnecessary extractions in some cases. 

Medical Oversight in Disciplinary Segregation Is Ineffective in Ensuring 

Detainee Well-Being 

Although ICE standards require face-to-face medical assessments of all 

detainees in segregation at least once daily to ensure their welfare, we observed 

Adelanto Center medical providers, including nurses, physicians, and mental 

health providers, conducting cursory walk-throughs of disciplinary segregation. 

For example, we observed two doctors walking through disciplinary segregation 

and stamping their name on the detainee records, which hang outside each 

detainee’s cell, indicating that they visited with the detainee. However, we 

observed them doing so without having any contact with 10 of the 14 detainees 

in disciplinary segregation. For the four detainees a doctor did speak with, the 

doctor asked if the detainee was “ok” in English, not necessarily a language the 

detainee understood. We confirmed with guards that these four detainees were 

non-English speakers, and the doctor left without any acknowledgment or 

response from the detainee. Although ICE’s detainee death review of the March 

2017 suicide at Adelanto previously identified similar issues with medical 

oversight of detainees in segregation, our spot inspection of the center 

confirmed these issues persist. 

 7 ICE, Performance-Based National Detention Standards, 2011, Section 4.3, Medical Care 

(Revised Dec. 2016). “This detention standard ensures that detainees have access to 

appropriate and necessary medical, dental and mental health care, including emergency 

services.” 

www.oig.dhs.gov 7 OIG-18-86 
OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Medical Care for Detainees Is 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. Four of the 13 detainees we interviewed 

reported waiting weeks and months to see a doctor. They also reported that 

their appointments were sometimes canceled with no explanation, and that 

they were then placed back on the waiting list for a future appointment. In 

2017, the medical unit conducted a quality improvement investigation and 

identified 60 to 80 clinic appointments that were canceled because contract 

guards were not available to take detainees from their cells to their 

appointments. 

Detainee statements also corroborated a 2017 outside medical review that 

reported wait times to see a provider for both acute illness/injury and chronic 

care needs are often excessively long. Further, ICE’s detainee death reviews for 

three Adelanto Center detainees who have died since fiscal year 2015 also cited 

medical care deficiencies related to providing necessary and adequate care in a 

timely manner. ICE must take these continuing violations seriously and 

address them immediately. 

Dental Providers Do Not Provide Basic Dental Care 

ICE standards expect detention facilities to provide dental care, including 

checkups, cleanings, and procedures, after an individual has been in detention 

for 6 months. The Adelanto Center, however, does not include time spent at 

other ICE facilities when calculating the 6 months, and only adds detainees 

requesting dental cleanings to a waitlist for dental care after they have been at 

the Adelanto Center for more than 6 months. Records indicated and center 

staff corroborated that the center was waiting for detainees to leave rather than 

providing cleanings. Further, the Adelanto Center has only two dentists on staff 

to provide care for up to 1,940 detainees. According to center logs, no detainees 

received cleanings for almost 4 years. Dental cleanings began shortly before 

our visit due to findings from an external medical review. 

Our review of all requests for fillings since 2014 also found that although the 

center’s two dentists identified cavities and placed detainees on a waitlist for 

fillings, no detainees have received fillings in the last 4 years. One detainee we 

interviewed reported having multiple teeth fall out while waiting more than 2 

years for cavities to be filled. When we asked one of the dentists why fillings 

were not performed, he said he barely has time to do cleanings and screening, 

so as a result he does not do fillings. He offered extractions over other types of 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

dental care; we corroborated this information through detainee interviews. In 

our interviews with detainees, one reported having to wait 8 months for an 

extraction and another reported having the wrong tooth pulled. We reviewed 

the detainee dental records for tooth extraction and corroborated the detainee 

statements. 

During our interviews, a center dentist stated that he only provides “palliative 

care” and does not have time to complete cleanings or fillings. The dentist 

dismissed the necessity of fillings if patients commit to brushing and flossing. 

Floss is only available through detainee commissary accounts, but the dentist 

suggested detainees could use string from their socks to floss if they were 

dedicated to dental hygiene. 

Conclusion 

ICE must ensure the Adelanto Center complies with detention standards to 

establish an environment that protects the safety, rights, and health of 

detainees. 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. Mitigation and resolution of these issues require ICE’s immediate 

attention and increased engagement with the center and its operations. 

Recommendation 

Recommendation 1: We recommend that ICE conduct a full review of the 

Adelanto ICE Processing Center and the GEO Group’s management of the 

center immediately to ensure compliance with ICE’s 2011 Performance-Based 

National Detention Standards. As part of this assessment, ICE must review and 

ensure compliance with those standards addressing: 

1. Personal housekeeping requirements, associated with hanging 

bedsheets 

2. Segregation 

3. Medical Care 

Management Comments and OIG Analysis 

ICE concurred with the one report recommendation. Appendix A contains a 

copy of ICE’s management comments in their entirety. We also received 

technical comments from ICE, and we incorporated those comments in the 

report where appropriate. We consider this recommendation to be resolved and 

open. A summary of ICE’s response and our analysis follows. 

www.oig.dhs.gov 9 OIG-18-86 
OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

ICE Response to Recommendation 1: ICE concurred with this 

recommendation. ICE reported that it has scheduled a contractor to inspect the 

Adelanto ICE Processing Center, beginning October 10, 2018. The inspection is 

intended to gauge compliance with the 2011 PBNDS [Performance-Based 

National Detention Standards]. In addition, ICE Office of Enforcement and 

Removal Operations (ERO) has implemented a Special Assessment Review in 

response to this Management Alert. The Special Assessment Review is an 

additional detention facility review to target emergent concerns like those 

identified by the OIG. Additionally, ERO and the ICE Health Services Corps will 

meet to discuss an ongoing plan for providing technical assistance, monitoring, 

and oversight to ensure corrective actions are completed. ICE anticipates these 

actions to be completed by January 31, 2019. 

OIG Analysis: We consider these actions responsive to this recommendation, 

which is resolved and open. We will close this recommendation when we 

receive sufficient evidence that ICE has completed both the full inspection of 

Adelanto and a Special Assessment Review that will cover the areas of concern 

identified in this report. Once we receive documentation that these two 

inspections have been completed and ICE’s plan to address these reports, we 

will close this recommendation. 

Scope and Methodology 

We visited the Adelanto ICE Processing Center as part of our larger effort to 

inspect ICE detention facilities. We used ICE’s 2011 Performance-Based 

National Detention Standards to conduct our inspection, as these are the 

standards under which the center reported currently operating. These 

standards, which were developed in coordination with component stakeholders, 

prescribe the expected outcomes of each standard and the expected practices 

required to achieve them. ICE detention standards were also designed to 

improve safety, security, and conditions of confinement for detainees. 

During our inspection, we interviewed the following ICE staff members: ICE 

Supervisory Detention and Deportation Officer, ICE Assistant Field Office 

Director, Detention Management and Compliance Officer, and medical 

oversight staff at the Adelanto ICE Processing Center. We interviewed 

employees of the GEO Group, including the Warden, Assistant Warden, 

Grievance Coordinator, Classification Officer, Segregation Supervisor, Health 

Services Administrator, and medical providers. We also interviewed detainees 

held in the general population and segregation. We reviewed documentation 

from previous ICE inspections, center documents, detainee records, and 

documentation of grievances. 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

As part of our inspection we toured the following areas of the center: 

x General medical unit for detainees 

x Kitchens 

x Special Management Unit (segregation) 

x Modular housing units, including individual cells 

x Center intake 

x Control room 

We reviewed disciplinary and administrative segregation files, as well as 

medical files and records for detainee care, including dental logs for patients 

awaiting care. 

We conducted this review from May 2018 to July 2018 under the authority of 

the Inspector General Act 1978, as amended, and in accordance with the 

Quality Standards for Inspection and Evaluation issued by the Council of the 

Inspectors General on Integrity and Efficiency. Major contributors to this report 

are: John D. Shiffer, Chief Inspector; Stephanie Christian, Lead Inspector; 

Michael Rich, Lead Inspector; Ryan Nelson, Senior Inspector; and LaDana 

Crowell, Independent Reference Reviewer. 

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Appendix A 

ICE Response to the Draft Management Alert 

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Department of Homeland Security 

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Department of Homeland Security 

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Department of Homeland Security 

Appendix B 

Report Distribution 

Department of Homeland Security 

Secretary 

Deputy Secretary 

Chief of Staff 

General Counsel 

Executive Secretary 

Director, GAO/OIG Liaison Office 

Assistant Secretary for Office of Policy 

Assistant Secretary for Office of Public Affairs 

Assistant Secretary for Office of Legislative Affairs 

Director, ICE 

ICE Component Liaison 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees 

www.oig.dhs.gov 15 OIG-18-86 
Additional Information and Copies 

To view this and any of our other reports, please visit our website at: 

www.oig.dhs.gov. 

For further information or questions, please contact Office of Inspector General 

Public Affairs at: DHS-OIG.OfficePublicAffairs@oig.dhs.gov. 

Follow us on Twitter at: @dhsoig. 

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