Management Alert on 

Issues Requiring 

Immediate Action at the 

Theo Lacy Facility in 

Orange, California 

March 6, 2017 

OIG-17-43-MA
 
OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

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

March 6, 20 17 

MEMORANDUM FOR: 	 Thomas D. Homan 

Acting Assistant Secretary 

U.S. Immigration and Customs Enforcement 

FROM: 	 John 

Inspector 

Roth 

General 

~~~ 

SUBJECT: 	 Management Alert on Issues Requiring Immediate 

Action at the Theo Lacy Facility in Orange, California 

A November 16, 2016 unannounced Office of Inspector General (OIG) 

inspection of the Theo Lacy Facility (TLF) in Orange, California, raised serious 

concerns, some that pose health risks and others that violate U.S. Immigration 

and Customs Enforcement's (ICE) 2008 Performance-Based National Detention 

Standards (PBNDS) and result in potentially unsafe conditions at the facility. 

Because of concerns raised during the inspection, we recommended that ICE 

take immediate action to ensure compliance with the 2008 PBNDS and 

strengthen its oversight of TLF. Specifically, we expressed the following 

concerns about: 

• 	 Food handling at TLF poses health risks. Detainees were being served, 

and reported being regularly served, meat that appeared to be spoiled. 

Orange County Sheriffs Department (OCSD) staff members are not 

handling meat safely, including meat being sent to other ICE detention 

facilities. 

• 	 Unsatisfactory conditions and services at the facility, including moldy 

and mildewed shower stalls, refuse in cells, and inoperable phones. 

• 	 Some "high-risk" detainees are in less restrictive barracks-style housing 

and some "low-risk" detainees are in more restrictive housing modules; 

the basis for housing decisions is not adequately documented. 

• 	 Contrary to ICE detention standards, inspectors observed high-risk 

detainees and low-risk detainees together in parts of TLF. Although 

detainees were purportedly identified by classification level, this was not 

apparent to the inspectors. 

• 	 Moves from less restrictive barracks to more restrictive housing modules 

are not explained to detainees, nor are detainees given the opportunity to 

appeal changes, as required by ICE detention standards. 

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• 	 OCSD's more restrictive disciplinary segregation violates ICE detention 

standards. 

• 	 Neither ICE nor OCSD properly documents grievances from detainees to 

ensure resolution, notification of resolution, and opportunities to appeal. 

After inspecting this facility on November 16, 2016, the OIG team briefed local 

OCSD and ICE management on these concerns. To address the concerns 

detailed in the alert, we recommended that, as soon as possible, ICE prevent 

further health risks by ensuring that OCSD follow U.S. Department of 

Agriculture guidelines for safe food handling. We also recommended that ICE 

undertake a full review of TLF and OCSD's management of the facility to 

ensure its compliance with ICE's 2008 PBNDS. Finally, we recommended that 

ICE develop a comprehensive oversight plan for TLF to ensure OCSD's future 

compliance with ICE's 2008 PBNDS. 

We provided a draft of this alert to ICE for management comments and 

corrective actions. ICE concurred with the intent of all three recommendations 

and is implementing corrective actions to address our concerns. All three 

recommendations are resolved and open. We have included ICE's comments, 

proposed corrective actions, and our analysis in the alert, and we have 

attached a copy of the ICE response. 

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

provide copies of this alert to appropriate congressional committees with 

oversight and appropriation responsibility over the Department of Homeland 

Security. We will post a version of the alert on our website. 

You may call me with questions, or your staff may contact Laurel Loomis 

Rimon, Acting Assistant Inspector General for Inspections and Evaluations, at 

(202) 254-4100. 

Attachment 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Management Alert 

The Theo Lacy Facility (TLF), operated by 

the Orange County Sherriff’s Department 

(OCSD), houses U.S. Immigration and 

Customs Enforcement (ICE) detainees 

through an Intergovernmental Service 

Agreement. TLF has the capacity to house 

3,442 males, all with some degree of 

criminal history. Some detainees have been 

convicted of crimes, served their prison 

sentence, and have been transferred to TLF 

to await deportation by ICE or an 

immigration court hearing. Other detainees have violated immigration laws and 

are also awaiting either deportation or an immigration court hearing. At the 

end of October, 478 detainees were housed at Theo Lacy. That detainee count 

typically changes daily as new detainees enter the facility and others are 

released. 

Prior to detention, ICE reviews each detainee’s criminal record and assigns a 

risk level of high, medium/high, medium/low, or low. ICE bases its risk levels 

on the severity of past criminal charges and convictions, including immigration 

violations and other security risks, such as gang affiliation or a history of 

substance abuse. For example, individuals convicted of major drug offenses, 

national security crimes, and violent crimes such as murder, manslaughter, 

rape, robbery, or kidnapping are assessed as having a higher risk level than 

those convicted of minor drug and property offenses such as burglary, larceny, 

fraud, and money laundering. 

Facilities such as TLF that are maintained for ICE through an 

Intergovernmental Service Agreement are to comply with ICE’s 2008 

Performance-Based National Detention Standards (ICE detention standards). 

Poor Conditions at the Theo Lacy Facility 

Problems with Food Handling 

In the TLF kitchen, we identified a host of potential food safety problems, which 

could endanger the health of detainees at TLF and in other facilities serviced by 

the TLF kitchen. Of deepest concern, when inspecting the refrigeration units, 

we observed slimy, foul-smelling lunch meat that appeared to be spoiled. 

Figure 1. Entrance to Theo Lacy Facility 

Source: OCSD 

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According to kitchen staff, this meat was slated to be served to detainees for 

lunch the day of our site visit. Detainees reported being repeatedly served 

lunch meat that smelled and tasted bad, which they rinsed with water before 

eating. 

We also observed careless and potentially unsafe handling of food: 

x	 Meat that was marked as “keep frozen” on the manufacturing label was 

stored in a refrigerator with no indication of how long it had been 

thawing. 

x	 Lunch meat and ground beef was stored uncovered in large walk-in 

refrigerators. 

x	 Different types of unwrapped, sliced lunch meat were mingled in 

containers and not identified; for example, a container labeled as bologna 

contained bologna and sliced turkey. 

x	 Unwrapped lunch meat was stored in unlabeled, uncovered containers 

with no information describing contents, processing dates, or expiration 

dates. 

Figure 2. Thawing meat with no dates; different lunch meats stored together with no labels; 

label from bologna in refrigerator for 7 days past the prepared date; all observed by the Office 

of Inspector General (OIG) at TLF on November 17, 2016 

Source: OIG 

Further, ICE staff informed us: 

x	 Loaves of lunch meat were delivered frozen, thawed in the refrigerator for 

several days, sliced, refrozen, and sent to other detention facilities in the 

area. 

x Loaves of lunch meat were delivered frozen, thawed in the refrigerator for 

several days, then sliced and refrigerated for more than a week before 

being served. 

According to the U.S. Department of Agriculture (USDA), the safe storage time 

in a refrigerator for opened packages of lunch meat is 3-5 days. The practice of 

thawing, slicing, then refreezing meat for transport would make it difficult for 

TLF kitchen staff to adhere to those food safety recommendations. Further, by 

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not labeling the sliced, open lunch meat in the refrigeration unit, the kitchen 

staff has no way of knowing how long the portion packs have been in the 

containers. These practices could lead to detainee illness from ingesting spoiled 

meat. 

Recommendation 1: We recommend that, as soon as possible, ICE ensure 

that the Orange County Sherriff’s Department is following U.S. Department of 

Agriculture safe food handling guidelines to prevent health risks to detainees at 

the Theo Lacy Facility and other detention facilities that receive food from the 

Theo Lacy Facility. 

ICE Response: ICE concurs. OCSD reported that it follows the California Code 

of Regulations, Title 15 for Local Detention Facilities. Although ICE indicated 

that Theo Lacy kitchen facilities, sanitation, and food preparation, service, and 

storage must comply with standards set forth in the California Health and 

Safety and Retail Food Codes, it also acknowledged that it must have safe food 

handling practices to prevent health risks to detainees as outlined in the 

reporting of spoiled food slated for service to detainees. ICE reported that Theo 

Lacy food handling guidelines follow USDA methods or protocols for safe food 

handling. TLF has been using these food service handling guidelines prior to 

the contract with ICE (for over 5 years). Although, USDA's methods or protocols 

for safe food handling are not a requirement of ICE’s 2008 PBNDS, ICE concurs 

that OCSD must have safe food handling practices and guidelines to prevent 

health risks to detainees or other individuals in their custody. 

The standard from the 2008 PBNDS on Food Service requires, in part, that 

each facility has a food service program under the direct supervision of an 

experienced food service administrator (FSA) who is responsible for: 

x planning, controlling, directing, and evaluating food service; 

x establishing standards of sanitation, safety and security; and 

x developing specifications for the procurement of food, equipment, and 

supplies. 

According to ICE, TLF has a certified FSA (as well as two food service 

managers) and, in addition to ICE detention standards, follows the Orange 

County, California's Health Care Agency’s Environmental Health Services 

guidelines for food safety. County health inspectors routinely inspect OCSD 

facilities, including TLF. 

ICE also reported that OCSD is in the process of re-competing its pre-packaged 

lunch meat vendor, which was expected to be posted for bids before the end of 

January 2017. The procurement process is projected to take approximately 4 

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OFFICE OF INSPECTOR GENERAL 

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months. Although the contract re-compete is part of OCSD's routine 

procurement process, the sack lunches that are currently being prepared at 

TLF will be replaced with pre-packaged box lunches with set expiration dates 

that will be brought in from an outside vendor. Estimated completion date: May 

2017. 

Although ICE reported that TLF does not provide food to any other detention 

facility, this was reported in error. ICE revised its statement and indicated that 

it still provides food to other detention facilities; it is addressing its food 

handling issues by moving to a vendor that will provide pre-sliced and 

individually packaged lunch meat, which will address concerns at all affected 

facilities. 

OIG Analysis: ICE’s response to this recommendation addresses the intent of 

the recommendation. This recommendation is resolved and will remain open 

until ICE provides evidence that current food handling complies with USDA 

standards or similar standards that prevent health risks to detainees. Once 

completed, ICE should also provide a copy of the new pre-packaged box lunch 

contract that shows requirements ensuring set expiration dates are 

documented and followed. 

Lack of Cleanliness in Common Showers and Individual Cells 

In two modules housing 

detainees, common area 

showers were not clean. We 

found trash, mildew, and 

mold in the shower stalls. 

According to OCSD staff, 

detainees are required to 

clean their showers daily; 

however, detainees are only 

given a scrub brush and an 

all-purpose cleaner, which 

does not combat mold and 

mildew. Additionally, 

requiring detainees to 

clean common areas used 

by all detainees is in 

violation of ICE standards, 

as detainees are only 

required to clean their 

immediate living area. Figure 3. Moldy, mildewed shower stalls observed by OIG 

at TLF on November 16, 2016 Source: OIG 

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OFFICE OF INSPECTOR GENERAL 

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Also, in two of the modular housing units, we observed individual detainee cells 

that did not appear to be well-maintained or clean. In two cases, detainees had 

large collections of empty food containers and newspapers. According to ICE 

detention standards, garbage and refuse are to be collected and removed as 

often as necessary to maintain sanitary 

conditions and to avoid creating health hazards. 

Collections of items in individual cells could 

potentially attract vermin and present a health 

hazard for detainees. 

Unusable Telephones 

An ICE Office of Professional Responsibility, 

Office of Detention Oversight report from a 2013 

inspection of TLF identified telephone problems, 

including low volume and inoperable phones. In 

three modules we visited, the telephones were 

not operable. Detainees interviewed also 

confirmed that some phones did not work and 

the low volume on others prevented them from using the phones. 

Failure to Properly Document Detainee Classification Decisions and 

Comply with ICE Detention Standards 

Inadequate Documentation of Decisions on Detainee Classification 

ICE detention standards require detention facilities to implement a system to 

classify detainees based on past criminal convictions, including immigration 

violations, and other security risk factors. Facilities must physically house 

detainees according to their classification level. Through our observations and 

interviews with OCSD staff, we determined that OCSD is not properly 

documenting its detainee classification process, and its housing 

reclassifications do not comply with ICE detention standards. 

Before in-processing at TLF, ICE gives OCSD a classification form for each 

detainee that contains ICE’s classification risk assessment of high, 

medium/high, medium low, or low. Facilities are permitted to develop local 

classification systems, as long as the classification criteria are objective and 

uniformly applied and procedures meet ICE requirements. OCSD staff informed 

us that they do not change ICE’s initial classification level, but they consider 

Figure 4. Broken plug on phone 

observed by OIG at TLF on 

November 16, 2016 Source: OIG 

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the ICE’s classification along with their own detainee classification interview to 

determine the level of “criminal sophistication”1 and assign housing. 

Although OCSD personnel showed us examples of completed questionnaires 

from classification interviews, OCSD does not document these interviews in the 

detainee’s file. Through our review of detainee files, we found detainees 

identified by ICE as high risk who were housed in the least restrictive barracks 

and detainees identified by ICE as medium/low risk housed in more restrictive 

modular housing. Even though OCSD officials said they use ICE’s initial 

classification, we found no detainee file documentation showing they took this 

classification into consideration when determining initial housing assignments. 

Additionally, we found no correlation between ICE’s initial classification and 

OCSD’s assessment. 

High-risk and Low-risk Detainees Are Allowed to Mix 

ICE detention standards also specify that facilities may not mingle low-risk 

detainees with high-risk detainees. During the facility tour, we observed that 

detainees of all risk levels were housed in the barracks. OCSD staff explained 

that detainees of different classification levels do not “program” together, 

meaning they do not eat or attend religious services or recreation activities at 

the same time. Fundamentally, this setup satisfies the ICE detention 

standards’ prohibition against mingling high-risk detainees and low-risk 

detainees. However, while touring the barracks area, we noted that detainees of 

all risk levels were able to roam the entire area, accessing the phones, law 

library, and outdoor space, and entering and exiting the housing bays freely. 

Although OSCD personnel said each detainee is issued an armband and 

identification card indicating risk classification, these were not readily 

apparent to the OIG team. Some detainees were not wearing an armband at all. 

This type of mingling may allow a less restrictive living environment for 

detainees, but it skirts the ICE detention standards’ prohibition, which is 

designed to “protect the community, staff, contractors, volunteers, and 

detainees from harm.” 

Changes to Detainee Housing Do Not Comply with ICE Detention Standards 

During our review of detainee files, we determined that OCSD staff were not 

informing detainees of their reasons for moving detainees from barracks to 

more restrictive modules. There was also no evidence of a process for detainees 

to formally appeal such a move. OCSD staff told the OIG team that detainees 

1 OCSD staff referred to criminal sophistication as an overall assessment of a detainee’s 

criminal background, including gang affiliation, past incarceration record, and types of 

violations on criminal history. 

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housed in the modules were there because they needed closer supervision than 

the barracks allowed, but we determined the reasons behind the need were not 

properly documented in detainee files. OCSD also does not review detainees’ 

classifications before moving them from barracks to modules. 

According to ICE detention standards, facility classification systems must 

include procedures for detainees to appeal their classification levels, but OCSD 

staff said they never, for any reason, change ICE’s initial classification of 

detainees. Because they do not change classification levels, OIG concluded that 

OCSD is able to avoid the requirement for allowing detainees to appeal housing 

decisions. We also concluded that, as a result, OCSD staff can move detainees 

at will without technically violating ICE detention standards, and detainees are 

stripped of their right to appeal housing decisions, which should be based on 

their classification level. 

OCSD’s More Restrictive Disciplinary Segregation Violates ICE Detention 

Standards 

OCSD is violating ICE detention standards for disciplinary segregation. 

Detainees at TLF are placed in disciplinary segregation in a special 

management unit as punishment for violations of facility rules. According to 

OCSD staff and the OCSD-provided detainee handbook, disciplinary 

segregation at TLF means a person is isolated for 24 hours a day in a cell with 

no access to visitors, recreation, or group religious services. The detainees are 

released briefly every other day to shower. In contrast, ICE detention standards 

require that detainees placed in disciplinary segregation receive a minimum of 

1 hour of recreation five times per week, opportunities for general visitation, 

religious guidance, and limited access to telephones and reading material. 

However, through observation and interviews, we determined that detainees 

are not allowed any recreation time, visitation, religious guidance, or telephone 

access. They were permitted to access one book from the library for the 

duration of their stay in solitary, lasting up to 30 days. 

ICE Does Not Track Detainee Grievances 

We identified problems with processes for filing both written and oral 

grievances with ICE and OCSD. Detention standards require facilities to have a 

procedure for formal grievances to ensure detainees are being treated fairly. 

Detainees may file grievances related to the conditions of confinement, 

including medical care, staff misconduct, food, telephones, visiting procedures, 

and disability discrimination. TLF has two grievance processes, one overseen 

by ICE and one by OCSD. Detainees wishing to file a written grievance with 

ICE fill out an ICE form and place it in ICE’s box in their living area, which is 

picked up by a contractor daily. Detainees wishing to file a written grievance 

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with OCSD fill out a different form, which is placed in a different box and is 

picked up by supervising deputies after each shift. 

Through interviews with the ICE Grievance Officer we identified the following 

problems with the ICE grievance process: 

x	 ICE does not track written grievances from detainees in the facility to 

ensure the grievances are received, resolved, and that detainees receive a 

response. Grievances are maintained in a database owned by a private 

contractor, and the ICE Grievance Officer said ICE does not have access 

to this database. 

x ICE personnel do not document or track oral grievances from detainees, 

and detainees do not receive a documented response. 

x Detainees said they were not given the opportunity to appeal their 

grievances with ICE. 

x	 When ICE receives a written grievance that OCSD must address, ICE 

forwards the grievance to OCSD or the medical staff for response. 

However, after forwarding these grievances, ICE does not track them to 

ensure they are resolved and that detainees receive a response. 

Through interviews with OCSD officials and detainees, as well as document 

review, we identified the following problems with the OCSD grievance process: 

x	 ICE does not track these grievances or have visibility into these 

grievances filed with OCSD to ensure they are resolved and detainees 

receive a response. 

x	 OCSD sends ICE an email summarizing the grievance received and the 

resolution, but ICE personnel have no assurance they have been notified 

of all grievances or that all grievances have been fully resolved. We 

reviewed some of these emails and confirmed they did not include full 

details of detainees’ grievances, a description of the resolution, or 

confirmation that the detainee had been notified about the resolution. 

x	 Detainees said they were not given the opportunity to appeal grievances. 

We reviewed all 46 detainee grievances filed with OCSD in 2016, and 

found that there were no documented appeals. 

Recommendation 2: We recommend that ICE undertake a full review and 

inspection of the Theo Lacy Facility and the Orange County Sherriff’s 

Department’s management of the facility to ensure compliance with ICE’s 2008 

Performance-Based National Detention Standards. 

ICE Response: ICE concurs. ICE reported to us that the TLF is inspected 

yearly by ICE's contract inspector, the Nakamoto Group, and is scheduled for 

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its next full inspection to ensure compliance with the 2008 PBNDS during the 

week of October 23, 2017. In the interim, TLF will undergo an inspection by the 

ICE Office of Detention Oversight within the Office of Professional 

Responsibility, beginning February 7, 2017. At the end of the inspection, the 

Office of Detention Oversight will conduct an onsite out-briefing of facility staff 

and local field office management regarding any deficiencies identified during 

the review, followed by an official report of findings to ICE leadership. The Los 

Angeles Field Office (LAFO) will work with the facility to put in place any 

necessary corrective action plans, should deficiencies be identified. Estimated 

completion date: November 2017 

OIG Analysis: ICE’s response to this recommendation addresses the intent of 

the recommendation. In ICE’s corrective actions, we will look specifically at the 

handling and management of grievances and at the segregation processes used 

at TLF. This recommendation is resolved and will remain open until ICE 

provides evidence that it is in full compliance with the 2008 PBNDS, based on 

the results of an independent contractor’s full inspection and Office of 

Detention Oversight inspection. Once completed, ICE should provide a copy of 

the completed inspections identifying compliance with the standards. 

Recommendation 3: We recommend that ICE develop a comprehensive 

oversight plan for the Theo Lacy Facility to ensure the Orange County Sherriff’s 

Department’s future compliance with both the intent and the implementation 

of ICE’s 2008 Performance-Based National Detention Standards. 

ICE Response: ICE concurs. ICE reported that it recently instituted a group 

meeting at TLF for onsite ICE staff and facility leadership, including food 

service managers, for the purpose of discussing facility compliance issues and 

other areas of concern. In addition, the group has developed a facility-specific 

form that will be used to document routine and recurring inspections of the 

food service areas and food-related processes at the facility. 

According to ICE, its Detention Standards Compliance Officer is onsite at TLF 3 

weeks per month to work with facility staff and other onsite ICE supervisory 

personnel to monitor facility compliance and implement any necessary 

corrective action. ICE will continue to monitor and evaluate whether additional 

oversight staff should be deployed to TLF for additional coverage. 

LAFO will continue to engage with OCSD and monitor any developing issues to 

expeditiously remedy and correct any compliance deficiencies. In addition, 

LAFO management has continued to conduct independent onsite spot 

inspections of any notable problematic areas or areas of concern. The results of 

the spot inspections are immediately addressed with OCSD for any necessary 

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corrective action in order to ensure compliance with the 2008 PBNDS. 

Estimated completion date: November 2017 

OIG Analysis: ICE’s response to this recommendation addresses the intent of 

the recommendation. This recommendation is resolved and will remain open 

until ICE provides evidence it has modified its oversight of the facility to ensure 

the intent of the 2008 PBNDS is being met and the standards are being 

implemented. We will look specifically for changes in handling grievances and 

segregation at TLF. Corrective actions completed must include all areas of 

concern identified in the report, not just proper food handling. Once completed, 

ICE should provide a copy of its revised oversight plan to ensure ongoing 

monitoring of compliance at TLF. 

Scope and Methodology 

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

Supervisory Detention and Deportation Officer, Orange County Detainee 

Program; ICE Assistant Field Office Director, Detention Management and 

Compliance; and Medical Oversight at Theo Lacy facility. We interviewed three 

employees of the Orange County Sheriff’s Office: Orange County Administrative 

Manager, ICE Detention Custody Division; OCSD Classification Deputy, ICE 

Compliance; and Lieutenant, ICE Compliance. We also interviewed five 

detainees. 

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

x General medical unit for detainees housed in barracks-style housing 

x Medical modular housing detainees who require more frequent medical 

assistance 

x Kitchen, including food preparation, food storage, and equipment 

cleaning areas, intake/out-processing area 

x Special Management Unit (commonly known as solitary confinement) 

x Modular housing units, including individual cells, common showers, and 

medical units within modules 

x Barracks-style housing 

x Control room 

During the unannounced inspection, we interviewed ICE and OCSD staff from 

the facility and five detainees. We reviewed documentation from a previous ICE 

inspection and documentation of grievances. 

We used ICE’s 2008 PBNDS to conduct our inspection, as these are the 

standards the facility reported currently operating under. These standards, 

which were developed in coordination with component stakeholders, prescribe 

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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. 

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