Concerns about ICE 

Detainee Treatment 

and Care at Four 

Detention Facilities 

June 3, 2019 

OIG-19-47 
 

 

 

 

 OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

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

June 3, 2019 

MEMORANDUM FOR: Mark A. Morgan 

Acting Director 

FROM: John V. Kelly 

Acting Inspector General 

SUBJECT:	 Concerns about ICE Detainee Treatment and Care at 

Four Detention Facilities 

Attached for your information is our final report, Concerns about ICE Detainee 

Treatment and Care at Four Detention Facilities. We incorporated the formal 

comments from the U.S. Immigration and Customs Enforcement in the final 

report. 

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 Diana Shaw, 

Assistant Inspector General for Special Reviews and Evaluations, at 

(202) 981-6000. 

Attachment 

U.S. Immigration and Customs Enforcement 
 

 

 

 

 

 

 

 

 

 

 

DHS OIG HIGHLIGHTS
 

Concerns about ICE Detainee Treatment 

and Care at Four Detention Facilities 

June 3, 2019 

Why We 

Did This 

Inspection 

In response to concerns 

raised by immigrant rights 

groups and complaints to 

the Office of Inspector 

General (OIG) Hotline about 

conditions for detainees 

held in U.S. Immigration 

and Customs Enforcement 

(ICE) custody, we 

conducted unannounced 

inspections of four 

detention facilities to 

evaluate their compliance 

with ICE detention 

standards. 

What We 

Recommend 

We made one recommendation 

to improve ICE’s oversight of 

detention facility management 

and operations. 

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 

Overall, our inspections of four detention facilities revealed 

violations of ICE’s 2011 Performance-Based National 

Detention Standards, which set requirements for facilities 

housing detainees. This report summarizes findings on our 

latest round of unannounced inspections at four detention 

facilities housing ICE detainees. Although the conditions 

varied among the facilities and not every problem was 

present at each, our observations, detainee and staff 

interviews, and document reviews revealed several 

common issues. Because we observed immediate risks or 

egregious violations of detention standards at facilities in 

Adelanto, CA, and Essex County, NJ, including nooses in 

detainee cells, overly restrictive segregation, inadequate 

medical care, unreported security incidents, and 

significant food safety issues, we issued individual reports 

to ICE after our visits to these two facilities. All four 

facilities had issues with expired food, which puts 

detainees at risk for food-borne illnesses. At three 

facilities, we found that segregation practices violated 

standards and infringed on detainee rights. Two facilities 

failed to provide recreation outside detainee housing units. 

Bathrooms in two facilities’ detainee housing units were 

dilapidated and moldy. At one facility, detainees were not 

provided appropriate clothing and hygiene items to ensure 

they could properly care for themselves. Lastly, one facility 

allowed only non-contact visits, despite being able to 

accommodate in-person visitation. Our observations 

confirmed concerns identified in detainee grievances, 

which indicated unsafe and unhealthy conditions to 

varying degrees at all of the facilities we visited. 

ICE Response 

ICE concurred with the report recommendation and 

described corrective actions to address the issues 

identified in this report. We consider the recommendation 

resolved and open. 

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Table of Contents 

Background .................................................................................................... 2 

Results of Inspection ....................................................................................... 3 

Food Service Issues at All Facilities Endanger Detainee Health and 

Welfare .................................................................................................. 3 

Inappropriate Segregation Practices at Three Facilities Infringe on 

Detainee Rights ..................................................................................... 5 

Absence of Recreation outside Housing Units at Two Facilities May 

Reduce Detainee Mental Health and Welfare .......................................... 7 

Poor Conditions at Two Facilities Present Health Risks 

Improper Provision of Clothing and Toiletries at One Facility Hinders 

.......................... 8 

Detainee Abilities to Maintain Acceptable Personal Hygiene Practices..... 9 

Lack of In-Person Visitation at One Facility May Diminish Detainee 

Morale and Social Ties ......................................................................... 11 

Recommendation .......................................................................................... 12 

Management Comments and OIG Analysis .................................................... 12 

Appendixes 

Appendix A: Objective, Scope, and Methodology ................................. 14 

Appendix B: ICE Comments to the Draft Report ................................... 16 

Appendix C: Office of Special Reviews and Evaluations Major 

Contributors to This Report ................................................................. 23 

Appendix D: Report Distribution .......................................................... 24 

Abbreviations 

ERO Enforcement Removal Operations 

ICE Immigration and Customs Enforcement 

OIG Office of Inspector General 

PBNDS Performance Based National Detention Standards 

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Background
 

U.S. Immigration and Customs Enforcement (ICE) apprehends, detains, and 

removes aliens who are in the United States unlawfully. ICE Enforcement and 

Removal Operations (ERO) oversees the detention of aliens in nearly 200 

facilities that it manages in conjunction with private contractors or state or 

local governments. Contracts and agreements with facilities that hold ICE 

detainees require adherence to the 2000 National Detention Standards, ICE’s 

2008 Performance-Based National Detention Standards (PBNDS), or the 2011 

PBNDS. 

All ICE detainees are held in civil, not criminal, custody, which is not supposed 

to be punitive. According to ICE, the PBNDS establish consistent conditions of 

confinement, program operations, and management expectations within ICE’s 

detention system. These standards set requirements for areas such as: 

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

detainee searches, segregation1 (Special Management Units), and 

disciplinary system; 

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

x activities: e.g., visitation and recreation; and 

x grievance system. 

In response to concerns raised by immigrant rights groups and complaints to 

the Office of Inspector General (OIG) Hotline about conditions for detainees 

held in ICE custody, and consistent with Congress’ direction,2 we made 

unannounced visits to four detention facilities between May and November, 

2018: Adelanto ICE Processing Center (California), LaSalle ICE Processing 

Center (Louisiana), Essex County Correctional Facility (New Jersey), and 

Aurora ICE Processing Center (Colorado). The Adelanto, LaSalle, and Aurora 

facilities are owned and operated by the GEO Group Inc., and the Essex facility 

is owned and operated by the Essex County Department of Corrections. Based 

on their contracts or agreements, all four facilities must comply with the 2011 

PBNDS. Together these facilities can house a maximum of 4,981 detainees, 

according to ICE. 

This report summarizes the violations of ICE standards and problems we 

identified during our visits to the four facilities. However, some of the 

conditions and actions we observed at the Adelanto and Essex facilities 

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

administrative, disciplinary, or protective reasons.
 2 Joint Explanatory Statement, 164 CONG. REC. H2045, H2547 (daily ed. Mar. 22, 2018)
 

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represented immediate, unaddressed risks or egregious violations of the 

PBNDS and warranted individual reporting to ICE for corrective action.3 The 

inspection at the Adelanto facility revealed significant health and safety risks, 

including nooses in detainee cells, improper and overly restrictive segregation, 

and inadequate detainee medical care. At the Essex facility, we found 

unreported security incidents, food safety issues, and facility conditions that 

endanger detainee health. 

Results of Inspection 

This report summarizes findings on our latest round of unannounced 

inspections at four detention facilities housing ICE detainees. Because we 

observed immediate risks or egregious violations of detention standards at the 

Adelanto and Essex facilities, we issued individual reports to ICE after our 

visits to these two facilities and recommended ICE conduct a full review of the 

facilities to ensure compliance with ICE’s 2011 PBNDS. Overall, our 

inspections of the four detention facilities revealed violations of ICE’s detention 

standards and raised concerns about the environment in which detainees are 

held. Although the conditions varied among the facilities and not every problem 

was present at each, our observations, interviews with detainees and staff, and 

reviews of documents revealed several persistent issues. All four facilities had 

issues with expired food, which puts detainees at risk for food-borne illnesses. 

At three facilities, we found that segregation practices violated standards and 

infringed on detainee rights. Two facilities failed to provide recreation outside 

detainee housing units. Bathrooms in two facilities’ detainee housing units 

were dilapidated and moldy. At one facility, detainees do not receive 

appropriate clothing and hygiene items to ensure they could properly care for 

themselves. Lastly, one facility allowed only non-contact visits, despite being 

able to accommodate in-person visitation. Our observations confirmed 

concerns identified in detainee grievances, which indicated unsafe and 

unhealthy conditions to varying degrees at all of the facilities we visited. 

Food Service Issues at All Facilities Endanger Detainee Health and Welfare 

Our observations of all four facility kitchens indicated some level of 

noncompliance with ICE standards. We observed spoiled and moldy food in 

kitchen refrigerators, as well as food past its expiration date. We also found 

3 Management Alert – Issues Requiring Action at the Adelanto ICE Processing Center in Adelanto, 

California, OIG-18-86, Sept. 27, 2018, 

https://www.oig.dhs.gov/sites/default/files/assets/Mga/2018/oig-18-86-sep18.pdf; Issues 

Requiring Action at the Essex County Correctional Facility in Newark, New Jersey, OIG-19-20, 

Feb. 13, 2018, https://www.oig.dhs.gov/sites/default/files/assets/2019-02/OIG-19-20-

Feb19.pdf 

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meat thawing without labels indicating when it had begun thawing or the date 

by which it must be used. The issues at the LaSalle and Aurora facilities were 

minor and easily fixed during our visits, whereas those at the Adelanto and 

Essex facilities were egregious. At Essex, the food handling in general was so 

substandard that ICE and facility leadership had the kitchen manager 

replaced during our inspection. Overall, the issues we identified represent 

health and food safety risks. 

x At Essex, open packages of raw chicken leaked blood all over 

refrigeration units, as shown in figure 1; lunch meat was slimy, foulsmelling and appeared to be spoiled; and moldy bread was stored in the 

refrigerator. 

x At Adelanto, lunch meat and cheese were mixed and stored uncovered in 

large walk-in refrigerators; lunch meat was also unwrapped and 

unlabeled; chicken smelled foul and appeared to be spoiled; and food in 

the freezer was expired. 

x At LaSalle, some bread was out of date by up to 1 week. All bread was 

stored in the refrigerator. 

x At LaSalle and Aurora, open packaged food was not properly relabeled 

and dated for future consumption, as shown in figure 1. 

Figure 1. Open packaged raw meat and food items leaking blood, not relabeled and dated, 

observed by OIG at the Essex facility on July 24, 2018 (left); food not properly labeled or 

stored at LaSalle facility on August 7, 2018 (center); and unlabeled food with no description or 

date at Aurora facility on November 6, 2018 (right). Source: OIG 

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Inappropriate Segregation Practices at Three Facilities Infringe on 

Detainee Rights 

Facility staff may separate detainees from the general population and place 

them in either disciplinary segregation or administrative segregation for a 

number of reasons, including violations of facility rules, risk of violence, or 

their own protection from other detainees. Our spot inspections of the 

Adelanto, Essex, and Aurora facilities identified serious issues with the 

administrative and disciplinary segregation of detainees. Two facilities 

prematurely placed detainees in disciplinary segregation. All three facilities 

placed detainees in disciplinary segregation in restraints when outside their 

cells. One facility strip-searched detainees entering segregation. Two 

facilities did not provide detainees in segregation the required recreation 

time or time outside cells. These practices violate ICE detention standards 

and infringe on detainee rights. 

ICE standards4 obligate facilities to place detainees in disciplinary 

segregation only after they have committed a prohibited act. At Adelanto and 

Essex, detainees are placed in disciplinary segregation before the 

disciplinary hearing panel finds the detainee guilty of the charged offense. In 

addition, facility forms incorrectly state these detainees are in administrative 

segregation when they are actually in disciplinary segregation. 

Detainees in segregation at Adelanto, Essex, and Aurora were not treated with 

the care required under ICE detention standards. According to ICE standards,5 

placement in disciplinary segregation alone does not constitute a valid basis for 

using restraints. However, these three facilities require the use of restraints 

(handcuffs), as shown in figure 2, while detainees are outside their cells in 

disciplinary segregation. In addition, ICE standards6 also restrict the use of 

strip searches on detainees unless there is reasonable suspicion to do so. 

However, at Essex, detainees were strip searched when they entered either 

4 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.II, Special 

Management Units (Revised Dec. 2016). “A detainee shall be placed in disciplinary segregation 

only after a finding by a disciplinary hearing panel that the detainee is guilty of a prohibited act 

or rule violation....” 

5 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.E, Special 

Management Units (Revised Dec. 2016). “Placement in an SMU does not constitute a valid 

basis for the use of restraints while in the SMU or during movement around the facility.” 

6 ICE, Performance-Based National Detention Standards, 2011, Section 2.10.II, Searches of 

Detainees (Revised Dec. 2016). “A strip search shall be conducted only when properly 

authorized by a supervisor and only in the event that there is reasonable suspicion that 

contraband may be concealed on the person, or when an officer has reasonable suspicion that 

a good opportunity for concealment has occurred....” 

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disciplinary or administrative segregation, even though they were just being 

moved from another part of the facility, with no justification documented. 

Figure 2. Red placard indicating disciplinary segregation detainees must be moved in restraints 

at all times, compared to administrative segregation placard indicating social time approved. 

Observed by OIG at the Aurora facility on November 6, 2018. Source: OIG 

Although ICE standards7 require facilities to give detainees recreation time 

while in segregation, we found that detainees held in segregation at two 

facilities are offered very limited time outside their cells. At Adelanto, our 

review of disciplinary segregation files identified that some detainees were not 

offered any recreation or showers while in segregation. In addition, detainees in 

administrative segregation were only offered recreation 3 days a week instead 

of each day. At Essex, detainees in disciplinary segregation were only given 1 

hour per day outside their cell for showering, using the phone to speak with 

their attorney, and recreation time. 

Adelanto management admitted to an issue with recreation time due to the 

availability of outdoor recreation space and the need to keep segregated 

detainees separate from the general population. Facility management indicated 

that they had updated the recreation schedule to offer more time to those in 

segregation; however, the segregation unit had not yet implemented the new 

7 ICE, Performance-Based National Detention Standards, 2011, Section 2.12.V.Z, Special 

Management Units (Revised Dec. 2016). “Detainees in the SMU for administrative reasons shall 

be offered at least one hour of recreation per day, outside their cells and scheduled at a 

reasonable time, at least seven days per week. Detainees in the SMU for disciplinary reasons 

shall be offered at least one hour of recreation per day, outside their cells and scheduled at a 

reasonable time, at least five days per week.” 

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schedule. Essex staff reported limiting time for detainees in segregation due to 

limited staffing in the segregation unit. During our briefing with management, 

both facilities agreed to address the issue. 

Absence of Recreation outside Housing Units at Two Facilities May 

Reduce Detainee Mental Health and Welfare 

ICE standards8 require that all detainees be allowed outdoor recreation time 

outside their living area. However, the Essex and Aurora facilities do not 

provide outdoor space, and recreation for detainees was located within housing 

units. We observed enclosures inside detainee living areas with mesh cages at 

the top to allow in outside air, as shown in figure 3. We also identified, at the 

Aurora site, that female and male detainees had to share a recreation space, 

half-days each, so their access was limited. Further, detainees we interviewed 

at Aurora and Essex stated they wanted true outdoor recreation for the fresh 

air, sunshine, and exercise, and for playing soccer with their fellow detainees. 

Studies have shown that there are both health and social benefits to outdoor 

recreation. Reports have found that proximity to green space has reduced 

stress, depressive symptoms, and interpersonal violence. Positive impacts to 

outdoor recreation also include improved attention, self-discipline, and social 

ties. Detainees are held in civil, not criminal, custody; yet, according to the 

National Institute for Jail Operations,9 the loss or reduction of recreationrelated amenities (indoor recreation; no fresh air and direct sunlight) may 

result in increased idle time and a significantly lower quality of life. 

8 ICE, Performance-Based National Detention Standards, 2011, Section 5.4.II, Recreation 

(Revised Dec. 2016). The pertinent part of this standard requires that “detainees shall have 

access to exercise opportunities and equipment at a reasonable time of day, including at least 

one hour daily of physical exercise outside the living area, and outdoors when practicable. 

Facilities lacking formal outdoor recreation areas are encouraged to explore other, secure 

outdoor areas on facility grounds for recreational use. Daily indoor recreation shall also be 

available.” 

9 National Institute for Jail Operations, Prisoner Recreation: Right or Privilege, 2017, 

https://jailtraining.org/prisoner-recreation-right-or-privilege/ 

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Figure 3. General population outdoor recreation yard shared by two 80-person dorm modules 

with partially covered roof. Observed by OIG at the Aurora facility on November 6, 2018 (left). 

Also, as observed by OIG at the Essex facility on July 24, 2018, mesh cages were added to 

glass enclosures inside housing areas to provide “outdoor” recreation for detainees (right). 

Source: OIG 

Poor Conditions at Two Facilities Present Health Risks 

An expected outcome of ICE standards is that “facility cleanliness and 

sanitation shall be maintained at the highest level.”10 However, at the Adelanto 

and Essex facilities, we observed detainee bathrooms that were in poor 

condition, including mold and peeling paint on walls, floors, and showers, and 

unusable toilets, as shown in figure 4. At the Essex facility, mold permeated all 

walls in the bathroom area, including ceilings, vents, mirrors, and shower 

stalls. These environmental conditions present health risks as mold and 

mildew growth, for example, can lead to serious health issues for detainees, 

including allergic reactions and persistent illnesses. 

10 ICE, Performance-Based National Detention Standards, 2011, Section 1.2.I, Environmental 

Health and Safety (Revised Dec. 2016). “This detention standard protects detainees, staff, 

volunteers and contractors from injury and illness by maintaining high facility standards of 

cleanliness and sanitation, safe work practices and control of hazardous substances and 

equipment.” 

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Figure 4. Shower stall with mold, mildew, and peeling paint (left). Outdoor recreation area 

with stuffed and overflowing toilet (center). Observed by OIG at the Adelanto facility on May 

1, 2018. Detainee bathroom with mold and non-working toilet (right). Observed by OIG at the 

Essex facility on July 24, 2018. Source: OIG 

Improper Provision of Clothing and Toiletries at One Facility Hinders 

Detainee Abilities to Maintain Acceptable Personal Hygiene Practices 

Although facilities are required11 to provide detainees with size appropriate, 

presentable clothing, we found the Essex facility was issuing detainees clothing 

in size 3x and 4x, shown in figure 5. Inspection of the warehouse revealed that 

the facility only had size 3x and 4x with no other sizes available. The facility 

was also completely out of stock on boxer shorts and those previously provided 

to detainees were in size 3x and 4x, which detainees could not even keep on. 

Detainees reported and facility staff confirmed that improperly sized uniforms 

are never replaced, as detainees are required to keep uniforms provided during 

intake and wash them during their stay at the facility. 

The facility holds uniforms in their intake unit, where detainees are tasked 

with packing bags for new detainee arrivals that include clothing items. 

However, items are selected based on what is available, not on the actual size 

of the detainee. This process caused detainees to receive incorrect sized 

uniforms, and appropriate sized uniforms were not being restocked. The 

warehouse manager was unaware the facility was out of smaller sized uniforms 

11 ICE, Performance-Based National Detention Standards, 2011, Section 4.5.V.B, Personal 

Hygiene (Revised Dec. 2016). The pertinent part of this standard requires that at no cost to the 

detainee, all new detainees shall be issued clean, laundered, indoor/outdoor temperatureappropriate, size appropriate, presentable clothing during intake. 

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until we brought it to his attention. The facility ordered additional uniforms 

during our visit to replenish smaller sizes that were out of stock. 

Figure 5. Improperly sized uniform pants and boxer shorts issued to detainees. Observed by 

OIG at the Essex facility on July 24, 2018. Source: OIG 

Facilities are required to provide toiletry items,12 including shampoo, 

toothbrushes, toothpaste, lotion, and soap. When they enter the facility, 

detainees at Essex receive a bag with one bar of soap, one stick of deodorant, 

one toothbrush, a small tube of toothpaste, and a comb, shown in figure 6. 

Detainees reported never being given lotion or shampoo and never receiving 

any toiletries after intake. Our review of the facility toiletry stock revealed that 

the facility had no lotion on hand and the housing units did not have any 

toiletry supplies to provide to detainees. Facility staff told us the detainees just 

need to purchase hygiene items through the commissary, which is in direct 

violation of the ICE standards. 

Figure 6. Toiletry bag provided at intake 

and never replenished. Observed by OIG at 

the Essex facility on July 24, 2018. Source: 

OIG 

12 ICE, Performance-Based National Detention Standards, 2011, Section 4.5.V.D, Personal 

Hygiene (Revised Dec. 2016). The pertinent part of this standard requires that staff directly 

supervise the issuance of personal hygiene items and replenish supplies as needed. 

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Lack of In-Person Visitation at One Facility May Diminish Detainee 

Morale and Social Ties 

In the 2011 PBNDS, ICE outlines standards to ensure “that detainees shall be 

able to maintain morale and ties through visitation with their families, the 

community, legal representatives and consular officials, within the constraints 

of the safety, security and good order of the facility.”13 As part of this standard, 

ICE encourages facilities to provide opportunities for both contact and noncontact visitation with approved visitors. However, the Aurora facility allowed 

detainees only non-contact visits. Detainees were not allowed in-person 

visitation, even though the facility has rooms that can accommodate this for 

detainees, shown in figure 7. Further, detainees we interviewed at Aurora 

emphasized that contact visits, especially to see their children and other family 

members, should be allowed. 

Facility management indicated they had security concerns about the passing of 

weapons, drugs, or other contraband between visitors and detainees. Yet, 

facility management acknowledged the finding of our spot inspection that 

contact visits should be considered and implemented in coordination with ICE. 

Figure 7. Private visitation meeting 

rooms and open area room for 

contact visits exist though the 

facility does not use them. Observed 

by OIG at the Aurora facility on 

November 6, 2018. Source: OIG 

13 ICE, Performance-Based National Detention Standards, 2011, Section 5.7.I, Visitation 

(Revised Dec. 2016) 

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Conclusion 

Treatment and care of detainees at facilities can be challenging. Nevertheless, 

complying with the PBNDS and establishing an environment that protects the 

rights, health, and safety of detainees are crucial to detention. ICE could 

mitigate and resolve many of these issues through increased engagement and 

interaction with the facilities and their operations. 

Recommendation 

We recommend the Acting Director of U.S. Immigration and Customs 

Enforcement ensure that Enforcement and Removal Operations field offices 

that oversee the detention facilities covered in this report address the 

additional issues outlined in this report and ensure facility compliance with 

ICE’s 2011 Performance-Based National Detention Standards. 

Management Comments and OIG Analysis 

We obtained management comments to the draft report from ICE. We included 

a copy of those comments, in their entirety, in appendix B. We also made other 

revisions, where appropriate, to address separate technical comments ICE 

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

ICE Response: Concur. ICE Enforcement and Removal Operations has 

reviewed each of the issues outlined in this report, and field offices have taken 

corrective action at each facility when warranted. ICE has identified ongoing 

actions to address the OIG deficiencies identified. 

Specifically, according to ICE, improvements have been made to the Essex 

County Correctional Facility (Essex), including: replacing the Food Service 

Manager, training staff on proper food handling, removing and replacing menu 

items with input from detainees, and conducting random food quality testing. 

Essex also reported improvements in its segregation practices, including 

documenting why detainee strip searches were conducted and revising 

recreation schedules to add additional recreation time. ICE has reported 

improvements to facility conditions, including an extensive and systematic 

cleaning and renovation of the ICE detainee housing units and improving its 

provision of toiletries for detainees. 

At the LaSalle ICE Processing Center, ICE reported taking corrective action to 

address food labeling. 

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At the Adelanto ICE Processing Center, ICE reported improvements to food 

service and facility conditions, including: implementing staff instructions on 

proper food handling and storage, with daily management checks to ensure 

compliance; increasing recreation time for detainees; cleaning showers daily, 

with weekly inspections; monitoring shower maintenance and sanitation by 

facility staff; and cleaning, power washing, and painting showers with a special 

acrylic marine paint. 

At the Aurora ICE Processing Center, ICE reported the Food Service Manager 

had the packaged food properly relabeled and dated, and provided remedial 

counseling to staff on proper food storage. 

ICE responded it is committed to correcting all issues identified by OIG. ICE 

will provide documentation to OIG as each facility is reviewed to ensure 

corrective actions have been completed. Estimated Completion Date: 

September 30, 2019. 

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

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

receive documentation confirming that the follow-up inspections and other 

corrective actions have been completed. 

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Appendix A 

Objective, Scope, and Methodology 

The Department of Homeland Security (DHS) Office of Inspector General (OIG) 

was established by the Homeland Security Act of 2002 3XEOLF/DZïE\

amendment to the Inspector General Act of 1978. 

DHS OIG initiated this inspection program, consistent with Congress’ 

direction, and in response to concerns raised by immigrant rights groups and 

complaints to the DHS OIG Hotline about conditions for aliens in U.S. 

Customs and Border Protection and ICE custody. We generally limited our 

scope to the ICE PBNDS for health, safety, medical care, mental health care, 

grievances, classification and searches, use of segregation, use of force, 

language access, and staff training. We focused on elements of the PBNDS 

that could be observed and evaluated without specialized training in medical, 

mental health, education, or corrections. Our visits to these four facilities 

were unannounced so we could observe normal conditions and operations. 

Prior to our inspections, we reviewed relevant background information, 

including: 

x OIG Hotline complaints 

x ICE Performance-Based National Detention Standards 

x DHS Office for Civil Rights and Civil Liberties reports 

x ICE Office of Detention Oversight reports 

x Information from nongovernmental organizations 

We visited four facilities: 

x Adelanto ICE Processing Center, California (May 1–3, 2018); 

x LaSalle ICE Processing Center, Louisiana (July 10–12, 2018); 

x Essex County Correctional Facility, New Jersey (July 24–26, 2018); and 

x Aurora ICE Processing Center, Colorado (November 6–8, 2018). 

During the inspections we: 

x	 inspected areas used by detainees, including intake processing areas; 

medical facilities; kitchens and dining facilities; residential areas, 

including sleeping, showering, and toilet facilities; legal services areas, 

including law libraries, immigration proceedings, and rights 

presentations; recreational facilities; and barber shops; 

x	 reviewed facilities’ compliance with key health, safety, and welfare 

requirements of the PBNDS for classification and searches, segregation, 

use of force and restraints, medical care, mental health care, staffing, 

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training, medical and nonmedical grievances, and access to translation 

and interpretation; 

x	 interviewed ICE and detention facility staff members, including key ICE 

operational and detention facility oversight staff, detention facility 

wardens or someone in an equivalent position, and detention facility 

medical, classification, grievance, and compliance officers; 

x	 interviewed detainees held at the detention facilities to evaluate 

compliance with PBNDS grievance procedures and grievance 

resolution; and
 

x	 reviewed documentary evidence, including electronic and paper 

medical files and grievance logs and files. 

We conducted this review under the authority of the Inspector General Act of 

1978, as amended, and according to the Quality Standards for Inspection and 

Evaluation issued by the Council of the Inspectors General on Integrity and 

Efficiency. 

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Appendix B 

ICE Comments to the Draft Report 

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OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

www.oig.dhs.gov 22 OIG-19-47 
 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix C 

Office of Inspection Major Contributors to This Report 

John D. Shiffer, Chief Inspector 

Stephanie Christian, Lead Inspector 

Michael Rich, Lead Inspector 

Kim Lake de Pulla, Lead Inspector 

Ryan Nelson, Senior Inspector 

Erika Algeo, Independent Referencer 

www.oig.dhs.gov 23 OIG-19-47 
 

 

 

OFFICE OF INSPECTOR GENERAL 

Department of Homeland Security 

Appendix D 

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 

ICE Liaison 

Office of Management and Budget 

Chief, Homeland Security Branch 

DHS OIG Budget Examiner 

Congress 

Congressional Oversight and Appropriations Committees 

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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. 

OIG Hotline 

To report fraud, waste, or abuse, visit our website at www.oig.dhs.gov and click 

on the red "Hotline" tab. If you cannot access our website, call our hotline at 

(800) 323-8603, fax our hotline at (202) 254-4297, or write to us at: 

Department of Homeland Security 

Office of Inspector General, Mail Stop 0305 

Attention: Hotline 

245 Murray Drive, SW 

Washington, DC 20528-0305