A Nicaraguan man who was detained at the Adelanto ICE Processing Center died in March 2017 after he was found hanging in his cell from his bedsheets. Not long after, two other detainees also used sheets in an attempt to hang themselves.

When federal officials arrived in May of this year for a surprise inspection of the privately run immigration detention facility, they found nooses made from bedsheets in 15 of 20 cells.

“When we asked two contract guards who oversaw the housing units why they did not remove the bedsheets, they echoed it was not a high priority,” officials with the Department of Homeland Security inspector general’s office wrote in a scathing report made public Tuesday detailing dangerous conditions found at the facility during their unannounced visit.

The nooses are just one of many problems posing “significant health and safety risks” identified by federal inspectors at Adelanto, which can house nearly 2,000 detainees as they await the outcome of their immigration cases.


Detainees reported waiting “weeks and months” to see a doctor, and inspectors met with a dentist who dismissed the necessity of fillings, and suggested that detainees use string from their socks to floss, the report said.

Inspectors also said they found that detainees were commonly subjected to disciplinary segregation before being found guilty of violating rules.

The report is the latest from government inspectors to document significant deficiencies at Adelanto since it opened in 2011.

It comes one year after immigrant advocates raised alarms about conditions at the facility following the deaths of three detainees in a three-month period in 2017.


The Times reported in August 2017 that there had been at least five attempted suicides at the facility in less than one year, according to a review of 911 calls.

Lori Haley, a spokeswoman for Immigration and Customs Enforcement, said in a statement that immigration officials take the findings seriously and have “agreed to conduct a full and immediate review of the center to ensure compliance with detention standards and expedite necessary corrective actions.”

Tens of thousands of ICE detainees have passed through the Adelanto facility since it opened seven years ago. It is owned and operated by the GEO Group, which runs dozens of private prisons and detention centers around the country.

Among those held in the facility are asylum seekers, people caught in immigration sweeps and those identified by authorities as potentially deportable after landing in jail.


Some detainees arrive at the facility soon after crossing the border; others after having lived in the U.S. for decades. They can stay in detention for months, and in some cases years, as their cases are decided.

Pablo Paez, a spokesman for GEO Group, referred questions about the inspector general’s report to ICE.

According to the report, in the months after Osmar Epifanio Gonzalez-Gadba, 32, of Nicaragua was found hanging from bedsheets in his cell and later died, ICE compliance reports documented at least three suicide attempts by hanging at Adelanto, two of which specifically used bedsheets.

Still, when inspectors visited the facility, they found braided sheets that both staff and detainees referred to as nooses hanging from the vents in 15 of the approximately 20 male detainee cells that they visited in four housing units.


The guard who escorted the inspectors began removing the nooses but stopped after realizing how many there were, the report says. Some detainees said they use the unfurled sheets for privacy, while others said they used them as clotheslines.

One detainee, however, told inspectors that he had seen “a few attempted suicides using the braided sheets by the vents.”

“The guards laugh at them and call them ‘suicide failures’ once they are back from medical,” the detainee told officials.

Inspectors also found during their visit that all 14 detainees who were in disciplinary segregation at the time were put there before being found guilty of a prohibited act or rule violation.


And though ICE standards require face-to-face medical assessments of all detainees in segregation at least once a day, inspectors observed two doctors in the unit stamping their name on detainee records outside their cells “without having any contact with 10 of the 14 detainees in disciplinary segregation.”

The report also notes that some detainees reported waiting “weeks and months” to see a doctor and said that appointments were canceled without explanation, with detainees placed back on the waiting list.

From November 2017 to April 2018, detainees filed 80 medical grievances with the facility for not receiving urgent care, not being seen for months for persistent health conditions and not receiving prescribed medication, according to the report.

Inspectors also highlighted serious problems with dental care at the facility, saying detainees are placed on wait lists for months and, sometimes, years to receive basic care, “resulting in tooth loss and unnecessary extractions in some cases.”


No detainees have received fillings in the last four years, according to the report. One detainee reported multiple teeth falling out while waiting more than two years for cavities to be filled.

One dentist at the facility told inspectors he did not have time to complete cleanings or fillings, according to the report.

“The dentist dismissed the necessity of fillings if patients commit to brushing and flossing,” the report states. “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.”

This is not the first time government inspectors have noted problems — often related to medical care — at the Adelanto facility.


An annual review in November 2011 found that “medical officials were not conducting detainee health appraisals within 14 days of arrival,” and nurses were performing health assessments without proper training or certification.

A 2012 report by ICE’s Office of Detention Oversight found that many requests for medical care were delayed. That report also said the death of detainee Fernando Dominguez Valdivia in March of that year followed “egregious errors” by medical staff and that a review found it could have been prevented.

A report on the 2015 death of Raul Ernesto Morales-Ramos, also prepared by the Office of Detention Oversight, said Adelanto failed to provide Morales-Ramos with timely and comprehensive medical care, among other lapses.

More recently, the Office of Detention Oversight’s review of Gonzalez-Gadba’s 2017 suicide also faulted Adelanto for failing to meet national standards. That report said that in the days before his death, Gonzalez-Gadba reported he had been sexually assaulted at Adelanto, but medical staff did not conduct a medical assessment in response to that allegation.


It also said that guards failed to check on Gonzalez-Gadba, who was being held in segregated housing, at least every 30 minutes, as required.

He was found hanging in his cell 37 minutes after an officer’s last logged security round, according to the review.

In its report, the inspector general’s office also noted the medical care deficiencies that were found at Adelanto following the deaths of detainees and urged immigration officials to fix the problems.

“ICE must take these continuing violations seriously and address them immediately,” the report says.


Haley, the ICE spokeswoman, said a contracted inspection firm is scheduled to inspect Adelanto again this month.

“Comprehensive medical care is provided from the moment detainees arrive and throughout the entirety of their stay,” she said.

Speaking about the nooses, she said “ICE recognizes that this can present a dangerous safety vulnerability and will intensify efforts to address this issue.”

paloma.esquivel@latimes.com


Twitter: @palomaesquivel

brittny.mejia@latimes.com

Twitter: @brittny_mejia

UPDATES:


6:45 p.m.: This article was updated with additional reporting and background.

This article was originally published at 1:15 p.m.