Staff at Adelanto ignored all but the most serious medical emergencies. After Hidalgo witnessed a detainee suffer seizures and staff do nothing to help him, he started organizing a detainee-run response team to help those suffering medical and mental health crises, which were frequent. When he asked the center’s staff for help, those working with the GEO Group, the private detention company that runs the center, would refer him to U.S. Immigration and Customs Enforcement. “If I asked ICE, they’d say, it’s GEO’s house, so ask them and go through them,” Hidalgo said. “Back and forth, so you end up getting nothing.”

Toiletries and clean clothes were in constant shortage and sick detainees were sometimes left in their soiled clothes, he told The Intercept. Detainees worked in the center’s kitchens for as little as $1 a day — or took cleaning shifts for no money but an extra ration of food. The food itself was so bad that it was sometimes infested with maggots, yet there was always too little of it — so that detainees would be forced to buy more at the center’s commissary. “It’s all about money,” said Hidalgo, who is now free on bond.

When Carlos Hidalgo was detained at the ICE processing center, in Adelanto, California, guards would mock the detainees lined up to get their meals by imitating the call of cows. “Moo! Here are the cows, walking through!”

A guard once told him, “They don’t pay me enough to give a shit about you.” During his time there, two detainees tried to hang themselves with their bedsheets. “They just don’t give a damn,” said Hidalgo. “You’re just another number, you’re just another detainee.”

In two stints at Adelanto — for nine months in 2014 and three in 2016 — Hidalgo learned to navigate the system and became a bit of an organizer among the detainees. He arranged for transgender detainees to stay together for protection and helped fellow detainees file formal grievances — earning himself reprimands and once a month in disciplinary segregation.

“Suicide Failures”

Last week, the Department of Homeland Security Office of Inspector General, which is tasked with independently monitoring the department’s agencies, published a scathing report confirming some of the problems Adelanto detainees like Hidalgo have long denounced, including widespread indifference to attempted suicide. In one particularly disturbing detail, investigators mentioned finding several nooses, made of bedsheets, hanging in detainees’ cells.

The report was the result of a surprise audit at the facility last May, and it offers an indictment of the Adelanto facility in unusually blunt language for an official document. “These violations pose a significant threat to maintaining detainee rights and ensuring their mental and physical well-being,” the report states. “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.”

But the findings hardly surprised Hidalgo. “There are other things that are worse that have been committed there,” he said. “That’s not the worst.”

For years, detainees and their advocates have denounced inhumane conditions at the center, which can house up to 1,940 detainees, making it, along with the Stewart Detention Center in Georgia, the largest privately run immigration detention facility in the country. The documented abuses include medical neglect, poor hygiene and nutrition, and violations of religious liberties, as well as suicides, deaths in custody, and sexual abuse at the hands of ICE staff and contractors.

According to the OIG report, inspectors visiting Adelanto found braided bedsheets hanging as “nooses” in 15 of the 20 cells they visited — a violation of ICE standards that prohibit detainees from hanging or draping objects from furniture or fixtures. In March 2017, a 32-year-old Adelanto detainee died after being found hanging from his bedsheets in a cell there. There were seven other documented suicide attempts at Adelanto between December 2016 and October 2017, at least two of them by detainees who tried to hang themselves using their bedsheets.

“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’re back from medical,” one detainee told inspectors. The report says that a senior ICE official told inspectors that “ICE management at Adelanto does not believe it is necessary or a priority to address the braided sheets issue.”

The report also criticizes excessive segregation and severely inadequate medical care. Inspectors found that 14 detainees were held in disciplinary segregation — i.e., solitary confinement — at the time of their visit, before an administrative process found them guilty of infractions and without a written order of segregation. “GEO Group staff indicated it is the center’s practice to place all detainees directly in disciplinary segregation after an alleged incident,” the report notes, a clear violation of ICE standards, as well as detainees’ rights to due process.

The report also found that detainees held in segregation were further penalized by losing contact visits with family or access to the commissary, even when those penalties were not sanctioned by the center’s rules. And inspectors observed staff moving six detainees in handcuffs and shackles, and were told by guards that they place all detainees in disciplinary segregation in restraints when outside their cells — yet another violation of ICE standards, which “gives the appearance of criminal, rather than civil, custody.”

Inspectors also found that a disabled detainee was improperly held in disciplinary segregation for nine days, until they raised the issue with the center’s administration. According to the report, in those nine days, the detainee never left his wheelchair to sleep on a bed or brush his teeth. A bag of beddings and toiletries remained untouched in the detainee’s cell.

Inspectors observed nurses, doctors, and mental health providers conducting “cursory walk-throughs” and stamping their names on detainees’ records hanging outside their cells without entering or speaking to them. Inspectors only observed medical staff talk to four of the 14 detainees they “visited” — and even in those cases, staff merely asked, in English, if the detainee was “OK.” “We confirmed with guards that these four detainees were non-English speakers, and the doctor left without any acknowledgement or response from the detainee,” the report notes.

Between November 2017 and April 2018, detainees at Adelanto filed 80 medical grievances saying that they were denied urgent care, medication, and medical visits for persistent health problems. In 2017 alone, between 60 and 80 clinical appointments were canceled because no guards were available to escort detainees to their visits — despite a long history of medical neglect allegations at the center, including three deaths since 2015 of detainees who had denounced lack of care.

The inspectors also found that detainees are placed on waitlists for months and sometimes years to receive basic dental care, despite the fact that ICE is required to provide dental care to those it holds for longer than six months. Detainees described to inspectors having multiple teeth fall out as they waited more than two years for cavities to be filled, having to wait more than eight months for an extraction, and having the wrong tooth pulled. Interviewed by inspectors, a dentist at the center told them that he “does not have time” for cleanings or fillings, adding that detainees would be fine if they committed to brushing and flossing. When reminded that floss is only available to detainees with a commissary account, the dentist replied that they “could use string from their socks to floss if they were dedicated to dental hygiene.”

Both ICE and the GEO Group said the report lacked appropriate “context,” but pledged to review the center’s practices and address issues. A spokesperson for ICE said in a statement in response to the report that “the safety, rights and health of detainees in ICE’s care are of paramount concern and Adelanto, like all ICE detention facilities, is subject to stringent, regular inspections.”

The spokesperson added that “ICE takes seriously the OIG’s findings and has agreed to conduct a full and immediate review of the center to ensure compliance with detention standards and expedite necessary corrective actions.”

A spokesperson for the GEO Group, which runs Adelanto, as well as dozens of detention centers across the country, said in a statement, “Our commitment is always, first and foremost, to high-quality care. For over thirty years, our employees have taken pride in our ability to provide quality services in safe, secure and humane environments for those entrusted to our care, and these findings of inadequacies are not consistent with our core values.”

Zero Accountability

“Adelanto is one of the worst immigrant prisons in the country,” said Liz Martinez, director of advocacy at Freedom for Immigrants, a southern California-based immigrant rights group that has coordinated volunteer visits to Adelanto since 2012 and runs a national hotline for detainees. “The OIG report confirms what we documented and exposed all along: that ICE and the GEO Group are systematically subjecting immigrants to intolerable conditions.”

“What’s more revealing, I think, is how the report details the unvarnished cruelty with which the staff and guards treat immigrants,” Martinez said. “The way they laugh after suicide attempts, the way they suggested using sock strings as floss. … They take pleasure in subjecting people to further misery.”

Just recently, a detainee at Adelanto told Freedom for Immigrants that in his cell block, guards removed all restroom curtains — the only privacy afforded to detainees. And two detainees told a volunteer that one night in late August the food was so bad that many detainees refused to eat — to which guards responded by pepper spraying them. “We hear stories all the time,” Martinez added. “The problem is when detained individuals report these kinds of incidents, no one believes them. And often they are retaliated against.”

The ICE spokesperson listed a number of measures in place at the agency to monitor facilities, including reviews by a third-party contractor. Facilities receiving a less than acceptable rating must be scheduled for a follow-up inspection within six months, the spokesperson said, and if a facility receives two consecutive final ratings of less than acceptable, ICE must discontinue use of the facility. In 2009, ICE also created the Office of Detention Oversight, a unit tasked with conducting independent reviews of detention conditions. The DHS Office for Civil Rights and Civil Liberties also conducts reviews whose findings are not publicly shared.

But as The Intercept has reported, while detention facilities are periodically inspected for compliance with ICE standards, the agency regularly gives its centers passing marks despite evidence of abuse and neglect. Last spring, the American Civil Liberties Union and nine other organizations wrote a letter to DHS denouncing ICE’s failure to comply with the detention standards set by Congress, criticizing the agency’s “unregulated self-assessment” and adding that “a close look at the inspections themselves reveals alarming evidence that they are sham assessments.”

Last June, a different OIG report concluded that ICE’s monitoring system is simply not working. “The inspections do not fully examine actual conditions or identify all deficiencies,” the OIG noted then. “ICE does not adequately follow up on identified deficiencies or consistently hold facilities accountable for correcting them, which further diminishes the usefulness of inspections.” ICE said in response to that report that the agency would “continue to ensure its detention facilities comply with relevant policies and standards through an aggressive inspections program,” and indicated that it would re-evaluate its inspection scope and conduct follow-up inspections.

“Adelanto has gotten passing inspections every year, even when people have died there in ways that were due to medical neglect,” said Grace Meng, a senior researcher at Human Rights Watch focused on the U.S. immigration system. “The inspection system is practically worthless. … Everyone gets a passing grade.”

The OIG began conducting unannounced inspections in March 2016. But while immigrant advocates welcomed the latest report on Adelanto as confirmation of the abuse and neglect they have long documented, they were skeptical that the report would bring any changes. “This isn’t new, it’s just been swept under the rug by ICE and the GEO Group for as long as they could and for as long as they were allowed to,” said Martinez, of Freedom for Immigrants. “There is zero accountability, which leads to a culture of impunity. … Adelanto is basically a microcosm of the horror that is the U.S. immigration detention system.”