By Susan Ferriss, Center for Public Integrity

U.S. Immigration and Customs Enforcement (ICE) is facing fresh pressure from a federal watchdog to end “improper” segregation, improve “inadequate” medical care, and protect detainees from a practice linked to suicide at a California facility that holds ICE detainees.

A “management alert” urging ICE to immediately address these threats to the safety and rights of detainees at the privately run Adelanto ICE Processing Center was released this week by the Department of Homeland Security’s Office of the Inspector General. ICE is part of the department. The sprawling Adelanto detention center sits 90 miles northeast of Los Angeles in the Mojave Desert city of Adelanto and is owned and operated by the Boca Raton, Florida-based GEO Group, one of the country’s largest private prison companies.

GEO contributed $250,000 to President Donald J. Trump’s inauguration and is benefiting from new ICE contracts—even as it fights lawsuits and other complaints related to alleged medical neglect and abusive conditions at Adelanto, as the Center for Public Integrity reported in September.

The center reviewed documents issued by Homeland Security’s Office of Detention Oversight finding that the death of one Adelanto detainee “could have been prevented” with more acceptable medical care, and that the death of another occurred in the wake of medical care that did not meet ICE standards.

The new Homeland Security, or DHS, inspector general alert was issued after officials carried out an unannounced visit to Adelanto in May, at a time when 307 contact guards were responsible for 1,659 detainees.

“Although this form of civil custody should be non-punitive,” inspector general officials wrote, “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.”

In response to the alert, Pablo Paez, GEO’s vice president for corporate relations, reached by email, referred questions about findings to ICE. The agency did not immediately respond to requests for comment.

In California, Freedom for Immigrants, an organization that aids detainees and monitors conditions, said: “The report confirms what we’ve documented through our own monitoring efforts.”

Liz Martinez, a spokeswoman for the group, said violations uncovered by the DHS IG “are further proof” that Adelanto is a “hostile environment that endangers the lives of thousands of detainees,” among them “asylum seekers, victims of human trafficking, legal permanent residents (who’ve been placed in detention for some reason) and other immigrants.”

As they toured cells, DHS IG officials reported, they saw, in violation of ICE standards, bundles that guards and detainees referred to as “nooses” hanging from cell vents. Detainees said they braid sheets into bundles and then unfurl them at times to provide privacy in a bathroom or bunk area or to use as a clothesline.

But in March 2013, the inspector general alert says, a man found hanging from bed sheets in his Adelanto cell died at a local hospital. Afterward, two suicide attempts at Adelanto also involved bed sheets. Nationally, four of 20 detainee deaths between October 2016 and July 2018 involved “self-inflicted strangulation,” the alert says, citing ICE news releases.

The alert also says that during interviews with Adelanto detainees, one told officials: “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.”

“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,” officials who worked on the alert also wrote. “According to a senior ICE official,” the report states, “local ICE management at Adelanto does not believe it is necessary or a priority to address the braided sheets issue.”

“ICE must prioritize addressing the issue of sheets hanging in detainee cells, as they represent the potential to assist suicide acts,” the alert concludes.

Officials also found during their visit that 14 detainees at Adelanto were in “disciplinary segregation” and concluded that all 14 had been placed there “before they were found guilty of a prohibited act or rule violation.” A practice of placing detainees directly in disciplinary segregation “to prevent further issues with the detainee” violated due process, officials found. In seven cases, officials also found, detainees were also subjected to penalties that were not subsequently approved by a disciplinary panel.

“ If detainees can’t get dental floss through their commissary accounts, the dentist suggested, ‘detainees could use string from their socks to floss if they were dedicated to dental hygiene,’ officials wrote. ”

“We learned that these detainees lost the ability to purchase or keep commissary items [which can include hygiene products] in their cells while in disciplinary segregation,” officials wrote. Further, according to center staff, “all detainees in disciplinary segregation lose contact visits with family.”

Officials also observed GEO contract guards at Adelanto moving six segregated detainees who had been placed in handcuffs and shackles—a practice, guards told officials, used whenever segregated detainees are outside cells. Using restraints routinely, the alert says, “does not comport with ICE standards and gives the appearance of criminal, rather than civil, custody.”

IG representatives also intervened when they found a disabled detainee inappropriately held in segregation for nine days, during which “the detainee never left his wheelchair to sleep in a bed or brush his teeth.”

“During our visit,” officials wrote, “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.”

IG investigators additionally uncovered violations of standards requiring communications assistance so detainees in segregation can understand both their rights and the reasons for any discipline. During their visit, officials wrote, they encountered a blind detainee with limited English proficiency in segregation who had no “auxiliary aids or translated materials.”

The alert was equally critical with regard to medical care. Officials wrote that they observed Adelanto medical providers making “cursory walk-throughs” in areas where detainees were in segregation and said they reviewed documents revealing multiple grievances about untimely medical care, including dental.

About 80 medical grievances were filed between November 2017 and April 2018, for “not being seen for months for persistent health conditions and not receiving prescribed medication.”

According to logs, no detainees received dental cleanings for four years, the alert says. One of the two dentists at Adelanto told officials that he doesn’t have time for fillings. If detainees can’t get dental floss through their commissary accounts, the dentist suggested, “detainees could use string from their socks to floss if they were dedicated to dental hygiene,” officials wrote.

Officials also concluded: “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.”

Officials with the DHS Office of the Inspector General urged ICE to conduct a full review of Adelanto and GEO’s management of the center. ICE has reported, the officials wrote, that it has scheduled a contractor to inspect the detention center beginning in a little more than a week.

The Center for Public Integrity is a nonprofit investigative journalism organization based in Washington, D.C.