DHS OIG, OIG-24-23, Results of an Unannounced Inspection of ICE's Golden State Annex in McFarland, California (2024)

OIG-24-23 April 18, 2024 FINAL REPORT Results of an Unannounced Inspection of ICE's Golden State Annex in McFarland, California OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Washington, DC 20528 | www.oig.dhs.gov April 18, 2024 MEMORANDUM FOR: Patrick J. Lechleitner Senior Official Performing the Duties of the Director U.S. Immigration and Customs Enforcement FROM: SUBJECT: Joseph V. Cuffari, Ph.D. Inspector General JOSEPH V CUFFARI Digitally signed by JOSEPH V CUFFARI Date: 2024.04.18 08:52:15 -07'00' Results of an Unannounced Inspection of ICE’s Golden State Annex in McFarland, California Attached for your action is our final report, Results of an Unannounced Inspection of ICE’s Golden State Annex in McFarland, California. We incorporated the formal comments provided by your office. The report contains seven recommendations aimed at improving care of detainees at Golden State Annex. Your office concurred with all seven recommendations.

Based on information provided in your response to the draft report, we consider recommendations 1, 2, 3, 5, and 7 resolved and open. We consider recommendations 4 and 6 resolved and closed. Once your office has fully implemented the recommendations, please submit a formal closeout letter to us within 30 days so that we may close the recommendations. The memorandum should be accompanied by evidence of completion of agreed-upon corrective actions.

Please send your response or closure request to [email protected]. 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 contact me with any questions, or your staff may contact Thomas Kait, Deputy Inspector General at (202) 981-6000.

Attachment OIG Project No. 23-001-ISP-ICE(b) DHS OIG HIGHLIGHTS Results of an Unannounced Inspection of ICE’s Golden State Annex in McFarland, California April 18, 2024 Why We Did This Inspection In accordance with the Consolidated Appropriations Act, 2023, we conduct unannounced inspections of ICE detention facilities to ensure compliance with detention standards. From April 18 to 20, 2023, we conducted an in-person inspection of the Golden State Annex in McFarland, California, to evaluate their compliance with ICE detention standards. What We Recommend We made seven recommendations to improve ICE’s oversight of detention facility management and operations in Golden State. What We Found During our unannounced inspection of U.S. Immigration and Customs Enforcement’s (ICE) Golden State Annex (Golden State) in McFarland, California, we found that Golden State complied with ICE’s Performance-Based National Detention Standards 2011 (PBNDS 2011), as revised in December 2016, for use of force, the voluntary work program, access to the law library and legal services, and detainee segregation with one noted exception.

Golden State generally complied with standards for health care, although medical contractors noted delays in optometry care. The facility could not ensure it was completing detainee classification within the required 12 hours, or that all required reclassification paperwork was in detainees’ files. Further, Golden State did not comply with grievance log or response requirements, and detainees housed in segregation did not have access to required recreation facilities. Regarding responses to detainees’ requests, the facility did not always respond to them within the 3-day standard, nor did they always respond in the detainee’s preferred language.

In addition, neither Golden State nor ICE maintained copies of requests in detainees’ files. Also, a roof leak in one of the housing units caused unsafe and unsanitary facility conditions. Finally, ICE paid approximately $25.3 million for unused bed space in the 12 months preceding our inspection. ICE Response For Further Information: Contact our Office of Public Affairs at (202) 981-6000, or email us at: [email protected].

ICE concurred with all seven recommendations. We consider recommendations 1, 2, 3, 5, and 7 resolved and open. We consider recommendations 4 and 6 resolved and closed. www.oig.dhs.gov OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Table of Contents Background .......................................................................................................................................... 1 Results of Inspection ............................................................................................................................

2 Golden State’s Staff Complied with Standards for Use of Force, Voluntary Work Program, Access to Law Library and Legal Services, and Segregation .................................. 2 Golden State’s Medical Staff Generally Complied with Medical Standards but Did Not Ensure Detainees Received Timely Optometry Care .............................................................. 4 Golden State’s Staff Did Not Properly Record Intake and Classification Actions ................. 4 Golden State’s Medical Staff Did Not Take Required Actions on Paper Medical Grievances .................................................................................................................................

5 Golden State Did Not Provide Adequate Outdoor Recreation to SMU Detainees ................ 6 Staff-Detainee Communication Practices at Golden State Were Deficient ........................... 7 Golden State Did Not Comply with Cleanliness and Sanitation Standards .......................... 8 ICE Continues to Pay for Unused Bedspace ............................................................................

9 Recommendations ............................................................................................................................. 11 Management Comments and OIG Analysis ....................................................................................... 11 Appendix A: Objective, Scope, and Methodology ............................................................................. 15 DHS OIG’s Access to DHS Information ...................................................................................

16 Appendix B: ICE Comments on the Draft Report .............................................................................. 17 Appendix C: Office of Inspections and Evaluations Major Contributors to this Report .................. 22 Appendix D: Report Distribution ....................................................................................................... 23 Abbreviations ERO Golden State ICE Mesa Verde PBNDS 2011 SMU Enforcement and Removal Operations Golden State Annex U.S. Immigration and Customs Enforcement Mesa Verde Detention Facility Performance-Based National Detention Standards 2011 Special Management Unit www.oig.dhs.gov OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Background U.S. Immigration and Customs Enforcement (ICE) houses detainees at roughly 120 facilities nationwide, and the conditions and practices at those facilities can vary greatly.

Facilities must comply with ICE detention standards to provide a clean and safe environment and protect the health, safety, and rights of detainees. As mandated by Congress,1 we conduct unannounced inspections of ICE detention facilities and ensure compliance with applicable ICE detention standards. Our program of unannounced inspections of ICE detention facilities has identified and helped correct violations of these detention standards at facilities across the country. From April 18 through 20, 2023, we conducted an unannounced, in-person inspection of Golden State Annex (Golden State) in McFarland, California, and identified concerns regarding detainee care and treatment that we present in this report.

ICE Enforcement and Removal Operations (ERO) oversees the detention facilities it manages in conjunction with private contractors or state or local governments. In December 2019, ICE contracted with The GEO Group, Inc. to provide detention, transportation, and medical services to three facilities under the same contract: Mesa Verde Detention Facility (Mesa Verde), Golden State, and Central Valley Modified Community Correctional Facility. Between April 20, 2022, and April 19, 2023, Golden State had an average daily population of 136 detainees. ICE’s contract with The GEO Group, Inc. requires them to comply with ICE’s Performance-Based National Detention Standards 2011 (PBNDS 2011).

According to ICE, PBNDS 2011 establishes consistent conditions of detention, program operations, and management expectations within ICE’s detention system. These standards set requirements in areas such as: • environmental health and safety, including cleanliness, sanitation, security, detainee searches, segregation, and disciplinary systems; • detainee care, e.g., food service, medical care, and personal hygiene; • activities, including visitation and recreation; and • grievance systems. At the start of our onsite inspection, Golden State housed approximately2 166 adult male ICE detainees and no female detainees. Our onsite team included contracted medical experts who reviewed Golden State’s compliance with applicable medical standards of care;3 we have incorporated their assessments in our findings.

During our inspection, we conducted a walk- 1 Consolidated Appropriations Act, 2023, Pub.

L. No. 117-396, Custody Operations Reporting.

2 The detainee population fluctuates throughout the day as detainees arrive and depart the facility. 3 In addition to the PBNDS 2011 standards, our medical contractors also determine compliance with certain standards from the National Commission on Correctional Health Care’s 2018 Standards for Health Services in Jails. www.oig.dhs.gov 1 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security through of Golden State facilities, including detainee housing units and indoor and outdoor recreation areas. We also requested and reviewed documents and files and interviewed ICE personnel, Golden State officials, and detainees. Results of Inspection We found that Golden State complied with standards for use of force, the voluntary work program, access to law library and legal services, and detainee segregation with one noted exception.

Golden State generally complied with PBNDS 2011 standards related to health care, although our medical contractors noted that detainees experienced delays receiving optometry appointments. The facility could not ensure it was completing classification within 12 hours or that all required reclassification paperwork was in detainees’ files. Further, Golden State did not comply with grievance log or response requirements, and detainees housed in segregation did not have access to required recreation facilities. The facility did not always respond to requests within 3 days and did not always respond to detainees’ requests in their preferred language.

In addition, neither Golden State nor ICE maintained copies of requests in detainees’ files. Also, a roof leak in one of the housing units at Golden State caused unsafe and unsanitary facility conditions. Finally, ICE paid approximately $25.3 million for unused bed space in the 12 months preceding our inspection. Golden State’s Staff Complied with Standards for Use of Force, Voluntary Work Program, Access to Law Library and Legal Services, and Segregation PBNDS 2011 requires appropriate levels of force and restraint to protect the people involved in use of force incidents.4 Generally, appropriate levels of force and restraint mean that facility staff should avoid using techniques such as chokeholds, and they are not allowed to use restraints as a form of punishment.5 PBNDS 2011 also requires staff involved in use of force incidents to submit reports documenting a use of force incident in a timely manner.6 Golden State reported five use of force incidents in the 6 months prior to our inspection.

Through our review of video footage and reports of the incidents, we found the facility staff generally complied with these standards. However, we could not confirm that a use of force incident on February 7, 2023, conformed to all required standards because a technical issue with the video surveillance system led to the partial loss of video footage during the incident. We found that once facility staff recognized the loss of 4 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section (I). 5 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section (V)(E).

6 PBNDS 2011 (Revised 2016), Standard 2.15, Use of Force and Restraints, Section (II)(11). www.oig.dhs.gov 2 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security footage, they contacted the software vendor who was unable to conclusively determine a cause for the loss. Nevertheless, the situation surrounding the use of force and the subsequent escorting of the detainees away from the housing area appeared appropriate. Golden State also complied with standards related to the voluntary work program. PBNDS 2011 requires facilities to provide detainees with the opportunity to participate in voluntary work assignments to earn money while confined.7 Based on our review of policies, procedures, records, and observations, we found that Golden State complied with this standard.

The facility provided program information and position-specific training for detainees who chose to participate in the program. Detainees received payment for their hours worked and work schedules did not exceed 8 hours per day or 40 hours per week as required. PBNDS 2011 also requires facilities to provide detainees with a properly equipped law library supplied with legal materials and equipment.8 We found that Golden State complied with this standard by maintaining a law library adequately equipped with legal materials and equipment that allowed detainees to print and photocopy documents. The law library was accessible for 1 hour a day Monday to Friday in accordance with standards.

Housing units also had computers where detainees could access legal resources and submit requests for printing legal documents. According to PBNDS 2011, facilities are also required to have special management units (SMUs), which house detainees segregated from the general detainee population.9 There are two types of segregation: administrative and disciplinary. Facilities place detainees in administrative segregation when a detainee needs to be segregated from the general population for nonpunitive reasons such as medical observation or protective custody. Facilities place a detainee in disciplinary segregation when they determine a detainee has committed a prohibited act as defined by the Special Management Unit standards.10 Detainees housed in both types of segregation must receive daily medical assessments, welfare checks at least every 30 minutes, and segregation status reviews at prescribed intervals to determine whether continued placement is appropriate.

Detainees housed in the SMU are also allowed detainee privileges such as legal materials and visits, telephone calls, and recreation time. At the time of our site visit, Golden State housed three detainees in their SMU, all for administrative segregation purposes. Based on our review of the detainees’ files, we found the facility generally complied with the standards for segregation. However, as discussed later in this report, Golden State did not fully comply with the recreation requirements within this standard.

7 PBNDS 2011 (Revised 2016), Standard 5.8, Voluntary Work Program, Section (I). 8 PBNDS 2011 (Revised 2016), Standard 6.3, Law Libraries and Legal Material, Section (II)(1). 9 PBNDS 2011 (Revised 2016), Standard 2.12, Special Management Units, Section (II)(1). 10 Id. www.oig.dhs.gov 3 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Golden State’s Medical Staff Generally Complied with Medical Standards but Did Not Ensure Detainees Received Timely Optometry Care PBNDS 2011 requires that detainees have access to appropriate and necessary medical care, to include specialty health care.11 The GEO Group, Inc. manages all aspects of the health care delivery process at Golden State and arranges with community providers for some specialty care needs.

The facility complied with most PBNDS 2011 standards related to medical care, including program administration, emergency care, health care records, sick call, chronic care, pharmacy management, medical diets, and privacy. However, our medical contractors noted delays in detainees’ receipt of optometry care. Specifically, the general lack of optometry providers in the surrounding community delayed detainee’s timely receipt of care. Facility staff confirmed that from January 1, 2023, through June 21, 2023, they requested 42 optometry appointments from outside providers and the average length of time between detainees receiving approval for optometry appointments from an outside provider and the actual appointment date was 79 days.

Delayed access to optometry care could lead to negative health effects. Golden State’s Staff Did Not Properly Record Intake and Classification Actions PBNDS 2011 states facility staff must complete the initial classification process12 and initial housing assignment within 12 hours of a detainee’s admission to the facility and after completion of the in-processing health screening.13 During our review of 16 detainee files, we could not determine if classification took place within 12 hours of admission for 13 of the 16 files, and we could not determine if classification took place after the in-processing health screening for 14 of the 16 files. Although medical staff include a timestamp on the in-processing health screening records to document the time they completed the screening, the classification paperwork does not contain a timestamp to document when initial classification occurs. Without a final timestamp, the facility cannot ensure classification is occurring after the in- processing health screening or within 12 hours of a detainee’s admission to the facility, as required by PBNDS 2011.

This is important because Golden State must ensure that detainees are not at a health risk to themselves or others before entering the facility and co-mingling with others. Additionally, PBNDS 2011 requires that facility staff place classification forms and supporting documentation in detainees’ files.14 Although Golden State complied by having the special vulnerabilities worksheet placed in all files, we found that in 2 of the 16 files, facility staff initialed the space denoting a reclassification, but no reclassification paperwork was in the file, 11 PBNDS 2011 (Revised 2016), Standard 4.3, Medical Care, Section (V)(A)(2;5). 12 PBNDS 2011 (Revised 2016), Standard 2.2, Custody Classification System (I), “Classification is the formal process for managing and separating detainees based on verifiable and documented data.” 13 PBNDS 2011 (Revised 2016), Standard 2.2, Custody Classification System, Section (V)(D). 14 PBNDS 2011 (Revised 2016), Standard 2.2, Custody Classification System, Section (V)(J). www.oig.dhs.gov 4 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security as required.

By not adhering to the standard, Golden State cannot ensure detainees’ files properly reflect their history at the facility. Golden State’s Medical Staff Did Not Take Required Actions on Paper Medical Grievances Golden State complied with most, but not all requirements for the grievance system. PBNDS 2011 requires facilities to have a procedure for detainees to file grievances and receive a timely response.15 Facility staff must properly maintain detainee files with the grievances in them.16 Furthermore, staff must respond to grievances in a detainee’s preferred language.17 We reviewed a sample of 26 grievances submitted by detainees and found that facility staff mostly responded to the detainee grievance in the same language written by the detainee for all the grievances in our sample. However, facility staff did not always provide timely action of medical grievances and did not properly record paper grievances.

Later in this report we discuss compliance with non-medical grievances. Facility staff must ensure that the administrative health authority receives all medical grievances within 24 hours.18 Our review of 10 medical grievances — 5 paper and 5 electronic — found that medical staff did not act on any of the paper medical grievances within 24 hours as required. We determined this by comparing the date submitted by the detainee to the date received by the healthcare workers. The delayed action in response to medical grievances could negatively impact detainees’ health care.

In addition, Golden State stores all detainee medical data electronically and, therefore, requires medical staff to scan paper medical grievances and upload them to the detainee’s electronic file. We reviewed five paper medical grievances and found that four of the five paper medical grievances were not scanned and stored into the detainee’s electronic file. By not uploading the paper medical grievance to the electronic file, medical professionals do not have the opportunity to review all medical information for a detainee. PBNDS 2011 also requires that facilities maintain accurate records for filed grievances and document their resolution in a grievance log and the detainee’s file.19 The facility provided a log of paper grievances submitted by detainees.

We reviewed the corresponding detainee’s file for the submitted paper grievance and found that in four of the six files we reviewed, not all grievances listed in the paper grievance log were in the detainee’s file. The detainee’s file must 15 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (II)(3). 16 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (II)(7). 17 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (V)(C)(3).

18 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (V)(A)(4). 19 PBNDS 2011 (Revised 2016), Standard 6.2, Grievance System, Section (II)(7). www.oig.dhs.gov 5 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security include proper documentation of grievances to document the treatment each detainee receives and show the accuracy and timeliness of grievance responses. Golden State Did Not Provide Adequate Outdoor Recreation to SMU Detainees PBNDS 2011’s recreation standards require that each detainee has access to recreation and exercise.20 During our inspection the team observed that detainees housed in general population had access to two outdoor recreational areas that were equipped with exercise equipment, an artificial turf field with soccer goals, and a handball court. These detainees also had access to the facility’s indoor recreational space with activities like board games and arts and crafts.

Although Golden State provided access to recreational and exercise programs and activities to detainees in general population, it did not follow standards related to outdoor recreation for detainees in SMU. During our inspection of the SMU facilities, the team observed that the SMU outdoor recreational space did not comply with PBNDS 2011 standards. PBNDS 2011 states that each detainee in a SMU shall receive (or be offered) access to exercise opportunities and equipment outside the living area and outdoors.21 We observed the designated space for SMU recreation consisted of a small, fenced-in, empty area with no exercise equipment, as seen in Figure 1. The SMU recreation area is also limited in access because it doubles as the facility’s secure intake area used during detainees’ arrival to the facility.

Using the designated recreation area as part of the detainee transfer process could delay or eliminate recreation time for detainees in SMU if there is a scheduling conflict. The absence or reduction of access to a formal outdoor recreational area violated ICE standards and the rights of the detainee.22 20 PBNDS 2011 (Revised 2016), Standard 5.4, Recreation, Section (I). 21 PBNDS 2011 (Revised 2016), Standard 5.4, Recreation, Section (II)(4). 22 In October 2023, the facility purchased three pieces of portable exercise equipment for detainees in SMU, including an ab roller wheel, a weighted medicine ball, and push up bars. www.oig.dhs.gov 6 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Figure 1.

SMU Recreational Area, Observed on April 18, 2023 Source: Department of Homeland Security OIG photo Staff-Detainee Communication Practices at Golden State Were Deficient PBNDS 2011 encourages and requires direct and written contact among staff and detainees to enhance security, safety, and orderly facility operations.23 This communication standard includes a detainee’s right to submit questions and requests to the facility and to ICE. Golden State’s Staff Did Not Always Reply Timely to Detainee Requests or Provide a Response in the Detainee’s Preferred Language PBNDS 2011 requires a staff member to respond to detainee requests within 3 business days and in a language understood by the detainee.24 Golden State provided request logs containing 9,063 requests from detainees to the facility between December 1, 2022, and April 18, 2023. Of the 9,063 requests, detainees submitted 7,603 electronically and 1,460 by paper. We reviewed a sample of 60 requests and found 22 percent (13 of the 60) did not receive a response within 3 23 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section (I).

24 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section (V)(B)(1)(a); (V)(B). www.oig.dhs.gov 7 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security business days. In addition, none of the five requests submitted in a language other than English received a response in the detainee’s preferred language. We also reviewed a sample of 60 requests submitted to ICE and found 60 percent (36 of the 60) did not receive a response within 3 business days. In addition, four of nine requests submitted in a language other than English did not receive a response in the detainee’s preferred language.

Neither the facility nor ICE can ensure a detainee understands the response to their request if it is not in the detainee’s preferred language.25 Golden State Did Not Keep Request Copies in Detainees’ Files Finally, during our review of a sample of requests to the facility and to ICE, we reviewed whether Golden State maintained documentation of the requests and the corresponding responses in detainee files, as required by PBNDS 2011.26 Partway through our review, facility staff informed us of an ICE ERO memo,27 which they mistakenly believed exempted them from the requirement to maintain electronic request documentation in detainee files. The memorandum states that the use of tablet technologies is permissible for facilitating staff-detainee communication, but it does not state that facilities are exempt from the PBNDS 2011 requirement to maintain copies of requests in detainee files. Subsequently, facility staff confirmed that we would not find electronic request documentation in the detainee files during our review. Golden State Did Not Comply with Cleanliness and Sanitation Standards PBNDS 2011 states staff shall maintain facility cleanliness and sanitation at the highest level.28 While inspecting the housing area at Golden State, we located a large water stain running from the ceiling to the windows and continuing to the floor in one of the dorms.

Detainees and staff informed us the water stain was from an ongoing leak from the roof, as seen in Figure 2. Staff provide detainees blankets to soak up the water when it rains because the water pools on the floor and causes a slipping hazard, forcing detainees to live in a potentially dangerous setting. Facility staff submitted the first work order for the leak in December 2022, 4 months prior to our inspection. There were also work orders for leaks in three other housing units and in the intake area.

The cause of the roof leak was unknown, and to date, facility janitorial staff have made 25 In addition to PBNDS 2011 (Revised 2016) standards, facilities must also comply with Title VI, 42 U.S.C. § 2000d et seq., which prohibits discrimination based on race, color, and national origin in programs and activities receiving federal financial assistance, and Executive Order 13166 (2000) that mandates federal agencies provide meaningful access to persons with limited English proficiency. 26 PBNDS 2011 (Revised 2016), Standard 2.13, Staff-Detainee Communication, Section (V)(B)(2). 27 October 10, 2018, memo titled, Use of Tablet Technology for Electronic Grievances, from Assistant Director for Custody Management, Tae Johnson, with the concurrence of the Acting Assistant Director for Field Operations, David Jennings. 28 PBNDS 2011 (Revised 2016), Standard 1.2, Environmental Health and Safety, Section (II)(1). www.oig.dhs.gov 8 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security only temporary, short-term patches.

We asked when the leaks would be fixed permanently, and facility staff said it could take up to 6 months to have it fixed by a specialist. Figure 2. Water Stains from a Ceiling Leak that Dripped Down Walls, Observed on April 18, 2023 Source: DHS OIG photo ICE Continues to Pay for Unused Bedspace ICE’s contract with The GEO Group, Inc. requires ICE to pay the facility for a guaranteed minimum of 560 detainees. We analyzed 12 months of population counts at Golden State, from April 20, 2022, through April 19, 2023, and found that detainee populations were consistently less than the contractual guaranteed minimum amount of 560 detainees, with an average detainee www.oig.dhs.gov 9 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security population of 136 for all 12 months, as seen in Figure 3.

During the 1-year timeframe we reviewed, ICE paid approximately $25.3 million for unused bed space. 29 Figure 3. Monthly Average of Occupied vs. Empty Beds Based on the Guaranteed Minimum of 560 Detainees between April 20, 2022, and April 19, 2023 Source: DHS OIG analysis of data provided by Golden State Further, the Golden State facility is located approximately 26 miles northwest of Mesa Verde, which also houses ICE detainees. During the 3 months that preceded our site visit to Golden State, Mesa Verde housed an average of 47 detainees per day.

Golden State’s average detainee population during that same 3-month timeframe was 152 detainees. Combining the detainee population from Golden State and Mesa Verde would have resulted in an average detainee population of 199 detainees, keeping Golden State significantly under the guaranteed minimum of 560 detainees. Specifically, if the detainee populations from Golden State and Mesa Verde were combined and housed at Golden State, there still would have been an average of 361 open beds at the facility. 29 DHS OIG is currently conducting an audit of ICE’s acquisition and management of detention space, to include a review of the extent to which the contracts and agreements are in accordance with Federal and Department requirements. www.oig.dhs.gov 10 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Recommendations We recommend the Executive Associate Director of ERO direct the San Francisco Field Office, responsible for Golden State, to: Recommendation 1: Establish a plan to reduce wait times for optometry appointments.

Recommendation 2: Include a timestamp on the classification documentations for initial classification of each detainee and ensure staff maintain all classification paperwork, to include reclassification, in the detainee’s file. Recommendation 3: Collect medical grievances within 24 hours of submission by a detainee and ensure staff maintain a copy of all paper medical grievances in the detainee’s medical file. Recommendation 4: Provide SMU detainees access to commensurate recreational areas as are available to detainees housed in general population, specifically areas that include exercise opportunities and equipment. Recommendation 5: Ensure staff’s communication with detainees adheres to standards, including: a. requests are responded to within 3 business days; b. requests are responded to in a detainee’s preferred language; and c. copies of detainee requests are kept in the detainee’s file.

Recommendation 6: Make necessary and permanent repairs to the roof leak described and depicted in this report. Recommendation 7: Review and update ICE’s contract with Golden State by assessing housing requirements and determining an appropriate guaranteed minimum to avoid excessive payment for unused bed space. Management Comments and OIG Analysis ICE provided written comments in response to the draft report and concurred with all seven recommendations. Appendix B contains ICE’s management comments in their entirety.

We also received technical comments from ICE on the draft report, and we revised the report as appropriate. We consider recommendations 1, 2, 3, 5, and 7 resolved and open. We consider recommendations 4 and 6 resolved and closed. A summary of ICE’s response and our analysis follows. www.oig.dhs.gov 11 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security ICE Response to Recommendation 1: Concur.

In August 2023, the Golden State medical department contracted with a local optometrist located in Bakersfield, California. If a noncitizen has an urgent need to see the optometrist/ophthalmologist, and the Golden State medical department is unable to schedule promptly with the current off-site specialist, a higher level of care request will be made to the Field Medical Coordinator and placement will be found where this need can be met with urgency. In January 2024, the Golden State medical department provided documentation as supporting evidence of efforts to address this recommendation. ICE requests that the OIG consider this recommendation resolved and closed, as implemented.

OIG Analysis: We consider these actions partially responsive to our recommendation. The facility provided consultation records of one detainee requiring optometry care in July 2023 and the corresponding optometry appointment in September 2023, which is approximately 60 days in between consultation and the appointment (19 days sooner than the average we reported). We will close this recommendation when ICE provides 3 months of documentation that continues to show reduced wait times for optometry care. We consider this recommendation resolved and open.

ICE Response to Recommendation 2: Concur. In September 2023, Golden State updated the pre- existing initial classification checklist to include a timestamp. In late September and early October 2023, Golden State also provided refresher training to all intake staff regarding the updated checklist. The completed forms are maintained in the detainee’s detention file and the intake supervisor monitors to verify the checklists are completed within the required time frame for each task.

In January 2024, ICE ERO provided the updated checklist and a training sign-in- sheet as supporting evidence of these actions. ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: We consider these actions partially responsive to our recommendation. ICE provided a revised checklist that has a specific field for intake staff to document the time of each new arrival item/process that is required.

ICE also provided a training sign-in-sheet from September 2023 and documentation that the training topics included the revised checklist. We consider this recommendation resolved and open. We will close this recommendation when ICE provides evidence that facility staff are maintaining all classification paperwork, to include reclassification, in the detainee’s file. ICE Response to Recommendation 3: Concur.

In October 2023, the Golden State health service administrator provided refresher training to all medical staff on the requirements of reviewing all medical grievances. In January 2024, ICE ERO provided copies of medical grievance logs as supporting evidence of this action. ICE requests that the OIG consider this recommendation resolved and closed, as implemented. www.oig.dhs.gov 12 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security OIG Analysis: We consider these actions partially responsive to the recommendation. The facility provided medical grievance logs from April through September 2023 that show medical staff responded to medical grievances within 24 hours of collection.

However, the logs do not demonstrate that facility staff are collecting grievances within 24 hours of submission and instead show that facility staff collected many of the medical grievances several days after the “date of letter.” We consider this recommendation resolved and open. We will close this recommendation when ICE provides evidence that facility staff are collecting grievances within 24 hours of submission and that facility staff are maintaining copies of all paper medical grievances in the detainee’s medical file. ICE Response to Recommendation 4: Concur, however, it is important to note that while portable recreational equipment was not permanently allocated to the Golden State SMU recreational area during the OIG’s inspection that occurred from April 18 to 20, 2023, such equipment was available for transfer from the main recreational area and/or other recreational areas for use by noncitizens upon request. In October 2023, Golden State purchased permanent recreation equipment for the SMU recreational area and in January 2024, ICE ERO provided purchase orders as corroborating evidence of these actions.

ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: We consider these actions responsive to the recommendation. ICE provided the purchase order for recreational equipment for detainees in SMU. ICE also provided evidence that detainees in SMU are offered recreation time in other areas of the facility when the area designated for SMU recreation is used for detainee transport.

We consider this recommendation resolved and closed. ICE Response to Recommendation 5: Concur. In September 2023, the Acting Assistant Field Office Director provided written clarification on staff communication to all ICE personnel overseeing Golden State. Further, in October 2023, Golden State released a memorandum informing program staff about the process for all staff communication with detainees.

In January 2024, ICE ERO provided copies of relevant documentation as supporting evidence of these actions. ICE requests that the OIG consider this recommendation resolved and closed, as implemented. OIG Analysis: We consider these actions partially responsive to our recommendation. The Golden State Facility Administrator sent a memo to the Program Departments at Golden State stating detainee requests should be collected on a daily basis and original requests should be placed in the detainee’s file.

In addition, the ICE Assistant Field Office Director of the San Francisco Field Office sent an email to the ICE Supervisory Detention and Deportation Officer of the Bakersfield Sub-Office saying, “[i]f the detainee sends you a request in a language other than English, before sending the response, please translate to the language in which the request was submitted.” We consider this recommendation resolved and open. We will close this www.oig.dhs.gov 13 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security recommendation when ICE provides 3 months of detainee request logs from the facility and from ICE that shows the facility and ICE are responding to requests within 3 business days, and responses are in the detainee’s preferred language. In addition, ICE should provide evidence that the facility keeps requests in the detainee’s file. ICE Response to Recommendation 6: Concur.

In October 2023, ICE ERO completed repairs to the roof. The Golden State maintenance staff will continue to monitor this area and the roof on an ongoing basis to identify and repair any future leaks, as appropriate. In January 2024, ICE ERO provided purchase orders and photographs as corroborating evidence of these actions. ICE requests that the OIG consider this recommendation resolved and closed, as implemented.

OIG Analysis: We consider these actions responsive to our recommendation. ICE provided documentation that the facility purchased roof repair items in September and October 2023. They also provided photographs of the roof, which appear to show that the facility completed the repairs. We consider this recommendation resolved and closed.

ICE Response to Recommendation 7: Concur.

ICE ERO

San Francisco Field Office staff will assess its use of Golden State and work with the detention operator to determine an appropriate guaranteed minimum level that does not adversely affect ICE’s operational readiness. Estimated Completion Date: November 29, 2024. OIG Analysis: We consider these actions partially responsive to the recommendation. We consider this recommendation resolved and open.

We will close this recommendation when ICE provides evidence of the analysis used to determine an appropriate guaranteed minimum level for Golden State and updates its contract with the facility accordingly. www.oig.dhs.gov 14 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix A: Objective, Scope, and Methodology The Department of Homeland Security Office of Inspector General was established by the Homeland Security Act of 2002 (Pub. L. No. 107-296) by amendment to the Inspector General Act of 1978. DHS OIG initiated this inspection at Congress’ direction. DHS OIG analyzes various factors to determine which facilities to inspect.

We review OIG Hotline complaints and prior inspection reports, and past and future inspection schedules of other ICE and DHS inspection organizations. We also consider requests, input, and information from Congress, the DHS Office of Civil Rights and Civil Liberties, nongovernmental organizations, and media outlets to determine which facilities may pose the greatest risks to the health and safety of detainees. Finally, to ensure we review facilities with both large and small detainee populations in geographically diverse locations, we consider facility type (e.g., service processing centers, contract detention facilities, and intergovernmental service agreement facilities) and applicable PBNDS. We generally limit our scope to the PBNDS 2011 for health, safety, medical care, mental health care, grievances, classification, searches, use of segregation, use of force, and staff training.

However, as noted in this report, our medical contractors also used the National Commission on Correctional Health Care’s 2018 Standards for Health Services in Jails when reviewing medical- related policies and procedures at the facility. Prior to our inspection, we reviewed relevant background information, including: • OIG Hotline complaints • • • ICE PBNDS 2011 ICE Office of Detention Oversight reports and other inspection reports Information from nongovernmental organizations We conducted our unannounced in-person inspection of Golden State from April 18 through April 20, 2023. During the inspection, we: • Conducted an in-person walk-through of the facility. We viewed areas used by detainees, including intake processing areas; medical facilities; residential areas, including sleeping, showering, and toilet facilities; legal services areas, including law libraries; and recreational facilities. • Reviewed the facility’s compliance with key health, safety, and welfare requirements of the PBNDS 2011 for classification, segregation, voluntary work program, access to legal services, access to medical care and mental health care, and medical and nonmedical grievances. www.oig.dhs.gov 15 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security • • Interviewed ICE and detention facility staff members, including key ICE operational and detention facility oversight staff and detention facility medical, classification, grievance, and compliance officers.

Interviewed detainees held at the detention facility to evaluate compliance with PBNDS 2011 grievance procedures and grievance resolution. • Reviewed documentary evidence, including medical files, detainee files, and grievance and communication logs and files. For our review of requests, we selected 60 requests out of the 9,063 by reviewing the request log and arbitrarily selecting one request at an interval of every few hundred. • Analyzed daily population counts and bed rate costs from April 20, 2022, through April 19, 2023, to identify payments from ICE to the facility for unused bedspace. We contracted with a team of qualified medical professionals to conduct a comprehensive evaluation of detainee medical care at the Golden State facility. We incorporated information provided by the medical contractors in our findings.

We conducted work for this report between April and August 2023 pursuant to the Inspector General Act of 1978, 5 U.S.C. §§ 401-424, and in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. DHS OIG’s Access to DHS Information During this inspection, DHS provided timely responses to our requests for information and did not deny or delay access to the information we requested. www.oig.dhs.gov 16 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix B: ICE Comments on the Draft Report www.oig.dhs.gov 17 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 18 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 19 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 20 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security www.oig.dhs.gov 21 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix C: Office of Inspections and Evaluations Major Contributors to this Report John Shiffer, Chief Inspector Steven Staats, Chief Inspector Adam Brown, Lead Inspector Gwen Schrade, Lead Inspector Benjamin Diamond, Senior Inspector Becky Sneed, Senior Inspector Mitch Trump, Senior Inspector Joshua Bradley, Inspector Catlin O’Halloran, Attorney Advisor Dorie Chang, Communications Analyst Jasmin Hammad, Independent Referencer www.oig.dhs.gov 22 OIG-24-23 OFFICE OF INSPECTOR GENERAL U.S. Department of Homeland Security Appendix D: Report Distribution Department of Homeland Security Secretary Deputy Secretary Chief of Staff Deputy Chiefs of Staff General Counsel Executive Secretary Director, GAO/OIG Liaison Office Under Secretary, Office of Strategy, Policy, and Plans Assistant Secretary for Office of Public Affairs Assistant Secretary for Office of Legislative Affairs ICE Audit Liaison Office of Management and Budget Chief, Homeland Security Branch DHS OIG Budget Examiner Congress Congressional Oversight and Appropriations Committees www.oig.dhs.gov 23 OIG-24-23 To view this and any other DHS OIG reports, Please visit our website: www.oig.dhs.gov Additional Information For further information or questions, please contact the DHS OIG Office of Public Affairs via email: [email protected] DHS OIG Hotline To report fraud, waste, abuse, or criminal misconduct involving U.S. Department of Homeland Security programs, personnel, and funds, please visit: www.oig.dhs.gov/hotline If you cannot access our website, please contact the hotline by phone or mail: Call: 1-800-323-8603 U.S. Mail: Department of Homeland Security Office of Inspector General, Mail Stop 0305 Attention: Hotline 245 Murray Drive SW Washington, DC 20528-0305