‘The Warden is the highest ranking official at ACF and is responsible for oversight of daily operations. The total number of ACF staff employed at the facility is MB In addition to the Warden, ACF supervisory staff consists of an Assistant Warden, a deputy administrator, [SIE managers, Siilcaptain, a chief of security, Mieutenants, Sg) sergeants, Midetention officers, THledical staff, ancy administrative and maintenance staff. In March 2012, an ICE detainee who had been housed at ACF died of alcoholic liver disease, sepsis, multi-organ failure, and bronchopneumonia after being transported to the Victor Valley Community Hospital in Victorville, California, This was the first ICE detainee death to ever occur at ACF, Following the death, ODO conducted a Detaince Death Review (DDR) to determine compliance with the PBNDS and established policies and procedures. Based on the findings of the DDR, ODO concluded ACF medical staff failed to provide adequate health care gation disclosed several egregious errors committed by ACF medical staff, including failure to perform proper physical examinations in response to symptoms and complaints, failure to pursue any records critical to continuity of care, and failure to facilitate timely and appropriate sects to offi teamens. ODO concluded ie detene's deal could ave bmn prevented and that the detainee received an unacceptable Tevel of medical care while detainc In November 2011, ERO Detention Standards Compliance Unit contractor, MGT of America, Inc., conducted an annual review of the PBNDS at the ACF East facility. ACF received an overall rating of “Does Not Meet Standards,” yet was found compliant with 39 of 40 standards reviewed. The inspection concluded medical officials were not conducting detainee health appraisals within 14 days of arrival, and registered nurses were performing health assessments without training or certification from the Clinical Director. In July 2012, ERO Detention Standards Compliance Unit contractor, The Nakamoto Group, Inc., conducted a pre-occupancy inspection of the ACF West facility. At that time, there were no ICE detainees housed at the West facility. ACF did not receive any rating since the review was only a pre-occupancy review. During this Cl, ODO reviewed 17 PBNDS at both the ACF East and West facilities. Eleven standards were determined to be fully compliant. Ten deficiencies were identified in the following six standards: Detainee Handbook (1 deficiency), Food Service (2), Funds and Personal Property (1), Grievance System (1), Law Libraries and Legal Material (2), and Medical Care (3). This report details all deficiencies identified by ODO and refers to the specific, relevant sections of the PBNDS. ERO will be provided a copy of this report to assist in developing corrective actions to resolve all identified deficiencies. These deficiencies were discussed with ACF and ERO staff on-site during the inspection, as well as during the closeout briefing conducted on September 18, 2012. Of particular concern, lavatories for kitchen workers in the West facility did not have appropriate supplies for hand-washing before handling or preparing food. Further, ODO’s review of 30 medical records of newly-arrived detainees indicated ten were not reviewed. by a physician within 24 hours, as required by the PBNDS. Furthermore, 12 of 25 sick call requests reviewed by ODO were not triaged within 48 hours as required. ODO also found (EE ‘Gffice of Detention Oversight ‘Adelanto Correctional Facility ‘September 2012 2 ERO Los Angeles OPR 201207738