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LOS ANGELES — For Carlos Inzunza, the image will be forever seared in his mind: a cellmate hanging by a twisted sheet at the Adelanto immigrant detention center in Southern California. The noose was cut loose by a guard just in time.
“There was a lot of despair over there,” said Mr. Inzunza, 43, who spent seven months at the center in the southwestern Mojave Desert last year. “I was in a cell with five other people. Two of them were anxious and wanted to commit suicide.”
Migrants imprisoned at the country’s largest privately-run adult immigration detention facility manage to regularly hang “nooses” fashioned from bedsheets in their cells, according to a report by federal inspectors made public on Tuesday.
During an unannounced visit in May, federal inspectors found that 15 out of 20 cells they inspected had what they described as nooses made of braided bedsheets hanging from vents, the Department of Homeland Security’s Office of the Inspector General reported in a 15-page “alert.”
The report also raised questions about inadequate medical care and “overly restrictive segregation” of immigrants housed at the Immigration and Customs Enforcement Processing Center, who had been detained for being in the United States illegally or were seeking protection under asylum laws.
Despite a suicide conducted with the use of bedsheets last year and three other unsuccessful attempts at the facility in 2017, workers had not impeded detainees from draping sheets in their cells, the report found.
“One detainee told us, ‘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,’” the inspectors said in their report.
It described the nooses as a “recurring problem” and a violation of safety standards that Immigration and Customs Enforcement, which oversees immigrant detention, “has not taken seriously.”
“The contract guard escorting us during our visit removed the first noose found in a detainee cell, but stopped after realizing many cells we visited had nooses hanging from the vents,” the report said, adding that inspectors also heard the guard instruct detainees to take down sheets.
The inspectors said some detainees told them that the braided sheets could be unfurled to temporarily create privacy within their cells, especially around the toilet; two said they tied them to a bedpost to serve as a clothesline.
The auditors urged ICE officials to prioritize the “issue of sheets hanging in detainee cells, as they represent the potential to assist suicide acts,” and said that the agency’s failure to address the matter “shows a disregard for detainee health and safety.”
“This is one of the most scathing reports that the Office of the Inspector General has ever issued about an immigration detention center. It reveals that it’s long past time for the federal government to ensure the safety of detainees there,” said Michael Kaufman, a lawyer for the American Civil Liberties Union of Southern California, who has been monitoring conditions at the Adelanto center since it opened in 2011.
There were seven suicide attempts at Adelanto between December 2016 and October 2017, according to the report, at least two of them involving sheets.
Adelanto is one of many privately run immigrant detention centers across the country. The facility, which holds nearly 2,000 adults, is operated under contract by the Geo Group, whose staff members are expected to follow standards of care set by the federal government.
The immigration agency has relied increasingly on private contractors to care for the exploding detainee population amid an intensified crackdown on illegal immigration by the Trump administration. More than 40,000 immigrants are in detention on any given day across the country.
Mr. Kaufman of the A.C.L.U. was the lead author of a 2015 report documenting substandard medical care at Adelanto that led to tragic consequences, he said, including the death of at least one detainee. “ICE has taken no meaningful steps since that time to address the problems,” he said.
Adelanto has been singled out frequently for lapses in safety and health care. Last year, about 35 detainees began a hunger strike over conditions at the facility. They demanded an end to what they described as cruel and unusual punishment, according to a letter they submitted to community groups and lawyers from whom they were seeking support.
“We hear from our clients that their concerns about access to mental and medical health care were routinely dismissed by guards. The longer they are there, the more their mental health deteriorates because of isolation and lack of proper care,” said Lindsay Toczylowski, executive director of the Immigrant Defenders Law Center in Los Angeles, which represents several detainees.
In response to the inspector general’s report, ICE said it “concurred” with its recommendation and was “implementing corrective actions to ensure the Adelanto ICE Processing Center meets required detention standards.” The agency said it would complete a full inspection of the facility “to ensure concerns identified in this report are fully inspected and addressed.”
A Geo Group spokesman referred questions to ICE.
Adelanto holds adult women and men in immigration custody, including those who are applying for asylum, who were apprehended during an immigration raid in the interior of the country, and who were, more recently, separated from their children at the border.
Unlike prisoners in the penal system, immigrants at the facility have committed no crimes other than illegally crossing the border, and are awaiting civil proceedings in the immigration courts.
The facility is 90 miles northeast of Los Angeles in the high desert, making it difficult for detainees to secure legal representation or receive family visits. “They are isolated from friends, family and access to counsel,” Ms. Toczylowki said.
The inspectors found that detainees were inappropriately segregated from others without a disciplinary hearing, as required by standards. For example, it said that 14 detainees were placed in isolation for behavioral issues before they had been found guilty of committing a prohibited act or violating a rule, which can include getting in a brawl or not following orders. A wheelchair-bound detainee was segregated nine days without adequate medical care and not allowed to leave his wheelchair during that time.
In violation of rules, according to the inspectors’ report, guards placed detainees who had been separated for disciplinary reasons in handcuffs and shackles when they were not inside their cells.
Physically restraining them “does not comport with ICE standards and gives the appearance of criminal, rather than civil, custody,” said the report.
The inspectors also found that detainees did not have access to medical care in a timely fashion, which they concluded was responsible for three deaths since 2015.
“I think there needs to be more training for the officers, particularly in the context of what immigration detention does psychologically to people,” said Douglas Jalaie, a Los Angeles lawyer whose clients at Adelanto have told him it is difficult to get the guards’ attention when help is needed. “You have individuals separated from their families for the first time in their life, and who have never been incarcerated before.”
Mr. Inzunza, who works as a handyman, was not present at the Adelanto facility when the inspectors did their review, but spoke to The New York Times about his time at the center last year, after he was transferred there from a county jail. The undocumented immigrant, who arrived in the United States when he was 14, said that he had languished for months at the center waiting for a bond hearing.
The facility, he said, houses migrants from dozens of countries, many of whom have no idea when they might be released or whether they might be deported.
“It is constant fights because everyone is very stressed out,” said Mr. Inzunza, who is fighting in court to remain in the United States. “We turned into lions in cages.”
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