California ICE facility fails every court-ordered health standard, monitor finds

Report documents medication delays, emergency care gaps, inadequate screenings

The California City detention center, located northeast of Los Angeles on the grounds of a former state prison, was the subject of a court-ordered investigation after U.S. District Judge Maxine Chesney in February ordered the government to demonstrate it was providing required medical treatment across eight components of the facility’s healthcare system.

Dr. Muthusamy Anandkumar, a physician who previously served as a medical expert for the Department of Homeland Security and has a history of auditing ICE detention centers, was appointed by the judge to conduct the inquiry. His report, filed with the court Monday, found the facility out of compliance with all eight areas identified by the judge.

“The facility lacks a reliable system to consistently provide adequate health care, placing individuals at serious risk of both immediate and long-term harm,” Anandkumar wrote.

The case originated with a class-action lawsuit filed in November by seven detained plaintiffs who alleged “life-threatening” problems with healthcare. The complaint included claims the facility was denying cancer treatment, regular insulin for diabetes, and basic disability accommodations.

Lawyers for the detained immigrants said the findings represent the first court-ordered investigation of the full scope of medical care at any ICE facility in the United States.

Anandkumar’s report was based on an inquiry over several months that included a review of 141 medical records, a three-day site visit in May, and interviews with 40 patients and staff.

The monitor found major flaws in emergency care, failures to provide medications in a timely manner, inadequate screenings for health conditions, and a lack of accommodations for people with disabilities. He suggested the failings were structural rather than occasional.

“This pattern indicates broader problems in the facility’s health care delivery system rather than occasional lapses in care,” Anandkumar wrote.

The report described significant dysfunction with the medication delivery system, including some patients reporting they had to stay up until 2 a.m. to get medications that were supposed to arrive around 7 p.m. The monitor also reported seeing “loose pills” on the floor in a medication room, indicating that medication handling and disposal practices were not consistently maintained.

Staff shortages were so severe that some staff were moved to clinical duties before finishing orientation, and staff who were not yet fully trained were tasked with training others, the monitor said.

Patients with serious psychiatric needs requiring inpatient treatment outside the facility have instead been left in detention until they “deteriorate” to such a degree that they are hospitalized, the report said, and are then returned to detention “often with little lasting improvement.”

A patient who uses a wheelchair reported being injured during transport to an outside facility on two separate occasions, the monitor wrote, saying staff acknowledged the incidents. Another patient with a disability reported being left in the shower area “for a long time” because no one escorted him back. People with disabilities said they had to rely on roommates instead of trained staff for help with basic activities.

The monitor also found that physical exams and record-keeping were inadequate, with doctors writing “WNL” for “within normal limits” instead of documenting specific findings for patients’ systems, such as “lungs clear.” In some cases, patients reported specific problems but no examination was documented for the body parts related to the symptoms, Anandkumar said.

“This is the most basic step in evaluating a medical complaint,” he wrote. “This creates a risk that the very problem the patient came in with was not properly evaluated.”

The process of referring people to specialists was also disorganized and inadequate, the monitor said, with patients waiting for referrals past deadlines noted in their medical records or being denied referral without a documented reason.

A DHS spokesperson did not respond to questions about the monitor’s findings but said the agency provides “comprehensive medical care” to detained people.

CoreCivic, the private prison corporation that operates the facility, is not a defendant in the lawsuit. Ryan Gustin, a CoreCivic spokesperson, said the company was still reviewing the monitor’s report but said “nothing matters more to CoreCivic than the health, safety and well-being of the people in our care.” He said an on-site ICE officer was responsible for monitoring compliance with applicable ICE detention standards and policies.

The 51-page report included recommendations to address the gaps in care and improve how the facility tracks medical care.

Tess Borden, managing attorney at the Prison Law Office, which is representing the detained people who sued the government, said in a statement that the monitor’s findings “tell a nightmarish story – psychiatric patients left without follow-up, medication and culture specimens improperly stored, specialist appointments that were missed or never scheduled.”

“This report confirms what thousands of people have experienced firsthand: in every area of health care, California City is failing,” Borden said.