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The supervised group home, Echo House, is one of about 100 providers that contract with ValueOptions, a for-profit firm that has handled mental health services for Maricopa County residents since 1998.
When Carl took his antipsychotic medications, he usually was able to cope with life in his own irregular way. But his meds were nowhere to be found when Phoenix police sorted through his clothes after he died.
Other events seem to have led Carl down his fatal path:
He had started spending time with a still-unidentified woman, and left Echo House for parts unknown after staffers told him that she couldn't stay with him there.
Around that time, someone stole Carl's bicycle, his lifeline -- along with city buses -- to the world.
His paranoia intensified.
He spoke to a friend about unnamed people (probably figments of his imagination) who were threatening to hurt him unless he gave them money.
Then Carl died, and it was a wretched death.
At the time, he was under a standing order from the Maricopa County Superior Court to live at Echo House and to receive a variety of mental health services from ValueOptions.
For their part, the home's staffers and Carl's case manager at ValueOptions were supposed to keep close tabs on him.
They failed, and the results were fatal.
No one at Echo House even filed a missing-persons report for five days after Carl vanished, though a staffer later told police that Carl hadn't disappeared before. Neither did anyone from the home immediately contact Carl's older brother Dwayne, who lives in south Phoenix, a part of town Carl often visited.
That staffer also revealed that Carl hadn't taken his antipsychotic medications with him, and told the cop "it was possible for Carl to be suicidal if he did not take his meds."
But Carl's pitiful end is just a starting point for this story.
"He was one of my favorite people ever," says Darlene Coon, proprietor of The Other Room, a working-class bar tucked away in a Glendale strip mall at 43rd Avenue and Peoria. "I've been in this business 40 years, and I never met anybody like that. He was kind, he was honest and he was a good guy. He had mental problems, but there was a lot more to him than that."
Carl started to frequent the little tavern soon after his release from Arizona State Hospital in late 2001. He would spend a few hours there almost daily, drinking his Cokes, playing pool, listening to the jukebox, gabbing.
On August 6, Coon and her patrons paid tribute to Carl at the bar. Beforehand, she passed out a flyer with a photograph of him wearing a big smile and a bright-red cap inscribed with "God Bless America."
The caption above the photo read, "Carl Gholson: A Gentleman and a Gentle Man." Beneath the picture: "Farewell from your friends at The Other Room."
Earlier that day, Dwayne Gholson had led an upbeat service for his brother at a south Phoenix funeral home. Family members from around the nation attended the ceremony, which concluded with the singing of the gospel standard, "Oh Happy Day."
"If you [saw] Carl on the street, he'd scare you at first with that look of his," says Gholson, a sales representative for a Phoenix firm. "But if you got past 30 seconds, he could win you over. My brother was sincerely empathetic toward people, and people felt it. He used to tell me, 'I see people in pain and pain don't have no color.' He had more purpose here than I ever did."
Much was made at the south Phoenix service of Carl's transcendent musical gifts.
"He'd talk to the music, and the music would talk back to him," his brother says. "He'd say, 'I'm gonna play a note only God can hear. That's what I'm gonna do.'"
Though he also played keyboards, bass and drums, the love of Carl Gholson's life was his saxophone.
While still in his teens, Carl became a first-tier sax player in the Phoenix rhythm-and-blues scene, red-hot in the late 1960s and early 1970s.
He performed with Dyke and the Blazers, the group that put out the famed 1967 single, "Funky Broadway" -- named not after the famed New York City thoroughfare but after the south Phoenix street that once was home to numerous nightspots.
And in 1971, at the age of 17, Carl played sax with Phoenix's Chuck Womack and the Sweet Souls on the catchy R&B tune, "Ham Hocks and Beans." Unlike Dyke's big seller, Womack's gem never made a dent in the charts.
But the song hung around, winning belated underground cult status.
Just last month, a small San Francisco label reissued "Ham Hocks" to a rousing reception on radio shows and in clubs on both coasts and in Europe.
"It was amazing how this man communicated through his horn," says Joy Ratterree, a retired therapist who befriended Carl while working at Arizona State Hospital.
"There's no telling how far he would've gone if he hadn't gotten sick. He really touched people's souls. He could have a tough time relating verbally, but never musically. He had a natural gift. It was one of the most rewarding professional relationships of my life. He often brought tears to people's eyes, including mine."